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Collaborative Evaluation of Rehabilitation in Stroke across Europe

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Title: Collaborative Evaluation of Rehabilitation in Stroke across Europe


1
Collaborative Evaluation of Rehabilitation in
Stroke across Europe
European commission Fifth framework Quality Of
Life Key action 6.4 The ageing population and
their disabilities Sekretariat für Bildung und
Forschung
2
  • Components of inpatient stroke rehabilitation
    crucial for patients outcome not well known
  • ?
  • Longitudinal studies comparing stroke care and
    recovery patterns across European countries
  • ?
  • Collaborative Evaluation of Rehabilitation in
    Stroke across Europe

3
CERISE-project
4
Flow of the study
6 M
2 M
4 M
CVA

Inpatient period
Months post-stroke
5
Overview
  • Study 1 Motor and functional recovery after
    stroke
  • Stroke 2007382101-2107
  • Study 2 Use of time by stroke patients
  • Stroke 2005361977-1983
  • Study 3 Content of PT and OT
  • Stroke 2006371483-1489
  • Study 4 Task characteristics of OT and PT
  • Disability and Rehabilitation 2006281417-1424

6
Overview
  • Study 5 The effect of socio-economic status on
    recovery
  • J Neurol Neurosurg Psychiatry 200778593-599
  • Study 6 Anxiety and depression after stroke
  • Disabil Rehabil, 2008 In press

7
Overview
  • Study 7 Comparative study on admission criteria
    to SRUs
  • J Rehabil Med 2006 3921-26
  • Study 8 Comparative study on follow-up services
    after inpatient stay
  • In preparation

8
Motor and functional recovery
  • Motor and functional recovery until 6 months
    after stroke between four European rehabilitation
    centres

9
Patients selection
  • 532 consecutive stroke patients
  • 4 rehabilitation centres
  • University Hospital Pellenberg (Belgium)
  • City Hospital and Queens Medical Centre (UK)
  • RehaClinic Zurzach (Switzerland)
  • Fachklinik Herzogenaurach (Germany)

10
Inclusion criteria
  • first ever stroke
  • age between 40 and 85 years
  • motor impairment on admission (RMA)
  • admitted lt 6 weeks after stroke
  • pre-stroke Barthel Index gt50
  • no other neurological disorders
  • informed consent

11
Methods
532 stroke patients
BE 127
UK 135
CH 135
DE 135
12
Evaluations
  • Demographic and prognostic data
  • on admission to the centre
  • Motor and functional recovery
  • on admission, at 2, 4 and 6 months after stroke
  • Rivermead Motor Assessment (RMA)
  • Barthel ADL Index (BI)
  • at 2, 4 and 6 months after stroke
  • Nottingham Extended Activities of Daily Living
    (NEADL)

13
Statistical analysis
  • Comparison prognostic data Chi², ANOVA, Kruskal
    Wallis tests
  • On admission
  • age older in UK CH
  • gender more men in DE
  • TSOA shorter in UK
  • urinary incontinence more in BE UK
  • swallowing problems more in UK
  • dysarthria more in BE
  • dysphasia more in CH
  • initial BI lower in BE UK
  • initial RMA-GF lower in BE UK

correction for case mix
14
  • Comparison recovery patterns random effects
    ordinal logistic model, controlling for
  • differences between centres in patient groups
    (case-mix)
  • different TSOA
  • multiple comparison
  • ? RMA-GF, BI and NEADL division in classes
  • RMA-GF five classes 0-2, 3-5, 6-7, 8-9,
    10-13
  • BI five classes 0-20, 25-40, 45-60,
    65-80, 85-100
  • NEADL six classes 0-2, 3-5, 6-8, 9-11,
    12-16, 17-22

15
  • Odds ratio (OR) chance to stay in lower classes
    compared between 2 centres
  • OR at different time points (t1, t2)

