Handouts Part 2 - Alberta Provincial Stroke Strategy

Transcription

Physical Activity
Activity is related to a host of health
issues
 Decreased mortality
 Improved function
 Better risk factor profile (blood pressure,
glucose tolerance, lipids, waist
circumference)
Sawatzky R, Liu-Ambrose T, Miller WC, Marra CA. Physical activity as a mediator of the
impact of chronic conditions on quality of life in older adults. Health Qual Life Outcomes
2007;5:68.
Gains are lost!!
 In spite of gains achieved with exercise or
physical activity programs – gains are
generally lost on follow-up.
Interventions
What works and what doesn’t work
ExStroke Trial(ExStroke Trial; BMJ August 2009)
Behaviour change with cardiac
population
 Intervention
 Pedometer based telephone intervention with
Participants met with trial instructor prior to
D/C
 Follow-up visits every 3 months during Year 1,
every 6 months during Year 2 (instructions
were repeated and activity plan adjusted)

 Repeated instructions and facilitation to
increase physical activity doesn’t change
behaviour
cardiac patients (Patient Educ Counsel 2009 Dec 16 epub)
 Intervention
based on social cognitive
theory – focused on self efficacy,
overcoming barriers to activity
 Calls at 1, 3 & 6 weeks. Booster calls at
12 and 18 weeks.
3
PREPARE Program (Diabetes Care 32:
1404-1410, 2009)
 Intervention
 180 minutes (see handout)
 patient story, professional story, diet, physical activity
(self efficacy, action plans, use of pedometer).
 Follow-up – 10 minute review at 3 and 6 months
 Program with pedometer led to increased physical
Different Approaches
activity and better glucose control at 12 months
Increase physical activity or decrease
sedentary time (or both?)
Sedentary Time
US population-based data: NHANES (2003/04 & 2005/06)
100
Sedentary time (%)
mean = 56.6%
80
60
40
20
0
6-11
12-19
20-39
40-59
60+
Age group
Bernhardt, J., et al., Inactive and alone: physical activity within the first 14
days of acute stroke unit care. Stroke, 2004. 35(4): p. 1005-9.
Healy et al. 2009 J Sci Med Sport, S44
Change in objectively measured sedentary across
time of day
55
sedentary time (mins)
50
Pre-intervention sed time
Post-intervention sed time
*
*
45
40
*
*
35
*
*
*
*
7:
00
-7
:5
9a
m
8:
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-8
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9a
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-9
:5
9a
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m
:0
010
:5
9a
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m
:0
011
:5
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9a
m
:0
012
:2
9p
1:
m
00
-1
:5
9p
2:
m
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-2
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9p
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-3
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00
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m
30
Time of day
Owen N, Ekelund U, Hamilton M, Gardiner P, & Dunstan D. Sedentary
behavior in adults: longitudinal, experimental, and intervention evidence.
Journal of Physical Activity and Health 2010; 7(Suppl 3): S334-336.
Owen, N., et al., Too much sitting: the population health science of sedentary behavior. Exerc
Sport Sci Rev, 2010. 38(3): p. 105-13.
4
Pattern of Activity
Importance of Light Intensity Activity
Dunstan, Healy et al 2010 at:
http://www.touchendocrinology.com/articles/too-muchsitting-and-metabolic-risk-has-modern-technology-caught-us
Take Home Message
 Light intensity activity more often
 Break up sitting time – pay attention to
pattern of activity
Katzmarzyk et al. MMSE 41 (5): 9981005, 2009.
Common Sense Model
(Rheumatology 2007;46:904-906)
 Lay beliefs about illness – allows people to make
Theory
sense of their symptoms and guide coping strategies.





Identity
Cause
Time-line
Consequences
Curability/Controllability
 The way that people think and feel about the above
things can influence their outcomes and how they
cope
5
Motivational interviewing
Dual Process Model
 Express empathy
 “two qualitatively different modes of
 Develop discrepancies
 Roll with resistance
 Support self efficacy
information processing operate in making
judgments and decisions and in solving
problems”
Miller WR. Motivational interviewing: preparing people for change. The
Guildford Press, New York. 2002.
Welschen, L.M., et al., The effectiveness of adding cognitive behavioural
therapy aimed at changing lifestyle to managed diabetes care for patients with
type 2 diabetes: design of a randomised controlled trial. BMC Public Health,
2007. 7: p. 74.
Dual Processes Theories in Social Psychology. Editors Chaiken & Trope:
1999.
Social Cognitive
Implementation Intentions
 Core determinants
 Different than goal intentions (i.e. my goal is
Knowledge of health risk and benefits of
different health practices
 Perceived self efficacy – control over a
behaviour


Use reinforcement, modeling
Outcome expectations – costs and benefits of
different behaviours
 Perceived facilitator – social and structural
impediments or facilitators

