Best Practices In Stroke Rehabilitation The Us Experience 1 30 09

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Presentation on 02-16-09 at the Global Experts Exchange for Post-Stroke Disability, San Diego, CA

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  • Best Practices In Stroke Rehabilitation The Us Experience 1 30 09

    1. 1. BEST PRACTICES IN STROKE REHABILITATION: The US Experience Richard D. Zorowitz, M.D. Chairman and Associate Professor of PM&R
    2. 2. PHASES OF STROKE REHABILITATION Needs specific rehabilitation services Needs rehabilitation program Needs further recuperation before rehabilitation decision Too incapacitated for rehabilitation Acute inpatient rehabilitation Skilled nursing facility Home services Outpatient services Extended care facility
    3. 3. OUTLINE <ul><li>Define key elements that constitute acute and long-term post-stroke physical rehabilitation </li></ul><ul><li>Review latest evidence and guidelines to identify insights regarding the key factors that define optimal outcomes in post-stroke rehabilitation </li></ul><ul><li>Propose examples of best practice in acute and long-term post-stroke physical rehabilitation </li></ul><ul><li>Describe communication, education and unmet needs of stroke survivors and family caregivers </li></ul>
    4. 4. www.oqp.med.va.gov/cpg/
    5. 5. KEY POINTS <ul><li>Primary goals of rehabilitation </li></ul><ul><ul><li>Prevent complications </li></ul></ul><ul><ul><li>Minimize impairments </li></ul></ul><ul><ul><li>Maximize function </li></ul></ul><ul><li>Secondary prevention is fundamental to preventing stroke recurrence </li></ul>
    6. 6. KEY POINTS (CONT’D) <ul><li>Critical elements for optimizing post-stroke rehabilitation </li></ul><ul><ul><li>Early assessment with standardized evaluations and validated assessment tools </li></ul></ul><ul><ul><li>Early employment of evidence-based interventions relevant to individual patient needs </li></ul></ul><ul><ul><li>Patient access to an experienced multidisciplinary rehabilitation team </li></ul></ul><ul><ul><ul><li>Team utilization of community resources for community reintegration </li></ul></ul></ul><ul><ul><li>Ongoing medical management of risk factors and co-morbidities </li></ul></ul>
    7. 7. OUTLINE <ul><li>Define key elements that constitute acute and long-term post-stroke physical rehabilitation </li></ul><ul><li>Review latest evidence and guidelines to identify insights regarding the key factors that define optimal outcomes in post-stroke rehabilitation </li></ul><ul><li>Propose examples of best practice in acute and long-term post-stroke physical rehabilitation </li></ul><ul><li>Describe communication, education, and unmet needs of stroke survivors and family caregivers </li></ul>
    8. 9. BEST PRACTICES <ul><li>Therapies are the most effective when they are selected based on task-specificity (from principle of use-dependency ) </li></ul><ul><ul><li>Practice guidelines are often specific to a particular impairment or function (eg, upper limb vs lower limb impairments) </li></ul></ul><ul><li>Current practice guidelines are limited by the lack of evidence for specific interventions </li></ul><ul><ul><li>Absence of supporting data due to paucity of data and inadequately controlled studies </li></ul></ul>
    9. 10. Horn SD et al. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S101-S14.
