Title: Collaborative Evaluation of Rehabilitation in Stroke across Europe
1Collaborative 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
3CERISE-project
4Flow of the study
6 M
2 M
4 M
CVA
Inpatient period
Months post-stroke
5Overview
-
- 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
6Overview
- 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
7Overview
- 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
8Motor and functional recovery
- Motor and functional recovery until 6 months
after stroke between four European rehabilitation
centres
9Patients 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)
10Inclusion 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
11Methods
532 stroke patients
BE 127
UK 135
CH 135
DE 135
12Evaluations
- 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)
13Statistical 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
16Pair 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 18Summary
- 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
19Use of time
- Use of time by stroke patients during inpatient
rehabilitation between four European
rehabilitation centres
20Use 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
21Use of time
- Generalized estimating equation model (GEE),
controlling for - dependency of the data
- differences in patient groups (case-mix)
- multiple comparison
22Absolute time in therapeutic activities Between
7.00 am and 5.00 pm
significant difference after correction for
case-mix
23Time available per patient per week per
professional group (in hours)
24Summary
- 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
25Content 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
26Methods
- 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
28Summary
- 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
29Use 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)
30Use 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
31Use of time (OT PT)
32Use of time (OT PT)
- Multivariate analyses
- activities on stroke patients (N 13 349)
- negative binomial regression model
- Two comparisons
- OT vs PT
- between centres
33Use 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)
34Use of time (OT PT)
35Use 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
36Summary
- 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
37Overall conclusion
more formal management
38Socio-economic variables
- Aim
- to examine the impact of the socio-economic
status on motor and functional recovery during
inpatient rehabilitation and after discharge
39Socio-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
40Socio-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
41Socio-economic variables
Barthel Index
RMA-arm
Education
Equivalent income
42Socio-economic variables
43Socio-economic variables
44Socio-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
45General conclusion
- Recommendations for health care policy
- Non-clinical aspects to be incorporated in
evaluation of rehabilitation programs - Socioeconomic aspects in stroke rehabilitation
46General conclusion
- Recommendations for future research
- Contextualisation of services in outcome
comparison - Socioeconomic aspects in case-mix
- Documentation of follow-up services
47Anxiety and depression
- To determine the prevalence of post-stroke
anxiety and depression - To explore the time course of post-stroke anxiety
and depression
48Anxiety 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
49Time 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
50Composition 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
52Many 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