to do this…)
 Implementation intentions specify the when,
where, and how of the responses (when
situation x happens, I will perform the
response y OR I intend to engage in PA at
the gym Tuesday afternoons after work)
Gollwitzer PM. 1999 American Psychologist 54 (7): 493-503.
Bandura A. Health Education and Behaviour 2004; 31(2): 143-164.
Resources
 http://hypertension.ca/bpc/resource-
center/educational-tools-for-health-careprofessionals/
6
Interstroke - Risk Factors
Lancet June 18, 2010; Interstroke Trial
APSS Conference
December 2010
Increasing and maintaining physical activity through behaviour change
By the end of this session you should be able to organize and lead all aspects of a physical
activity behaviour change intervention with stroke survivors. In order to do this you will learn:
 Pertinent terminology
 Why physical activity behaviour change is important for people with stroke
 Evidence regarding success of physical activity behaviour change interventions
 Components of a behaviour change intervention through participation in a
behaviour change intervention
I.
II.
III.
IV.
V.
VI.
Outline
Terminology & background information
Why focus on changing physical activity behaviour in people with stroke?
a. People with stroke typically have several co morbidities/risk factors for another
stroke [1, 2]
b. Interstroke findings [3]
c. People with stroke are generally inactive [4], and gains from interventions are lost
without continued activity [5]
d. Inactivity is related to a host of health issues
e. Inactivity or sedentary – semantics or an important distinction?
Evidence for change in physical activity behaviour in people with stroke
a. What doesn’t work?
b. What works?
Theoretical underpinning of intervention
a. Common sense model
b. Motivational interviewing
c. Social cognitive theory
d. Implementation intentions
Different approaches
An example session
Options for Measurement:
 Pedometers (Example – New Lifestyles http://www.new-lifestyles.com/) - less effective
at slower speeds.
 ActivPAL http://www.paltech.plus.com/products.htm (provides steps, sit to stand
transitions, sitting time)
 Step Activity Monitor
http://www.orthocareinnovations.com/pages/stepwatch_tradesystem (measures steps per
day as well as intensity of stepping (steps/min) – validated for people with stroke
 Actical (measures all types of activity, waist worn, more complicated analysis)
http://actical.respironics.com/PDF/ActicalBrochure.pdf. Step count not accurate at
lower speeds Esliger, D.W., et al., Validity of the Actical accelerometer step-count
function. Med Sci Sports Exerc, 2007. 39(7): p. 1200-4.
 Sensewear Arm Band http://www.sensewear.com/BMS/solutions_bms.php - (measures
energy expenditure, steps, postural allocation)
1
Trish Manns, Department of Physical Therapy, University of Alberta
Phone 780-492-7274 Email: [email protected]
APSS Conference
December 2010
PREPARE Program
From [6]
How?
 As part of a physical activity module at stroke prevention clinic
 Education sessions for individuals with stroke in hospital
 Other?
References:
1.
Kopunek, S.P., et al., Cardiovascular risk in survivors of stroke. Am J Prev Med, 2007.
32(5): p. 408-12.
2.
Mackay-Lyons, M.J., C. Macdonald, and J. Howlett, Metabolic syndrome and its
components in individuals undergoing rehabilitation after stroke. J Neurol Phys Ther,
2009. 33(4): p. 189-94.
3.
O'Donnell, M.J., et al., Risk factors for ischaemic and intracerebral haemorrhagic stroke
in 22 countries (the INTERSTROKE study): a case-control study. Lancet, 2010.
376(9735): p. 112-23.
4.
Sawatzky, R., et al., Physical activity as a mediator of the impact of chronic conditions
on quality of life in older adults. Health Qual Life Outcomes, 2007. 5: p. 68.
5.
Mudge, S., P.A. Barber, and N.S. Stott, Circuit-based rehabilitation improves gait
endurance but not usual walking activity in chronic stroke: a randomized controlled trial.
Arch Phys Med Rehabil, 2009. 90(12): p. 1989-96.
6.
Yates, T., et al., Rationale, design and baseline data from the Pre-diabetes Risk
Education and Physical Activity Recommendation and Encouragement (PREPARE)
programme study: a randomized controlled trial. Patient Educ Couns, 2008. 73(2): p.
264-71.
2
Trish Manns, Department of Physical Therapy, University of Alberta
Phone 780-492-7274 Email: [email protected]
Interstroke - Risk Factors
Lancet June 18, 2010; Interstroke Trial
FES and Similar Approaches
Kristin Musselman PhD, PT
Research Fellow
Johns Hopkins School of Medicine
Kennedy Krieger Institute
[email protected]
Stroke Education Days - APSS
1
Objectives
1. To understand the basics of FES
– Choosing appropriate clients, goals & parameters
2. To review the literature on FES & stroke
3. To become familiar with FES systems for
stroke
2
Outline
First Hour
1. Review of FES basics
2. FES for Upper Extremity
3. FES for Lower Extremity
***Break***
~15 min
~15 min
~15 min
~5-10 min
Second Hour
FES stations
Bioness, WalkAide, Odstock
3
1
Review of FES Basics
Functional electrical stimulation is the use of ES
as..?
A.
B.
C.
D.
An orthotic substitute for a muscle function
A means to prevent learned non-use
A tool for motor relearning
A, B & C
4
Which of the following is false regarding ES
muscle contractions?
A.
B.
C.
D.
Recruit a small number of motor units
Motor units fire synchronously
Large, fast fatigable units fire first
More resistant to fatigue than physiologic
contractions
5
Increasing which parameter(s) will increase the
strength of an ES contraction?
A.
B.
C.
D.
Pulse duration
Frequency
Intensity/amplitude
A&C
6
2
If stimulating a small muscle, the best response is
obtained by..?
A. Placing cathode on motor point, using
asymmetric waveform
B. Placing cathode on motor point, using
symmetric waveform
C. Placing anode on motor point, using asymmetric
waveform
D. Placing anode on motor point, using symmetric
waveform
7
Research supports which parameter as the most
important for achieving success with ES?
A.
B.
C.
D.
Duration of treatment
Waveform
Intensity/amplitude
Active participation of client
8
Which stroke client is a good candidate for FES
of the UE?
A.
B.
C.
D.
Peripheral nerve damage in UE
No AROM in UE
Pacemaker implanted
Impaired sensation in UE, some AROM
9
3
FES
Parameters
Settings
Pulse/cycle duration
150-200μs small muscles, 200-350μs large
muscles
Current amplitude
Sufficient for functional activity
Ramp-up/Ramp-down
Activity specific
Frequency
35-50 pps
On time
Activity specific
Off time
Activity specific
Treatment time
Activity specific
Electrode configuration
Parallel to muscle fibers; 1 channel small
muscles, 2 channels large muscles
From: Cameron, Michelle H. Physical Agents in Rehabilitation: From Research to Practice. 3rd ed. 2009.
10
Increasing Intensity of Rehab
FES leads to strength gains via Overload principle
– Greater strength gains occur when training at higher
contraction intensities
(Delitto & Snyder-Mackler 1990)
Box & Block Test
Cauraugh et al. 2000
Chronic stroke
Experimental = EMG-triggered ES
Control = AROM
12 30-minute sessions
11
Evidence-based Review of Stroke
Rehabilitation
Teasell et al. 2010 (ebrsr.com)
There is strong evidence that FES:
 improves upper extremity function in stroke
 reduces shoulder subluxation
 improves gait performance, when combined with
gait retraining
 improves gait and standing post-stroke, when
combined with biofeedback training
12
4
Hemiplegic Shoulder
Snels et al. 2002
 Methodological quality of reviewed studies moderate to poor
 Concluded that FES was 1 of the 2 most promising methods for
treatment of hemiplegic shoulder pain
Van Peppen et al. 2004
 Strong evidence found for increasing PROM & reducing caudal
subluxation with FES
 Insufficient evidence found for reducing pain with FES
13
Hemiplegic Shoulder
 Early post-stroke: FES is efficacious for preventing
subluxation & increasing UE function
 Chronic stroke: FES is efficacious for reducing pain
(Chantraine et al. 1999; Linn et al. 1999; Ada & Foongchomcheay 2002)
 FES for hemiplegic shoulder does not improve UE
function (Church et al. 2006, Price & Pandyan 2001)
14
Hemiplegic Shoulder
Goal – joint protection (early)
pain reduction (late)
Parameters – endurance
– Posterior deltoid and
supraspinatus (Baker and
Parker 1986, Kobayashi et al.
1999)
– Use minimum amplitude
needed to raise humeral
head into glenoid fossa
15
5
Hemiplegic Shoulder
Subluxed Shoulder
Subluxed Shoulder with FES
(Linn et al. 1999)
16
Hemiplegic Shoulder
FES Prescription (Linn et al. 1999)
 4X/day with >2 hrs between sessions
 Session length = 30 min wk 1, 45 min wk 2&3, 60 min
wk 4
 Asymmetrical biphasic waveform
 Pulse width = 300μs
 Frequency = 30Hz
 On time 15 sec (including ramp up/down of 3/3)
 Off time 15 sec
17
FES in UE
Popović et al. 2002
Therapeutic effect
18
6
FES in UE
Sullivan & Hedman 2004, 2007
 Combined sensory
& motor ES for a
home program
 Practice of
functional activities
 Hand switch to
trigger ES
19
The Bionic Glove