    10. 11. Evidence for Specific Interventions (Cochrane Review) PT, physiotherapy; ADL, activity of daily living; OT, occupational therapy; EMG, electromyographic; EST, electrostimulation therapy. Study Impairment Therapy Findings Pollack A, et al. Cochrane Database Syst Rev. 2006;(4):CD001920 Physical functioning PT <ul><li>No single therapy was superior for improving leg strength, balance, walking, or ADLs </li></ul><ul><li>Mixed therapy was better than no treatment or placebo for improving physical function </li></ul>Legg LA, et al. Cochrane Database Syst Rev. 2006;(4):CD003585 ADLs OT <ul><li>Patients who received OT were more independent in ADLs and more likely to sustain benefit </li></ul><ul><li>More research is needed to understand the best delivery of OT (ie, what form, when to provide OT, intensity, and duration) </li></ul>Woodford H, et al. Cochrane Database Syst Rev. 2007;(2):CD004585 Motor function EMG biofeedback <ul><li>Limited evidence suggests a benefit of EMG biofeedback used in combination with standard PT; however, other studies found no effect </li></ul>Pomeroy VM, et al. C ochrane Database Syst Rev. 2006;(2):CD003241 Movement control, functional ability EST <ul><li>Limited evidence in favor of EST, although many studies demonstrated no discernible benefit of EST over placebo or other physical therapy </li></ul><ul><li>Results were inconclusive </li></ul>
    11. 12. Evidence for Specific Interventions (Cochrane Review) EM, electromechanical; PT, physiotherapy; ST, speech therapy. Study Impairment Therapy Findings Merholz J et al. Cochrane Database Syst Rev. 2007;(4):CD006185 Walking EM-assisted training <ul><li>Some evidence showing EM-assisted training in combination with standard PT improves walking </li></ul><ul><li>Not clear whether EM-assisted training should be included in routine rehabilitation, or when/how often it should be applied </li></ul>Moseley AM, et al. Cochrane Database Syst Rev. 2005;(2):CD002840 Walking Treadmill training <ul><li>Insufficient evidence to determine the effects of treadmill training </li></ul>Wu HM, et al. Cochrane Database Syst Rev. 2006;(3):CD004131 Stroke recovery Acupuncture <ul><li>Limited data provided inconclusive results </li></ul>Greener J, et al. Cochrane Database Syst Rev. 1999;(4):CD000425 Speech Formal vs informal ST <ul><li>No differences could be determined between formal and informal therapy </li></ul>
    12. 13. Evidence for Specific Interventions (Cochrane Review) ST, speech therapy; LT, language therapy; ADL, activity of daily living. Study Impairment Therapy Findings Sellars C, et al. Cochrane Database Syst Rev. 2005;(1):CD002088 Dysarthria ST, LT <ul><li>No large clinical trials have tested whether ST or LT is effective in dysarthria </li></ul>Nair RD, et al. Cochrane Database Syst Rev. 2007;(1):CD002293 Memory Cognitive therapy <ul><li>Little evidence to support the efficacy of cognitive therapy in restoring memory function </li></ul>Bowen A, Lincoln B. Cochrane Database Syst Rev. 2007;(1):CD003586 Unilateral spatial neglect Cognitive therapy <ul><li>Cognitive therapy is associated with improvements in some tasks (eg, finding visual targets) </li></ul><ul><li>Not clear whether cognitive therapy is able to help patients carry out meaningful ADLs or live independently </li></ul>Lincoln NB, et al. Cochrane Database Syst Rev. 2000;(4):CD002842 Attention deficits Cognitive therapy <ul><li>Cognitive training improves alertness and sustained attention </li></ul>
    13. 14. OUTLINE <ul><li>Define key elements that constitute acute and long-term post-stroke physical rehabilitation </li></ul><ul><li>Review latest evidence and guidelines to identify insights regarding the key factors that define optimal outcomes in post-stroke rehabilitation </li></ul><ul><li>Propose examples of best practice in acute and long-term post-stroke physical rehabilitation </li></ul><ul><li>Describe communication, education, and unmet needs of stroke survivors and family caregivers </li></ul>
    14. 16. CARE PATHWAYS <ul><li>Strong evidence indicates care pathways do not improve stroke rehabilitation outcomes </li></ul><ul><li>Moderate evidence indicates care pathways do not reduce hospital costs or decrease hospital lengths of stay </li></ul>
    15. 17. EARLY INTERVENTION <ul><li>Stroke patients should be admitted to stroke rehabilitation units as soon as medically stable (until results from randomized controlled trials determine otherwise) </li></ul><ul><li>Strong evidence indicates early mobilization (as a component of stroke unit care) is associated with improved outcomes </li></ul><ul><li>Limited evidence supports early admission to stroke rehabilitation directly results in improved functional outcomes </li></ul>