OR (t2)
for centre 1 versus centre 2 rate of change in
odds ratio in time
OR (t1)
1) change of odd ratio in time 2) different
change between centres
lt1 patients in centre 1 have less chance to stay
in lower classes vs patients in centre 2 gt1
patients in centre 1 have more chance to stay in
lower classes vs patients in centre 2
16
Pair wise comparisons of the rate of change of
odds ratio over time (95 confidence limits)
between centers for RMA-GF, and BI and NEADL
BE vs DE
CH vs DE
CH vs BE
UK vs BE
UK vs DE
CH vs UK
17
  • RMA-LT NS
  • RMA-A NS

18
Summary
  • Motor and functional recovery better in German
    and Swiss centers versus UK centre respectively
    more therapy
  • Exception recovery Barthel Index better in UK vs
    German centre
  • 25 of German patients score gt85/100
  • UK patients moderate on admission
  • UK early discharge ? independence in ADL
  • UK high input of nursing care

19
Use of time
  • Use of time by stroke patients during inpatient
    rehabilitation between four European
    rehabilitation centres

20
Use of time
  • 60 stroke patients in each centre
  • observations at 10-minute intervals activity,
    location and interaction
  • observations from 7.00am till 10.00pm
  • equally distributed over the 5 week days

21
Use of time
  • Generalized estimating equation model (GEE),
    controlling for
  • dependency of the data
  • differences in patient groups (case-mix)
  • multiple comparison

22
Absolute time in therapeutic activities Between
7.00 am and 5.00 pm
significant difference after correction for
case-mix
23
Time available per patient per week per
professional group (in hours)
24
Summary
  • Study 1 motor and functional recovery is
    respectively better in German and Swiss centres
    compared to UK centre, but BI improved more in UK
    compared to DE
  • Study 2 significantly less therapy time in UK
    centre compared to other centres

25
Content of OT and PT
  • to compare the content of PT and OT
  • to compare the content of individual PT and OT
    sessions for stroke patients between centres

develop a reliable scoring list
26
Methods
  • scoring list of 12 therapeutic categories
  • ambulatory activities - lying activities
  • selective movements - ADL
  • mobilisation - leisure activities
  • sitting activities - domestic activities
  • standing activities - sensory training
  • transfers - miscellaneous
  • inter-rater reliability fair to high
    (ICC0.71-1.00)
  • ? list was used to score the content of 15 PT-and
    15 OT tapes in each centre

27




5 Mild
5 Mild


15 OT sessions

-

5 Moderate





5 Severe


30 therapy sessions
Centre



5 Mild




15 PT sessions

5 Moderate





5 Severe



28
Summary
  • PT and OT are distinct professions with clear
    demarcation of roles
  • Content of each therapeutic discipline was
    consistent between centres
  • Differences in stroke rehabilitation outcome
    could not be attributed to differences in content
    of PT and OT

29
Use of time (OT PT)
  • Aim
  • compare time allocated to
  • therapeutic activities (TA)
  • non therapeutic activities (NTA)
  • compare time OT and PT
  • in-between different units (SRU)

30
Use of time (OT PT)
  • Method
  • Diary
  • recording activities in 15 minutes time slots two
    weeks
  • Labelled
  • activity
  • number of patients
  • number of stroke patients
  • involvement of other people
  • location
  • frequency of each activity

31
Use of time (OT PT)
32
Use of time (OT PT)
  • Multivariate analyses
  • activities on stroke patients (N 13 349)
  • negative binomial regression model
  • Two comparisons
  • OT vs PT
  • between centres

33
Use of time (OT PT)
  • Results
  • 146 diaries PT 95 OT 51
  • N 20 421 observed and labeled periods
  • (Unit of analysis periods of 15 minutes)

34
Use of time (OT PT)
35
Use of time (OT PT)
TA vs N-TA
PRA vs N-PRA
significant differences on TA vs NTA for OT PRA
Patient co-ordination tasks TA ? no differences
between centres
36
Summary
  • German and Swiss centres rehabilitation
    programmes strictly timed ? Belgium and UK
    centres ad hoc organisation
  • German PTs and OTs spent 66.1 and 63.3, resp.
    on direct patient care ? UK 46 and 33

37
Overall conclusion
more formal management
38
Socio-economic variables
  • Aim
  • to examine the impact of the socio-economic
    status on motor and functional recovery during
    inpatient rehabilitation and after discharge