 Electronically senses voluntary wrist movements & provides
ES to finger & thumb muscles to produce grasp & release
(Prochazka et al. 1997, Popović et al. 1999)
20
The ReJoyce: In-Home TeleRehabilitation + FES
Kowalczewski et al. (under review NeuroRehabil Neural Repair)
Hometelemed.com
21
7
The ReJoyce: What is the evidence?
Kowalczewski et al.
Greater gains in functional tasks with ReJoyce compared with exercise therapy
22
The ReJoyce: What is the evidence?
Kowalczewski et al.
Improvements in pinch and grasp forces
23
NESS H200
Muscles targeted:
1.
2.
3.
4.
5.
extensor digitorum communis
extensor pollicis brevis
flexor digitorum superficialis
flexor pollicis longus
thenar muscles
3 exercise modes
3 functional modes
1. Key grip & release
2. Palmar grip & release
3. Static open hand posture
(Alon et al. 2002, Alon & McBride 2003)
24
8
NESS H200
Alon et al. 2002
chronic stroke
3 weeks of daily training
(twice daily, 10 → 45 min)
Orthotic effect
25
NESS H200
Ring & Rosenthal 2005
26
FES & Pre-gait Activities
Maležič et al. 1994
 NMES to gluteus maximus, quads and hamstrings of
hemiplegic leg
– Subjects stood with 11.4% more weight on hemiplegic leg
during FES
– Subjects shifted their weight onto hemiplegic leg 50.8%
faster with FES
27
9
FES for Gait
 Appropriate for clients with some walking ability
 Treatment tailored to client & his/her deficits
Wieler et al. 1999
 For foot drop:
– ES to peroneal nerve to elicit ankle dorsiflexion
– If dorsiflexion not sufficient, stim increased to elicit flexor reflex
 For knee or ankle instability during stance:
– Add ES to quads or tibial nerve
 For instability of hip/pelvis:
– Add ES of gluteus medius
28
FES for Gait – What is the evidence?
FES ↑ walking speed
(Laufer et al. 2009, Wieler et al. 1999)
 Kottink et al. 2004 – Systematic review
– 5/6 studies showed positive effect of FES on walking speed
 Robbins et al. 2006 – Meta-analysis
– FES has therapeutic effect on speed in subjects post-stroke
FES ↑ muscle strength
 Glanz et al. 1996 – Meta-analysis
₋ FES promotes recovery of muscle strength after stroke
29
FES for Foot Drop
 1st functional application in neuro condition
(Liberson et al. 1961)
 Target tibialis anterior
 External trigger
#1: Cathode over TA
30
10
FES for Foot Drop
 1st functional application in neuro condition
(Liberson et al. 1961)
 Target tibialis anterior
 External trigger
#1: Cathode over CPN
31
Odstock Dropped Foot Stimulator
 Single channel
 Synchronised to gait with
foot switch
 Odstock sounder – useful for
therapist
32
ODFS – What is the evidence?
Clinical
 Successfully treated >6000 pts in UK
 Compliance after 1 yr: 92% in MS. 86% in CVA
(FES: Applications in Rehabilitation 2007)
Research
ODFS ↓ effort of walking
(Taylor et al. 1999)
– 151 subjects with upper motor neuron lesions who had used
ODFS for 4.5 months
– Saw 31% reduction in Physiological Cost Index (PCI) of walking
– PCI = change in HR from resting to steady speed of walking
walking speed
33
11
NESS L300
 Stim to CPN & TA
 Triggered by force sensor
under foot
 Wireless
34
NESS L300 – What is the evidence?
↑ gait symmetry
Hausdorff & Ring 2008
Chronic hemiparesis
n=24
↑ daily use from 1 hr/day
to full day in 4 wks
Orthotic effect
35
↑ gait speed (Hausdorff & Ring 2008)
 Over-ground & negotiating obstacle course
36
12
Laufer et al. 2009
16 chronic stroke users followed for 1 year
2 mos
1 yr
Participation domain
(Stroke Impact Scale)
25.2%↑
36.7%↑
Gait speed (10mWT)
29.2%↑
58.2%↑
37
WalkAide
 Single channel (CPN)
 Leadless
 Single-handed application
 Built-in accelerometer (tilt sensor)
₋ ES on in late stance when lower leg
is behind body (tilted back) & off at
beginning of next stance when lower
leg is in front of body (tilted forward)
38
WalkAide – What is the evidence?
Stein et al. 2006
↑ walking speed
↓ effort of walking
39
13
What causes a ‘therapeutic’ effect?
 Increased strength, coordination & conditioning
(Wieler et al. 1999)
 Improved motor unit recruitment
(Newsam & Baker 2004)
 Corticospinal connections strengthened with 3-12
months of WalkAide use (Everaert et al. 2010)
 Increased cortical activation after 8 wk FES program
for hemiparetic wrist & hand (Page et al. 2010)
40
Increasing Intensity
  in speed correlated with amount of
WalkAide use (Stein et al. 2006)
41
14
December 2010
FES Workshop
K.Musselman
References
Ada L, Foongchomcheay A. Efficacy of electrical stimulation in preventing or reducing subluxation of the shoulder after
stroke: a meta-analysis. Australian Journal of Physiotherapy. 2002; 48: 257-67.
Alon G, McBride K, Ring H. Improving selected hand functions using a noninvasive neuroprosthesis in persons with
chronic stroke. J Stroke Cerebrovascular Dis 2002; 11: 99-106.
Alon G, McBride K. Persons with C5 or C6 tetraplegia achieve selected functional gains using a neuroprosthesis. Arch
Phys Med Rehabil 2003; 84: 119-24.
Baker LL, Parker K. Neuromuscular electrical stimulation of the muscles surrounding the shoulder. Phys Ther 1986; 66:
1930-7.
Cameron, Michelle H. Physical Agents in Rehabilitation: From Research to Practice. 3rd ed. St. Louis, Missouri. 2009
Cauraugh J, Light K, Kim S, et al. Chronic motor dysfunction after stroke: recovering wrist and finger extension by
electromyography-triggered neuromuscular stimulation. Stroke 2000; 31: 1360-4.
Chantraine A, Baribeault A, Uebelhart D, et al. Shoulder pain and dysfunction in hemiplegia: effects of functional
electrical stimulation. Arch Phys Med Rehabil 1999; 80: 328-31.
Church C, Price C, Pandyan AD, et al. Randomized controlled trial to evaluate the effect of surface neuromuscular
electrical stimulation to the shoulder after acute stroke. Stroke 2006; 37: 2995-3001.
De Kroon JR, IJzerman MJ, Chae J, et al. Relation between stimulation characteristics and clinical outcome in studies
using electrical stimulation to improve motor control of the upper extremity in stroke. J Rehabil Med 2005; 37: 65-74.
Delitto A, Snyder-Mackler. Two theories of muscle strength augmentation using percutaneous electrical stimulation. Phys
Ther 1990; 170: 158-64.
Everaert DG, Thompson AK, Chong SL, et al. Does functional electrical stimulation for drop foot strengthen corticospinal
connections? Neurorehabil Neural Repair 2010; 24: 168-77.
Glanz M, Klawansky S, Stason W, et al. Functional electrostimulation in poststroke rehabilitation: a meta-analysis of the
randomized controlled trials. Arch Phys Med Rehabil 1996; 77: 549-53.
Hausdorff JM, Ring H. Effects of a new radio frequency-controlled neuroprosthesis on gait symmetry and rhythmicity in
patients with chronic hemiparesis. Am J Phys Med Rehabil 2008; 87: 4-13.
Kobayashi H, Onishi H, Ihashi K, et al. Reduction in subluxation and improved muscle function of the hemiplegic
shoulder joint after therapeutic electrical stimulation. J Electromyogr Kinesiol 1999; 9: 327-36.
Kottink AI, Oostendorp LJ, Buurke JH, et al. The orthotic effect of functional electrical stimulation on the improvement
of walking in stroke patients with a dropped foot: a systematic review. Artif Organs 2004; 28: 577-86.
Laufer Y, Ring H, Sprecher E, et al. Gait in individuals with chronic hemiparesis: one-year follow-up of the effects of a
neuroprosthesis that ameliorates foot drop. J Neurol Phys Ther 2009; 33: 104-10.
Liberson WT, Holmquest HJ, Scot D, et al. Functional electrotherapy: stimulation of the peroneal nerve synchronized
with the swing phase of the gait of hemiplegic patients. Arch Phys Med Rehabil 1961; 42: 101-5.
Linn SL, Granat MH, Lees KR. Prevention of shoulder subluxation after stroke with electrical stimulation. Stroke 1999;
30: 963-8.
December 2010
FES Workshop
K.Musselman
Maležič M, Hesse S, Schewe H, et al. Restoration of standing, weight-shift and gait by multichannel electrical stimulation
in hemiparetic patients. Int J Rehabil Res 1994; 17: 169-79.
Newsam CJ, Baker LL. Effect of an electric stimulation facilitation program on quadriceps motor unit recruitment after
stroke. Arch Phys Med Rehabil 2004; 85: 2040-5.
Page SJ, Harnish SM, Lamy M, et al. Affected arm use and cortical change in stroke patients exhibiting minimal hand
movement. Neurorehabil Neural Repair 2010; 24: 195-203.
Popovic D, Stojanovic A, Pjanovic A, et al. Clinical evaluation of the bionic glove. Arch Phys Med Rehabil 1999; 80:
299-304.
Popovic MB, Popovic DB, Sinkjaer T, et al. Restitution of reaching and grasping promoted by functional electrical
therapy. Artificial Organs 2002; 26: 271-5.
Price CIM, Pandyan AD. Electrical stimulation for preventing and treating post-stroke shoulder pain: a systematic
Cochrane review. Clin Rehabil 2001; 15: 5-19.
Prochazka A, Gauthier M, Wieler M, et al. The bionic glove: an electrical stimulator garment that provides controlled
grasp and hand opening in quadriplegia. Arch Phys Med Rehabil 1997; 78: 608-14.
Ring H, Rosenthal N. Controlled study of neuroprosthetic functional electrical stimulation in sub-acute post-stroke
rehabilitation. J Rehabil Med 2005; 37: 32-6.
