SWD

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SWD Part A
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Opportunities and Challenges in Stroke
Rehabilitation

• Sharon Wood Dauphinee PT PhD FCAHS
• School of Physical Occupational Therapy
• McGill University, Montreal, Canada
• New Brunswick Heart and Stroke Association April,
  29th 2011

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Objectives of the Presentation

• To describe and discuss current opportunities
  and challenges faced by health and rehabilitation
  professionals in caring for people with stroke
• To include contributions by other researchers
  funded by the Canadian Stroke Network

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My Belief

• Every health professional wants to deliver the
  best possible medical care and rehabilitation to
  his/her patients.
• Use of scientific knowledge sounds like a good
  approach.

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Not the Tradition

• In fact, the whole world of medicine has a long
  history of relying on what authoritarian figures
  have to say, or on anecdotal experiences, both of
  which run the danger of promoting treatments that
  are not effective, are costly and may yield less
  than optimal outcomes.
• Jutai Teasell, Topics in Stroke
  Rehabilitation, 1071-8, 2003
• Menon et al. J Rehabilitation Medicine 41
  1024-32, 2009

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Sometimes Not Intuitive!

• Who would have thought that a simple aspirin
  would be more effective in preventing strokes
  than a complicated surgical procedure, the
  extracranial-intracranial bypass operation? In a
  randomized controlled trial, the operation was
  shown to be ineffective and in some cases
  harmful.
• Hart et al. Arch Neurol
  57326, 2000
• The EC/IC Bypass Study Group, NEJM
  3131191, 1985

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Opportunity 1

• Scientific Evidence (Knowledge) is available to
  guide health professionals as to the current
  best practices (most effective practices) for
  people with stroke.

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Scientific Evidence and its Use in Clinical
Practice

• Applying hard evidence to practice settings
• Other elements entering clinical decisions

Point Evidence is only one element in a complex
set of relationships
PatientClinic-ian Factors
Evidence
Knowledge
Ethics
Clinical Decisions
Constraints
Davidoff, 1999, Mt Sinai J Med
Guidelines
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• Evidence-based practice (EBP) has emerged as
  a national priority in efforts to improve the
  quality of health care.
• Institute of Medicine Crossing the Quality
  Chasm A new health System for the 21st Century.
  Washington, DC, National Academy Press, 2001
• In Canada, early enthusiasm came from
  McMaster University.

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Scientific Evidence Supports Evidence Based
Practice

• Evidence Based Practice is an approach to
  decision making in which the clinician uses his
  or her clinical experience and judgment, and the
  best evidence available, in consultation with the
  patient, to decide upon the treatment option that
  suits the patient.

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Challenge 1

• Obtain and maintain up to date knowledge given
  current patient loads, other work requirements,
  home and/or family obligations as well as
  recreational and leisure activities.

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Obtaining Clinical Knowledge In the Past

• We asked a general question in a need to know
  fashion.
• In my 1st study I thought that I needed to find
  out what had been written about team care
  following stroke.

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Search for the EvidencePast Procedures

• Searched the relevant clinical literature
• Critically evaluated primary studies, or found a
  pre-appraised review and searched a few data
  bases -MEDLINE, CINAHL, PEDro, OT Seeker
• Integrated the evidence, our experience and
  knowledge and patient factors to judge the
  evidence and make and execute a decision about
  treatment.

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Judging the Evidence
We have to decide on the level of evidence.
Its very cloudy
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• Currently, we believe that a well built clinical
  question is the key to evidence-based
  decisions----

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What do we do?

• Ask the question we want to answer in a specific
  format.
• It is a question with four components
• Patient
• Intervention (new
  treatment)
• Comparison (old
  treatment)
• Outcome(s)

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Clinical Scenario

• You are a PT working in an institution that
  treats people with post acute stroke. One of your
  patients, who had a stroke 4 weeks ago, asked if
  acupuncture would help her recover more quickly.
  Her brother who lives in Hong Kong received
  acupuncture for his stroke 5 years ago and says
  that it was very helpful. Before answering her
  question, you decide to check the literature.

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Question - Example

• Does the addition of acupuncture to a traditional
  program of therapeutic exercises enhance the
  return of motor function or functional abilities
  in post acute stroke ?

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Components of the Question

• P - person with post-acute stroke
• I - acupuncture traditional exercises
• C - traditional exercises alone
• O - gross motor function
• - fine motor function
• - activities of daily living

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• Today, maintaining your knowledge level for
  treating people with stroke is actually easier
  than you think!
• Two sources of information
• 1. The Evidence Based Review
• 2. StrokEngine

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Information Source I

• Evidence-Based Review of Stroke
• Rehabilitation (E-BRSR) 13th ed.
  