39
Socio-economic variables
  • Method
  • Educational level
  • the international standard classification of
    education (ISCED 97, WHO)
  • low below or equal to lower secondary level
  • high upper secondary level or higher
  • Equivalent income
  • the modified OECD scale
  • three categories for equivalent income (low,
    moderate or high) based on the respective median
    national equivalent income for the 4 countries

40
Socio-economic variables
  • Analyses
  • Descriptive statistics
  • patients characteristics on admission to the
    stroke rehabilitation unit
  • Functional and motor outcome compared between SES
    groups
  • Association between SES and motor and functional
    recovery
  • multivariate ordinal logistic regression models
  • two time-periods
  • the period of inpatient rehabilitation
  • the period between discharge and 6 months
    post-stroke

41
Socio-economic variables
Barthel Index
RMA-arm
Education
Equivalent income
42
Socio-economic variables
43
Socio-economic variables
44
Socio-economic variables
  • Conclusion
  • Education as the cultural dimension of SES
    seems to be of particular importance during the
    inpatient rehabilitation period
  • Equivalent income as the material indicator of
    SES seems to be of particular importance between
    discharge and 6 months post-stroke

45
General conclusion
  • Recommendations for health care policy
  • Non-clinical aspects to be incorporated in
    evaluation of rehabilitation programs
  • Socioeconomic aspects in stroke rehabilitation

46
General conclusion
  • Recommendations for future research
  • Contextualisation of services in outcome
    comparison
  • Socioeconomic aspects in case-mix
  • Documentation of follow-up services

47
Anxiety and depression
  • To determine the prevalence of post-stroke
    anxiety and depression
  • To explore the time course of post-stroke anxiety
    and depression

48
Anxiety and depression
  • Hospital Anxiety and Depression Scale at 2, 4,
    and 6 months after stroke 14 questions
  • HADS-A measures symptoms of anxiety
  • HADS-D measures symptoms of depression
  • score 8 on HADS-A anxiety disorder
  • score 8 on HADS-D depressive disorder

49
Time course of prevalence of anxiety and
depression (complete cases n435)
Anxiety  (HADS-A 8) Depression (HADS-D 8)
Anxiety  Cochran-Q Q2.7 p0.26 Depression
Cochran-Q Q5.2 p0.07
50
Composition of number of patients with anxiety
(HADS-Agt7) at two, four and six months after
stroke (total n435) and the associated severity
(median IQR)
Similar pattern for depression
51
  • Other patients are anxious/depressed at different
    time points half of the patients with
    anxiety/depression at two months have recovered
    at six months
  • Patients who remain anxious/depressed throughout
    the sub acute period suffer from more severe
    affective disorders that do not have the tendency
    to get milder

52
Many people contributed
  • British team N. Lincoln,B. Smith L. Connell
  • Swiss team W. Jenni, B. Schuback C. Kaske
  • German team W. Schupp, N. Brinkmann J. Jurkat
  • Belgian team
  • L. De Wit, K. Putman, I.Baert, H. Feys, W. De
    Weerdt
  • F. Louckx, M. Leys
  • E. Dejaeger, H. Beyens,
  • E. Lesaffre, A Komarek, K. Bogaerts, A-M De
    Meyer

53
  • Use of time by stroke patients. A comparison of 4
    European rehabilitation centres. Stroke
    2005361977-1983.
  • Stroke rehabilitation in Europe. What do
    physiotherapists and occupational therapists
    actually do? Stroke 2006341483-1489.
  • Motor and functional recovery after stroke. A
    comparison of four European rehabilitation
    centres. Stroke 2007382101-2107
  • Defining the content of individual PT and
    OTClinical Rehabilitation 200721450-459
  • The effect of socioeconomic status on functional
    and motor recovery after stroke a European
    multicenter study. J Neurol Neurosurg Psychiatry
    200778593-599
  • Use of time by physiotherapists and occupational
    therapists in a stroke rehabilitation unit a
    comparison between four European rehabilitation
    centres. Disabil Rehabil 2006281417-1424.
  • Inpatient stroke rehabilitation a comparative
    study of admission-criteria to stroke
    rehabilitation units in four European centres. J
    Rehabil Med 20073921-26
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