Robbins SM, Houghton PE, Woodbury MG, et al. The therapeutic effect of functional and transcutaneous electric
stimulation on improving gait speed in stroke patients: a meta-analysis. Arch Phys Med Rehabil 2006; 87: 853-9.
Snels IAK, Dekker JHM, van der Lee JH, et al. Treating patients with hemiplegic shoulder pain. Am J Phys Med Rehabil
2002; 81: 150-60.
Stein RB, Chong S, Everaert DG, et al. A multicenter trial of a footdrop stimulator controlled by a tilt sensor.
Neurorehabil Neural Repair 2006; 20: 371-9.
Sullivan JE, Hedman LD. At home program of sensory and neuromuscular electrical stimulation with upper-limb task
practice in a patient 5 years after a stroke. Phys Ther 2004; 84: 1045-54.
Sullivan JE, Hedman LD. Effects of home-based sensory and motor amplitude electrical stimulation on arm dysfunction
in chronic stroke. Clin Rehabil 2007; 21: 142-50.
Taylor PN, Burridge JH, Dunkerley AL, et al. Clinical use of the Odstock dropped foot stimulator: its effects on the speed
and effort of walking. Arch Phys Med Rehabil 1999; 80: 1577-83.
Van Peppen RP, Kwakkel G, Wood-Dauphinee S, et al. The impact of physical therapy on functional outcomes after
stroke: what’s the evidence? Clin Rehabil 2004; 18: 833-62.
Wieler M, Stein RB, Ladouceur M, et al. Multicenter evaluation of electrical stimulation systems for walking. Arch Phys
Med Rehabil 1999; 80: 495-500.
11/29/2010
Objectives
Clinical Application of Constraint
Induced
Movement Therapy (CIMT)
December, 2010
Southern Alberta Stroke
Rehabilitation Education Days
Veronica T. Rowe, CBIST, MS, OTR/L
Clinical Instructor
University of Central Arkansas
[email protected]
–
–
–
–
Screen
Evaluation
Treatment
Follow-up
• Your perceptions
• The “Real World”
• Ways to make CIMT work
Formerly: Project Coordinator
Emory University
Atlanta, Georgia
Reflection
•
•
•
•
• Review basic components of CIMT
• Explore CIMT as it applies to the clinical environment
Have you used CI therapy?
What are the primary components?
How do you select patients for CI therapy?
How would you document improvement with a CI
therapy program?
• Do you try to incorporate evidenced based
practice into your clinic?
• How might those concepts be related to CI
therapy?
Evidence-based practice in
neurorehabilitation
• “the integration of best research evidence with
clinical expertise and patient values”
Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000
Haynes, Devereaux, & Guyatt, 2002
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Components of CIMT protocol
• Restraint of less involved UE
• Constraint use of more involved UE
• Repetitive, task-oriented training
– Adaptive task practice (shaping)
– Repetitive task practice
• Adherence-enhancing behavioral strategies
(“transfer package”)
Restraining use of the less-affected UE
Any method to continually remind the patient to use the more
affected arm and hand
Types of restraint:
• pull-out sling
• splinted arm
• sling/cuffed end
• cuffed hand/wrist–mitt
• cast (pediatrics)
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Accelerometers
Restraining use of the less-affected UE
Any method to continually remind the patient to use the more
affected arm and hand
Provides data regarding duration of arm
movements in the home situation.
Nothing “magic about the mitt”
Types of restraint:
• pull-out sling
• splint – free arm
• sling / cuffed end
• cuffed hand / wrist – mitt
• cast (pediatrics)
•
•
•
•
sock
oven mitt
string on finger
watch/bracelet on
different wrist
• hand in pocket
• other ideas?????
Types of intensive practice
Shaping
Repetitive Task Practice
(Adaptive task practice)
Repeating tasks with continuous feedback
from the trainer. Tasks selected by the
patient, in collaboration with the
trainer, on the basis of personal
preference, relevance and interest.
Training method in which a motor or
behavioral objective is approached in
small steps, by successive
approximations or by making the task
more difficult in accordance with the
patient’s motoric capabilities.
 Grading and specificity of
tasks
 Feedback and intensity of
reps
 General practice of entire
functional activity
 Periodic feedback
 Typically practiced over
period of time
www.ucasports.com
www.nike.com
Just do it with one hand!
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Training
• Functional Task Practice
– Shaping
– Repetitive Task Practice
• Considerations
– Feedback
• Measurement performance
– Grading of tasks
• “How difficult should the task be?”
– The level of difficulty should be slightly more challenging than
“easy”
– Intensity
– Task specificity
Goal: Make coffee
Training
Developed from patient’s goals and designed to
address movement limitations
• Identify missing requisite functional movements
– Reach patterns (shoulder-elbow-forearm synergy)
– Grasp patterns (forearm-wrist – grasp patterns)
– Incorporate pre-grasp and release with reach
• Object affordances – we move according to previous
experiences
• It would be better to reach for a real object rather than a
non-functional “new” object
Goal: Make coffee
• Repetitive task practice
• Components
– Pick up / open bag of coffee
– Scoop beans into grinder
– Grind coffee
– Place filter and pour coffee into filter
– Pour water into coffee maker
– Pour coffee into cup
– Drink!!!
– Entire task
Document progress – speed
of completion, self rated
performance (how well);
self-rated confidence;
quality (any spillage?)
http://www.coastdental.com.au/info/assets/jaz.jpg
http://sekhargurugubelli.com/wp-content/uploads/2009/12/CoffeeCup.JPG
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Goal: Make coffee
• Adaptive task practice (shaping)
– More structured activity
– Feedback: amount and frequency of
knowledge of results and performance
increased
– Grading of tasks and task progression
through specific “control parameters” –
spatial/temporal domains
– Intensity – several sets of multiple repetitions
– Task specificity – part task practice –
“naturally dividing activities into units that
reflect their inherent goals” Winstein, 1991, and
Schmidt, 1991
“The outcome of therapy is
development of a skill” Jim Gordon, III Step
Skill is the ability to
achieve goal (task)
with consistency,
flexibility and
efficiency.
http://www.aotf.org/
When questioning whether the goal
was achieved – assess for:
 Consistency
◦ Rate of goal achievement (# of successes / # of attempts)
◦ Accuracy (spatial errors, temporal errors)
 Efficiency
◦
◦
◦
◦
◦
Time required
Speed
Duration
Distance
Dual task performance
 Flexibility
Example – writing task
• Goal of the patient
– “To write checks legibly”
• Skill
– writing
• Efficiency
– legibly
• Flexibility
– on checks vs. on dry erase board
• Consistency
– write more than one check
◦ Performance under different conditions or environments
◦ Predictable vs. unpredictable conditions
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Adherence-enhancing
behavioral strategies
•
•
•
•
•
Transfer package tools
Behavior contract
Home Diary
Home Exercise program
Behavioral contract
Caregiver contract
Home diary
Home skill assignment / Home practice
Problem solving to overcome barriers of use
of UE in home environment
Behavior contract
Guidelines for mitt use
Safety!!!!!!
Activity modification
Caregiver contract
Home Diary
 Patient/Caregiver fills out daily
 Review at the beginning of each session
to:
• Assess compliance/safety wearing mitt at
home
• Explore ways activities maybe modified for
greater success
• Provide feedback/encouragement of use of
limb at home/community
• Encourage individual problem solving
activities not previously encountered and
facilitate patient self-progression of exercise
program
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Home Exercise Program
Chosen jointly between patient and therapist
 How to turn your home into a gymnasium
– Visualize rooms, decide upon meaningful activities,
ask patient to choose.
Application of CIMT in ExCITE
Timing of administration
– Subacute
– Clinic
Wearing mitt
– Forced use
– 90% waking hrs (“signature CIMT/ExCITE”)
Intensity of practice
– 6 hrs/day, 5 days/wk for 2 wks
Type of practice
– Shaping (adaptive task practice)
Screen
• Can be phone screen or brief physical screen
• Determine appropriateness for CIMT
• Give patient “preparation homework” for first
session
– list of goals
– tasks for practice at home
– times a mitt will be worn
Screening – Predictors of Outcome
ExCITE data – Fritz, et al. (2005, 2006, 2007)
– Finger extension only predictor of outcome on the
WMFT
– Descriptive data
• Age (only) predicted MAL (not WMFT)
• Not – hand dominance, side of stroke, gender
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CIMT – patient selection
Minimum movement criteria (ExCITE)
MAL: AMOUNT SCALE
0 – NOT USED (Did not use arm for that activity).
.5
1 – VERY RARELY (Occasionally tried to use the arm).
1.5
2 – RARELY (Sometimes used my weaker arm, but most of the activity with
my stronger arm).
• Higher Functioning