    16. 18. DURATION OF GAINS <ul><li>Patients achieve greater short-term and long-term functional improvements with rehabilitation in specialized stroke units compared with general medical units </li></ul><ul><li>Patients may continue to improve for up to one year </li></ul><ul><li>However, moderate evidence shows that functional gains decline after 5 years </li></ul>
    17. 19. EARLY SUPPORTED DISCHARGE <ul><li>Access to an interdisciplinary stroke rehabilitation team can reduce hospital stay for high-level stroke patients by approximately </li></ul><ul><li>1 week </li></ul><ul><li>Conflicting evidence exists with regard to the costs associated with home intervention versus usual care </li></ul><ul><li>It is not known whether survivors of moderate to severe stroke can be managed exclusively with early supported discharge programs </li></ul>
    18. 20. OUTPATIENT REHABILITATION <ul><li>Strong evidence shows that additional home-based rehabilitation does not result in improved functional outcomes when compared to routine care </li></ul><ul><li>Moderate evidence indicates that hospital-based outpatient rehabilitation improves short-term outcomes, but not long-term outcomes, compared with routine care </li></ul>
    19. 21. OUTPATIENT REHABILITATION <ul><li>It is unclear whether hospital-based or home-based outpatient rehabilitation therapies are superior </li></ul><ul><li>Limited evidence suggests that subgroups of stroke patients may benefit from different outpatient treatment approaches, for example: </li></ul><ul><ul><li>Day hospital services may reduce death and institutionalization in elderly, frail patients </li></ul></ul><ul><ul><li>Home-based outpatient therapy may improve function and quality of life in younger patients </li></ul></ul>
    20. 22. OUTLINE <ul><li>Define key elements that constitute acute and long-term post-stroke physical rehabilitation </li></ul><ul><li>Review latest evidence and guidelines to identify insights regarding the key factors that define optimal outcomes in post-stroke rehabilitation </li></ul><ul><li>Propose examples of best practice in acute and long-term post-stroke physical rehabilitation </li></ul><ul><li>Describe communication, education, and unmet needs of stroke survivors and family caregivers </li></ul>
    21. 24. EDUCATION <ul><li>Addresses needs of patients and caregivers </li></ul><ul><li>Accessing emergency care, if necessary </li></ul><ul><li>Adjustment to stroke </li></ul><ul><li>Availability of/access to community resources </li></ul><ul><li>Caregiver support </li></ul><ul><li>Advance directives </li></ul><ul><li>Communication with other care providers </li></ul><ul><li>Health risks </li></ul><ul><li>Home modifications/safety </li></ul><ul><li>Assistive devices </li></ul><ul><li>Medication </li></ul><ul><li>Specific healthcare procedures/techniques </li></ul><ul><li>Self-advocacy </li></ul><ul><li>Nutrition </li></ul><ul><li>Hydration </li></ul><ul><li>Prevention of new conditions/ worsening of existing conditions </li></ul><ul><li>Signs and symptoms of recurring stroke </li></ul>
    22. 25. EDUCATION (CONT’D) <ul><li>Medications </li></ul><ul><ul><li>Identification of appropriate medication </li></ul></ul><ul><ul><li>Administration </li></ul></ul><ul><ul><li>Indications/contraindications </li></ul></ul><ul><ul><li>Storage </li></ul></ul><ul><ul><li>Dispensing </li></ul></ul><ul><ul><li>Errors </li></ul></ul><ul><ul><li>Side effects </li></ul></ul>
    23. 26. <ul><li>Portable profile </li></ul><ul><ul><li>Advance directives </li></ul></ul><ul><ul><li>Allergies </li></ul></ul><ul><ul><li>Emergency contact information </li></ul></ul><ul><ul><li>Functional status </li></ul></ul><ul><ul><li>Hospital preference </li></ul></ul><ul><ul><li>Insurance information </li></ul></ul><ul><ul><li>Medical conditions/major surgeries </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><ul><li>Medication sensitivities </li></ul></ul></ul><ul><ul><ul><li>Current dosages </li></ul></ul></ul>COMMUNICATION
    24. 27. CONCLUSIONS <ul><li>Key elements that constitute acute and long-term post-stroke physical rehabilitation are general in nature </li></ul><ul><li>Evidence and guidelines for insights regarding the key factors that define optimal outcomes in post-stroke rehabilitation are still lacking </li></ul><ul><li>Examples of best practice in post-stroke acute and long-term physical rehabilitation are general in nature </li></ul><ul><li>Communication and education needs of stroke survivors and family caregivers are evolving </li></ul>

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