• Last updated September, 2010
• Dr. R Teasell Parkwood Hospital University of
  Western Ontario
• Freely available at www.ebrsr.com

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History of Stroke Rehabilitation Evidence-Based
Review

• 2001 Dr. Teasel and colleagues in London, ON
  searched multiple data bases for stroke trials
  (1970-2001)
• Yield 2,500 abstracts of articles for review
• Two reviewers systematically extracted
  information from each randomized controlled trial
  (RCT) and used the PEDro Scale to evaluate the
  quality of the RCT

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PEDro Physiotherapy Evidence Database 1929 -
present

• Producer Centre for EB Physiotherapy, U Sydney
• Subject Randomized Controlled Trials with
  quality ratings using the PEDro scale
  PT systematic reviews Practice
  guidelines
• Size 5500 records
• Language mostly English
• Free on the Internet
• http//www.pedro.fhs.usyd.edu.au
  
• www.pedro.fhs.usyd.edu.au/FAQs/Scale/scalei
  tems.htm

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Study Evaluation Tool PEDro Scale (yes or
no)

• 1 random assignment to groups
• 2 concealed allocation
• 3 groups alike at baseline
• 4 blinding of subjects
• 5 blinding of treating personnel
• 6 blinding of assessors

• 7 85 of subjects have data on at least 1 key
  outcome
• 8 subjects received assigned treatment
• 9 results available for 1 key outcome
• 10 measures of variability available for 1 key
  outcome

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Levels of Evidence Assigned to Each Intervention

• 1a- Strong- supported by 1 meta-analysis
• 2 fair RCTs
• 1b- Moderate- supported by 1 RCT of fair
• quality
• 2- Limited- supported by 1 controlled trial
  with
• at least 10 subjects in each arm
• 3- Consensus- agreement by experts (group)
• 4- Conflicting- disagreement between RCTs

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E-BRSR Educational ModulesTeasel et al. 2010

• Principles of Stroke Rehabilitation
• Motor Recovery Post Stroke
• Cognitive Disorders Post Stroke
• Medical Complications
• Psychosocial Issues
• Secondary Prevention of Stroke

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Educational Modules- contd

• Clinical Assessment Tools
• Cognitive Disorders and Apraxia
• Perceptual Disorders
• Aphasia
• Dysphagia and Aspiration Post Stroke
• Nutritional Interventions

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Selected Findings

• Limited Evidence early admission to rehab
  directly results in better functional outcomes.
• Strong Evidence greater intensity of therapy
  results in modest improvements over the short
  term (1 to 6 months)
• Conflicting Evidence those with hemorrhagic
  rather than ischemic strokes have worse long term
  outcomes

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Selected Findings contd

• Moderate evidence functionally orientated rehab
  results in less incontinence than a Bobath
  approach
• Limited evidence physical activity reduces risk
  of stroke gt25
• Limited evidence light alcohol consumption (1-2
  drinks per day) reduces risk of ischemic stroke

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Selected Findings- contd

• Conflicting evidence Motor Learning is superior
  to Bobath approach for function.
• Moderate evidence massage reduces pain and
  anxiety post-stroke.
• Moderate evidence successful treatment of
  post-stroke depression reduces cognitive
  impairment.

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Information Source II StrokEngine

• (www.strokengine.ca)
• (www.strokengine-assess.ca)
• Nicol Korner Bitensky OT PhD

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StrokEngineMoving evidence-based stroke
rehabilitation into clinical practice

• Researchers
• Nicol Korner-Bitensky (PI), Anita Menon (co-PI),
  Mark Bayley, Daniel Bourbonnais, Johanne
  Desrosiers, Chantal Dumoulin, Pamela Duncan,
  Janice Eng, Lesley Fellows , Joyce Fung, Jeff
  Jutai, Aura Kagan, Francine Kaizer, Lorie Kloda,
  Mindy Levin, Rosemary Martino, Nancy E. Mayo,
  Stephen Page, Carol L. Richards, Annie Rochette,
  Nancy Salbach, Robert Teasell, Aliki Thomas,
  Sharon Wood-Dauphinee

www.strokengine.ca
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StrokEngine

• Interactive website with modules on stroke-
  related treatments
• Each module created through a systematic review
  of current literature
• Updated by ongoing review of new stroke-related
  studies
• Each module has 5 sections Patient/Family
  Clinician Quick Review Clinician In-depth
  Review Clinician How To Best Practices

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In Summary

• The challenges in obtaining up to date scientific
  information about best practices for treating
  people with stroke are fewer than you think!

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Opportunity 2

• Applying Evidence Based Knowledge in Clinical
  Practice

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What do You Know?

• You know your patients
• You know how to find the information.
• You know the strength of the evidence, generally,
  for people with stroke.
• You know the potential impact of the different
  interventions on patients.
• You have in-house knowledge to decide how
  difficult it will be to apply the various
  evidence recommendations in your setting.

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What do you do?

• Discuss with your team members
• Call on clinical experience and common sense, to
  integrate the evidence, the patients particular
  clinical circumstances as well as the patients
  preferences
• Apply the evidence to your decision making for
  your patient if appropriate!

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An Example

• You are considering whether or not circuit
  training would be appropriate for some of your
  patients with stroke.

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Applying Evidence to your Patient Questions to
Ask

• Were the study patients (in which circuit
  training worked) similar to your patient?
• Is the intervention realistic in your setting?
• Are the outcomes in line with your and your
  patients treatment goals?
• How big is the benefit in relation to the risk of
  an adverse event due to treatment?

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Applying Evidence contd

• Are there social or cultural factors that might
  affect suitability or acceptance?
• What are the wishes of the patient and/or the
  family ?