>200 wrist extension, > 100 extension of all digits
• Lower Functioning
>100
wrist extension,
2.5
3 – HALF PRE-STROKE (Used my weaker arm about half as much as before the
stroke).
3.5
100
thumb and two other digits
4 – 3/4 PRE – STROKE (Used my weaker arm almost as much as before the
stroke).
4.5
5 – SAME AS PRE – STROKE (Used my weaker arm as much as before the
stroke).
http://www.counseling.msu.edu/files_counseling/content/touching-hands.jpg
Evaluation
Determine your assessment tools
What is meaningful functional improvement?
WHO, 2001: International Classification of Functioning, Disability and Health (ICF)
Relationship of treatment to broader health and societal functioning
Thus, the effectiveness of the rehabilitation
intervention extends beyond simply its affect on the
movement system but also to the individual’s healthrelated quality of life.
Evaluation tools used in ExCITE
• Body Structures/Function
WMFT, FM, ROM
• Activities
MAL
• Participation
SIS
• Personal Factors
Screen for depression (only at Emory)
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First Treatment Session
Guidelines are Patient Specific
• Review concepts behind CIMT
• Patient empowerment and responsibility
• Self-initiated
• Review Patient’s goals
• List - specific and functional
• Collaborative goal
setting
• Coordination with
other disciplines
http://division-dtm.org/blog/wp-content/mbp-randomimage/Close%20up%20Shaking%20Hands%20000007894628XSmall_20091002002800.jpg
First Treatment Session
• Assess patient’s goals
– Movement analysis of functional task
– Example: “use my hand to eat with a fork in
public”
Task-Specific Training
• Problem solving
– The defined functional goal
– Existing impairments
– Patient comprehension
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11/29/2010
CIMT protocol
• What do patients think?
ExCITE Exit Interview
Given your experience with ExCITE training, how helpful do
you feel each of the following aspects was for achieving
results in your particular case?
1-not helpful at all -------- 7-very helpful
 Having to wear the mitt for most of your waking hours
during your two week training?
◦ 61% -- 6-7 helpful to very helpful
◦ >90% -- 4 somewhat helpful to very helpful
 The number of hours and days your spent with the
trainer each day?
◦ 79% -- 6-7 helpful to very helpful
http://www.ivorytowermetaphysics.com/wpcontent/uploads/2010/11/thinking-man.jpg
Perceptions and experiences of two survivors of stroke
who participated in constraint-induced movement
therapy home programs.
Gillot, A., et al. American J Occupational Therapy (2003) 57:168-176.
Neurorehab as an ongoing process
“I think I’m disappointed in the fact that I read all of the articles that
said people have remarkable results.” Although Janice did not
believe that she had “remarkable results” she was pleased with the
results she achieved because she was recognizing functional
improvements in her daily occupations. “I definitely do more
things with the right hand, and its just automatically grabbing
glasses, a dish rag, a broom with the right hand… I’m going to keep
(CIMT) up, I think it’s going to be evolving instead of ending”
Stroke patients’ and therapists’ opinions of
constraint-induced movement therapy.
Page, S., et al., Clinical Rehabilitation (2002); 16:55-60.
• 208 pts with stroke
68% not interested in CIT - citing concerns with practice
schedule and restrictive device schedule
• 85 PTs and OTs in Northeast
Cited concerns about patient adherence and safety, and
facilities without clinical resources to provide CIT
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11/29/2010
“Real World” Application
How might you use CIMT?
Important aspects to consider:
• Appropriate screening
– too low AND too high
-Motivation
-Cognition/Safety
-Family support
-Appropriate and ethical allocation of
resources
What practicalities and limitations do
you expect?
• Timing of intervention
• Involvement of family
• Involvement of other disciplines
Things sacrificed in the “Real World”
Minimum movement criteria (ExCITE)
• No “perfect” patients (movement criteria, family
support, decreased time to devote to CIMT, pain,
decreased activity tolerance, etc.)
 Higher Functioning
– CIMT most appropriate for mild to moderately
affected stroke survivors
What about everyone else?
What do I tell patients who are not
appropriate?
CIMT – patient selection
>200 wrist extension, > 100 extension of all digits
 Lower Functioning
>100 wrist extension, 100 thumb and two other digits
 Grasp and release movements are enough to pick and
release a tennis ball or washcloth
 Cognitive status is adequate
What about the rest of the arm?
Pain and fatigue?
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11/29/2010
Factors that may limit outcomes
•
•
•
•
•
•
•
•
Who benefits most?
• Wrist, finger extension and thumb abduction
of 20 degrees or more
• Active elbow extension (at least 20 degrees)
• Active shoulder elevation (abduction/flexion)
and external rotation
• Motor Activity Log AOU index of < 2.5
Shoulder subluxation
Pain or pain syndromes
Soft tissue shortening and contractures
Excessive spasticity
Other pathologies (e.g., fracture, arthritis)
Social support (too much or too little)
Intrinsic motivation
Cognitive ability
– Rarely used to used 50% pre-stroke
Reasons to consider incorporating outcome measures
in today’s rehab environment:
•
•
•
• Non-standardized evaluation tools
“Right decision, wrong decision, the worst
decision is indecision: Methods for choosing
outcome measures”
Sarah Blanton, DPT, NCS
•
•
•
•
•
•
19 July 2007
Why do you (or don’t you) use standardized
evaluation tools?
•
Demonstrate objective reasoning to increase length of stay/justification for more therapy visits
Demonstrate need for patient to receive additional treatments
Obtain objective information for differential diagnosis/referral = ie, screening for depression or cognitive
neuropsych issues
Program performance / Quality improvement
Monitor effectiveness of a treatment approach
One way to continue to work on clinical quality goals despite the oppressive and often depressing
healthcare environment today
Monitor patient performance across continuum from inpatient to outpatient
Feedback to demonstrate areas of improvement to patient to facilitate self-efficacy
Objective reasoning for the team to understand your decisions regarding supervision/safety issues or to
physician for particular treatment recommendations or to family for specific supervision, or equipment
recommendations
Formalized movement analysis
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11/29/2010
Motor Activity Log
• Using the Motor Activity Log as a clinical tool
to explore the patient’s environment and
ongoing progress
Variations in application of CIMT
Timing of administration
– Acute/Subacute/Chronic
– Clinic vs. Home-based
Wearing mitt
–
–
–
–
Forced use
90% waking hrs (“signature CIMT/ExCITE”)
mCIMT – 5 hrs/day
Distributed CIMT – 9.5 hrs/day
Intensity of practice
– ExCITE: 6 hrs/day, 5 days/wk for 2 wks
– mCIMT: 30 min/day, 3 days/wk for 10 wks
– Distributed CIT: 3 hrs/day for 20 days
• Decreased total time to spend with our patients
– Home Exercise Program
– “Turn your home into a gymnasium”
• Kitchen – wipe counter, open fridge, set table, sweep/mop floor,
put away groceries, cook, open/close lids, EAT!
• Bedroom – light switch, make bed, put clothes away
• Den – write letter, use remote, dust furniture, clean windows,
vacuum
• Car – open door, turn radio dial, fasten seat belt
• Laundry - sort, wash, dry, fold clothes
• Study - write letter, computer, games (cards, scrabble, checkers,
etc.)
• Decreased intensity (one-on-one tx sessions)
– Groups (Leung, Ng, & Fong, 2009)
– Coordination with other disciplines:
•
•
•
•
•
•
•
Occupational Therapy
Physical Therapy
Speech Therapy
Recreational Therapy
Nursing
Aides
Others?
http://www.homehealthohio.org/sk
illed-homecare/images/occupationaltherapy.jpg
http://www.gardensofrich
ardson.com/images/inset
photo_09.jpg
Type of practice
– Shaping (adaptive task practice)
– Traditional therapy
http://currentsocial.com/wpcontent/uploads/2010/05/speech_therapy.jpg
http://cdn11.g5search.com/
assets/9024/nurse-andpatient-atbedside.jpg?1256320547
http://wesleymc.com/dotAs
set/a81ed9ae-8ad0-4c3088e4-894e638a1efb.jpg
www.aotf.org
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11/29/2010
CIMT – Collaboration of Care
Home based forced use protocol
Stroke is a “family disease”
Pt and family members can be instructed in home program that
consists of the following:
Visser-Meily, 2006
Rehabilitation should be a family – centered approach
Family members strengths and needs are considered
throughout each phase of the rehabilitation process.
Family plays a central role in terms of assessments,
interventions and outcomes.
A recent study indicated that only 4-20% of caregivers
were involved in establishing the patient’s rehabilitation
goals.





Donning/doffing mitt
Behavior contract
Home diary to record hours of mitt use, activities
Individualized home program to attempt while using mitt
Incorporate self-assessment – MAL, evaluate success in performing
functional goals, adhering to wearing mitt / exercising, attempting novel
tasks
Follow up phone calls made to encourage mitt use and
address any concerns regarding home program
J. Monaghan, 2005
• Not immediate feedback from therapist
– Family / Social support education
– Work on patient self efficacy
• “Solving problems” as a key component to developing
motor skills
– One-on-one CIMT as a training/learning period
• Training – teaching something specific
• Learning – being able to generalize
Confidence building and
Empowerment
• Active collaboration
• Structured participant problem solving
• Opportunities for ongoing, self-assessment of
performance
– “Piano lessons” model
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11/29/2010
Self Assessment of Perceived Self
Efficacy
• Please name one thing that you wanted to be able to do (before
beginning ExCITE participation) with your weaker arm that you
now can do.
• Please name one thing that you wanted to be able to do (before
beginning ExCITE participation) with your weaker arm that you
still cannot do.
• Decreased focus – other things are going on in
the patient’s life
• Decreased follow up of patient (may not be
able to see patient daily)
– Collaborative goal setting
– Limits accountability
• Remote technologies (Page & Levine, 2007)
• Accelerometer
• Transfer package
– Behavior contract
– Home diary
– Home exercise program
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11/29/2010
Developing a CIMT program
• Delivery?
– Individual vs. Group
– Home vs Clinic
– Time (acute vs. inpatient vs. outpatient)
CIMT – Options for modes of delivery
• Outpatient - Single session
• Coordination with other interventions?
– Biofeedback, e-stim, resistance training, Botox, robotics,
Saebo-flex, traditional therapy, etc.
• Coordination with other disciplines?
– OT, PT, ST, RT, nursing, etc.
• Financial costs to patient/clinic?
• Patient flow – Therapist productivity?
SHOULD BE BASED UPON INDIVIDUAL NEED
•
Outpatient - Single session
Screen
– Can be phone screen or brief physical screen
– Determine appropriateness for CIMT
– Give patient “preparation homework” for first session – list of goals, tasks for
practice at home, times a mitt will be worn
• Session 1
•
– Evaluation – physical assessment, WMFT, CAMT, MAL, SIS
– Review home diary / behavior contract; determine therapeutic activities
Midterm phone conversation to assess status, problem-solve difficult tasks,
modification/progression of tx
o Remote technologies (Page & Levine, 2007)
• Session II (2-3 weeks later – depending upon patient)
• Outpatient – Multiple sessions
• Intensive CIMT clinic
Traditional delivery of 4-6 hr/day x 2-3 weeks
• Screen
Outpatient– Multiple sessions
– Therapist and/or CIMT clinic manager
• Evaluation
– Outcome measures
– Review behavior contract
– Review home diary
• Daily sessions
–
–
–
–
Use of adaptive task practice incorporated in treatment sessions
Review of home diary/home program
Modification of home program as sessions progress
Interdisciplinary – OT, PT, ST, RT, nursing (as
appropriate)
– Post evaluation – physical assessment, WMFT, CAMT, Exit Interview
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11/29/2010
Intensive CIMT clinic
Intensive CIMT clinic
• Phone Screen
– Cursory assessment of movement for appropriateness of CIMT
– Instruct patient to identify goals for therapy; determine times he/she can wear
the restraint; how family may assist during the process
– Resources – monetary, socially/familial, transportation, time, etc.
• Physical Screen
–
–
–
–
Should be required before accepting into program
Consider role of family, strongly encourage “family decision”
Consider – “IS THIS THE MOST EFFECTIVE USE OF THE PATIENT’S RESOURCES?”
Patient should arrive prepared to discuss specific therapy goals, behavior
contract
In Summary –
Considerations in Designing a CIMT Program
• Screening
– “Is this the right program for your client?”
•
•
•
•
•
•
Establish safety
Complete behavioral contract
Establish scheduling
Discuss upkeep of logs (home diary, home practice)
Identify areas most meaningful to the client
Practice schedule
– “What works best for your patient and your facility?”
• Follow-up: client’s self-efficacy
• Evaluation
– Essential to monitor efficacy of program
– Strongly encourage 1-3 month follow-up evaluation
• Training schedule
– Consider traditional, mCIMT, distributed CIMT training schedules
– Modify as necessary and appropriate to patient
needs/resources/stamina
– Would “booster sessions” help?
– Consider options of “camps” to decrease costs and utilize benefits
of group therapy
Future considerations:
CIMT and other interventions
•
•
•
•
•
•
Robotic-assistive therapy
Telerehabilitation
Virtual reality
Mental imagery
Pharmaceutical interventions
Cortical stimulation
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11/29/2010
Accelerated Skill Acquisition
Program (ASAP)
• Skill – motor learning and selfmanagement
• Capacity – impairment mitigation
• Motivation – intrinsic drive
http://www.corbisimages.com/images/67/59FBD8AAB735-4138-88A6-C8EC755B7582/42-20330142.jpg
Wolf & Winstein, “Intensive Physical Therapeutic
Approaches to Stroke Recovery”, in Nudo & Cramer,
Eds. Brain Repair after Stroke
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11/29/2010
Acknowledgments and Thank you to
Steven L. Wolf, Ph.D., PT, FAPTA, FAHA,
and Sarah Blanton, DPT, NCS
Final Thoughts
Evidence based practice
• A fundamental connection for the future of
neurorehabilitation
• It is not likely that any single approach will be
as effective as a combination of interventions.
Stein, 1995
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05/12/2010

Disclosure: No conflicts to report 

Objective: to inspire informed decisions f
during intervention design and delivery ...
no matter where you practice on the continuum of care.

Public awareness and patient education Prevention of stroke
Hyperacute stroke management
Acute inpatient stroke care*
k
Stroke rehabilitation and community reintegration*
Selected topics in stroke management*
Diane MacKenzie OTReg(NS), MA(Ed)



Evidence based practice (EBP) reminder
Review influences of interprofessional (IP) and shared decision making (SDM)
Hands on decision‐making practice!
d
d
k
 Tap into your knowledge & experience, all the great things you have learned today, and consider how to make IP shared decision‐making work in practice!
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10.
Organized stroke care (subacute stroke rehabilitation units)
Initial assessment performed by clinicians experienced in stroke
Timely access to specialized, interdisciplinary stroke rehabilitation
Timely access to appropriate levels of rehabilitation intensity for stroke survivors
Stroke rehabilitation support provided to caregivers
Long‐term rehabilitation services widely available in nursing and continuing care facilities and in outpatient and community programs
Optimization of strategies to prevent the recurrence of stroke
Outcome data for stroke rehabilitation required
Definition, dissemination, and implementation of best practices
Ongoing monitoring and evaluation
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www.canadianstrokestrategy.ca
www.heartandstroke.ca
www.canadianstrokenetwork.ca
www.strokeengine.ca
www.ebrsr.com
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2.
3.
4.
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8.
9.
10.
A Patient’s Guide to Canadian Best Practice Recommendations for Stroke Care
Moving beyond discipline specific ‐ toward interprofessional and shared
Use it or lose it
Use it and improve it
Specificity
Repetition matters
Intensity matters
Time matters
Salience matters
Age matters
Transference
Interference

Consensus

Majority Rules

Minority Rules

Expert

Consultation

Command
Pg S227
 through discussion the group arrives at a decision that all can live with
 after discussion a vote is taken to determine the decision
 subset of the larger group charged with responsibility for making a decision
 an individual deemed to have specialized expertise makes the decision
 process to formally solicit input although the final decision is made by one person or a subgroup
 a person with authority makes a decision potentially without input from others
http://www.gov.ns.ca/health/primaryhealthcare/bbtt.asp 
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What components of care require decision?
What kind of decision has to be made?
Is recovery considered?
Who contributes to the decision?
h
b
h d
Who prioritizes the contributing information?
Is the person/family information considered?
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What guides your current practice?
How do you seek evidence for assessments and interventions?
Are you on an interprofessional team?
f
l
How are team decisions made?
How ‘involved’ is the client and family with the decisions?
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05/12/2010


1/3 of therapists in study rarely use research evidence in clinical decision‐making
Significantly associated with research use
Challenge to increasing best practice:
 Gap due to lack of evidence seekers
 Team member traits
 Academic preparation in EBP
 Seekers
 EBP self‐efficacy
 Receptives
 Belief that research findings are useful
 Pragmatists
 Research participation

Best practice not routinely used
 Traditionalists 
Need to tailor KT strategies to traits

Proposal
 Examine internal & external factors influencing  No protected work time for appraisal
 Lack of confidence & skills for interpretation, synthesis and application

readiness to adopt best practice
 Assess impact of e‐collaborative platform for KTA

across disciplines and organisations in accelerating implementation of best practices along the continuum of care, and how e‐technologies influence access, sharing, creation, and application of knowledge.”
 Standardized presentation
Moving beyond discipline decision‐making toward inclusion of interprofessional and client/family perspectives
P j t h
Project hopes:
 “enhance our understanding of collaborative work Interactive e‐learning may be relevant solution

Best practice across continuum to include:
 family related problem identification
 Standardized assessments & interventions

Best practices including family‐related Best practices including family
related interventions reduce family stress, illness and institutionalization

Results ‐ indicate low family‐related focus post‐
stroke for the 3 disciplines studied
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05/12/2010
Shared decision‐making:
 Need innovative and wide ranging strategies
 Diverse clients
 Interprofessional teams
 Range of contexts and health services

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Not one single solution
Requires substantial change to practice for implementation of EBM and SDM
Evidence Based Practice (EBP)
Shared Decision Making (SDM)
Interprofessional teams (IP)
Perceptions:
 56‐68% information was provided re illness
 46‐53% no information provided about care, medication, rehabilitation, support.  ~80% perceived no participation at all in goals and needs.
Relevance:
 Strategies required for family involvement and shared decision‐making for discharge

3 level model
 Individual (micro)
 Healthcare team (meso)
 Health care system / social / global (macro)
How do these influence our clinical decision‐making process?

Information exchange  Interprofessional and client collaboration
 Sharing knowledge
 Common understanding
 Shared decision‐making
Caseload creation, shared decision‐making and implementation simulation
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“Although patients who are involved in decision making about their health have better outcomes, healthcare professionals often do not involve them in these decisions”
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Suggestions for research could better evaluate healthcare professionals involving patients in the process of making decisions about their health so that we can understand this better in the future.
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Printed educational materials
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Client Creation – Template A
 Create a client from your experience and  may improve process outcomes ... but not discipline knowledge
necessarily client outcomes!
 Caseload Discussion ‐
Caseload Discussion Participant caseloads will be clients created from template A
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Shared Decision Making – Template B
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Service Implementation Plan – Template C
 Work through each client’s SDM form
 Be creative  plan how to implement the SDM IP EBP!
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THANK YOU Alberta Provincial Stroke Strategy (APSS) !
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Légaré, F., Stacey, S., Pouliot, S., Gauvin, F., Desroches, S., Kryworuchko, J., Dunn, S., Elwyn, G. Frosch, D., Gagnon, M., Harrison, M.B., Pluye, P., & Graham, I.D. (2010). Interprofessionalism and shared decision‐making in primary care: a stepwise approach towards a new model. Journal of Interprofessional Care, Early Online, 1–8. DOI: 10.3109/13561820.2010.490502
Légaré F, Ratté S, Stacey D, Kryworuchko J, Gravel K, Graham ID, Turcotte S. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews 2010, Issue 5. h lh
f i
l C h
D b f S
i R i
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Art. No.: CD006732.DOI: 10.1002/14651858.CD006732.pub2.
Lindsay P, Bayley M, Hellings C, Hill M, Woodbury E, Phillips S. Canadian Stroke Strategy Best Practices and Standards Writing Group on behalf of the Canadian Stroke Strategy, a joint initiative of the Canadian Stroke Network and the Heart and Stroke Foundation of Canada Can Med Assoc J. 2008;179:S1–S25.
Lindsay P, Bayley M, McDonald A, Graham ID, Warner G, Phillips S: Toward a more effective approach to stroke: Canadian Best Practice Recommendations for Stroke Care. CMAJ 2008, 178(11):1418‐1425.
Menon, A., Korner Bitensky, N., & Straus, S. (2009). Best practise use in stroke rehabilitation: From trials & tribulations to solutions! Disability and Rehabilitation
32(8): 646–649.
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Almborg, A.H., Ulander, K., Thulin, A., & Berg, S. (2009). Discharge planning of stroke patients: the relatives' perceptions of participation. J Clin Nurs, Mar, 18(6), 857‐65.
Barratt, A. (2008). Evidence Based Medicine and Shared Decision Making: The challenge of getting both evidence and preferences into health care. Patient Education and Counseling 73, 407–412. 10.1016/j.pec.2008.07.054
Bovend'Eerdt, TJH, Botell, R.E. & Wade, D.T. (2009) Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide. Clin Rehabil April l d hi i l i
li i l id Cli R h bil A il vol. 23 no. 4 352‐361
Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, Katz RC, Lamberty K, Reker D: Management of Adult Stroke Rehabilitation Care: a clinical practice guideline. Stroke 2005, 36(9):e100‐143.
Farmer AP, Légaré F, Turcot L, Grimshaw J, Harvey E, McGowan JL, Wolf F. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004398. DOI: 10.1002/14651858.CD004398.pub2. Kleim, J.A. & Jones, T.A. (2008). Principles of experience‐dependent neural plasticity: implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, Vol. 51, S225–S239.
Poissant, L., Ahmed, S., Riopelle, R.J., Rochette, A., Lefebvre, H. & Radcliffe‐Branch, D. (2010). Synergizing expectation and execution for stroke communities of practice innovations. Implement Sci. Jun 8;5:44.
Rochette, A., Korner Bitensky, N., & Desrosiers, J. (2007). Actual p
p
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versus best practise for families post‐stroke according to three rehabilitation disciplines. J Rehabil Med, 39, 513‐519. doi: 10.2340/16501977‐0082 Rochette, A., Korner Bitensky, N., & Thams, A. (2009). Changing clinicians’ habits: Is this the hidden challenge to increasing best practices? Disability & Rehabilitation, 31(21): 1790–1794. DOI: 10.1080/09638280902803773 Salbach, N.M, Guilcher, S.J.T., Jaglal, S.B., & Davis, D.A. (2010). Determinants of research use in clinical decision making among physical therapists providing services post‐stroke: a cross‐
sectional study. Implementation Science 2010, 5:77.
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Clinical decision‐making through the continuum Session EXCERCISES to make the shared decision‐making process explicit. Template A – Client Creation Client Description: ________________________________ Age:______________ Time since onset: _____________________________ Location of Practice on Care Continuum: _______________________________________ Average Length of Stay: _____________________ Issues
Priorities
EBP Intervention
Intervention Delivery (Dosage)
Template B – Shared Decision‐Making Location of Practice on Care Continuum: _______________________________________ Average Length of Stay: _____________________ Client: ____________________________ Priorities
Issues
EBP Intervention (s)
Dosage/Intensity
Client & Family Centered
Preferences
Discipline(s)
Program Delivery
MacKenzie 2010 Facilitators
Barriers
1 Clinical decision‐making through the continuum Session EXCERCISES to make the shared decision‐making process explicit. Template C – Service Implementation Plan Location of Practice on Care Continuum: _______________________________________ Average Length of Stay: _____________________ Delivery Methods: individual, group, community, self‐directed, web‐based, etc. Time 0100 ‐ 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 ‐
2400 Monday Tuesday
MacKenzie 2010 Wednesday
Thursday Friday
Saturday
Sunday
2

Handouts Part 2 - Alberta Provincial Stroke Strategy

Transcription

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