Taking Charge after Stroke (TaCAS) is an effective intervention for improving outcomes for people living in the community after a stroke. It aims to spark intrinsic motivation by putting the person with stroke "in the driving seat" and focusing on their dreams and goals beyond just the stroke. The TaCAS trial found Take Charge improved quality of life, independence, and participation at 6 and 12 months follow-up compared to usual care. It was effective with as few as one session and showed better results with two sessions. Take Charge is a low-cost, easy to deliver intervention that can change clinical practice by supporting better long-term stroke recovery outcomes through enhancing intrinsic motivation.
This workshop was presented at the Queensland Mining Industry Health and Safety Conference 2014 and presents progress on the Working Well Program and ways to support mental health in the workplace.
How can front-line professionals incorporate the emerging brain health ...SharpBrains
(Session held at the 2014 SharpBrains Virtual Summit; October 28-30th, 2014)
12:30-2pm. How can front-line professionals incorporate the emerging brain health toolkit to their practices?
- Elizabeth Frates, Director of Medical Student Education at the Institute of Lifestyle Medicine
- Dr. Catherine Madison, Director of the Ray Dolby Brain Health Center at California Pacific Medical Center
- Barbara Van Amburg, Chief Nursing Officer at Kaiser Permanente Redwood City
- Dr. Wendy Law, Clinical Neuropsychologist at Walter Reed National Military Medical Center
- Chair: Dr. Michael O’Donnell, Editor-In-Chief of the American Journal of Health Promotion
Learn more here:
http://sharpbrains.com/summit-2014/agenda/
Whole Health in Your Practice Day 1/3 MorningCristalyne Bell
Whole Health is part of collaborative effort by the Pacific Institute for Research and Evaluation, VA Office of Patient Care and Cultural Transformation, and University of Wisconsin Integrative Health Program to transform healthcare and help people live healthier, happier lives, and more purpose-driven lives.
Learn more: https://wholehealth.wisc.edu/courses-training/whole-health-in-your-practice/
From Burnout to Engagement: Strategies to Promote Physician Wellness and Work...Modern Healthcare
Slides from a Modern Healthcare presentation.
http://www.modernhealthcare.com/article/20150225/INFO/302259999/webinar-from-burnout-to-engagement-strategies-to-promote-physician
Faced with long hours, unrelenting administrative burdens and the pressure to treat patients quickly, a growing number of physicians are experiencing burnout, a condition characterized by loss of empathy, exhaustion, and a low sense of accomplishment. According to a Mayo Clinic survey from 2012, nearly one in two U.S physicians reported at least one symptom of burnout, up from 22% in 2001. For hospitals with stressed caregivers, the stakes are high. Burned out, dissatisfied physicians are far more likely to make medical errors and are less able to communicate effectively with patients and co-workers. They're also at a higher risk for substance abuse and are more likely to leave clinical practice altogether.
This workshop was presented at the Queensland Mining Industry Health and Safety Conference 2014 and presents progress on the Working Well Program and ways to support mental health in the workplace.
How can front-line professionals incorporate the emerging brain health ...SharpBrains
(Session held at the 2014 SharpBrains Virtual Summit; October 28-30th, 2014)
12:30-2pm. How can front-line professionals incorporate the emerging brain health toolkit to their practices?
- Elizabeth Frates, Director of Medical Student Education at the Institute of Lifestyle Medicine
- Dr. Catherine Madison, Director of the Ray Dolby Brain Health Center at California Pacific Medical Center
- Barbara Van Amburg, Chief Nursing Officer at Kaiser Permanente Redwood City
- Dr. Wendy Law, Clinical Neuropsychologist at Walter Reed National Military Medical Center
- Chair: Dr. Michael O’Donnell, Editor-In-Chief of the American Journal of Health Promotion
Learn more here:
http://sharpbrains.com/summit-2014/agenda/
Whole Health in Your Practice Day 1/3 MorningCristalyne Bell
Whole Health is part of collaborative effort by the Pacific Institute for Research and Evaluation, VA Office of Patient Care and Cultural Transformation, and University of Wisconsin Integrative Health Program to transform healthcare and help people live healthier, happier lives, and more purpose-driven lives.
Learn more: https://wholehealth.wisc.edu/courses-training/whole-health-in-your-practice/
From Burnout to Engagement: Strategies to Promote Physician Wellness and Work...Modern Healthcare
Slides from a Modern Healthcare presentation.
http://www.modernhealthcare.com/article/20150225/INFO/302259999/webinar-from-burnout-to-engagement-strategies-to-promote-physician
Faced with long hours, unrelenting administrative burdens and the pressure to treat patients quickly, a growing number of physicians are experiencing burnout, a condition characterized by loss of empathy, exhaustion, and a low sense of accomplishment. According to a Mayo Clinic survey from 2012, nearly one in two U.S physicians reported at least one symptom of burnout, up from 22% in 2001. For hospitals with stressed caregivers, the stakes are high. Burned out, dissatisfied physicians are far more likely to make medical errors and are less able to communicate effectively with patients and co-workers. They're also at a higher risk for substance abuse and are more likely to leave clinical practice altogether.
8. Recovery Oriented Services in Mental Health and Addiction Management.pdfKingsleyOkonoda
Recovery from mental illness involves much more than recovery from the illness itself. People with mental illness(es) may have to recover from the stigma that they incorporated into their very being; from the iatrogenic effects of treatment settings; from the lack of recent opportunities for self-determination; from the negative side effects of unemployment; and crushed dreams.
JTC - What Is Psychotherapy? by Anne BurkeAnne Burke
Johnstown Therapy Centre - What Is Psychotherapy?
An introduction to Psychotherapy & Counselling at the Johnstown Therapy Centre in Dun Laoghaire, Co. Dublin.
What is the future of personal brain health? SharpBrains
Accelerating innovation is poised to enable systematic brain health self-monitoring and self-care, which in turn can transform what it means to live healthy and fulfilling lives. What concrete steps can individuals take to manage and enhance brain health and heal illness throughout the various stages of life?
- Chair: Alvaro Fernandez, CEO of SharpBrains, YGL Class of 2012
- Barbara Arrowsmith Young, author of The Woman Who Changed Her Brain
- Alexandra Morehouse, VP Brand Management at Kaiser Permanente
This session took place at the 2013 SharpBrains Virtual Summit: http://sharpbrains.com/summit-2013/agenda/
University of Utah Health Improving Wellness: 40 Champions, 20 Projects, 12 M...University of Utah
On December 14, 2017, the Wellness & Integrative Health’s Resiliency Center, Accelerate, and the Spencer S. Eccles Health Sciences Library will presented a Faculty Wellness Poster Session. Each department in the School of Medicine highlighted the past year’s Wellness Champion projects, which were focused on personal resilience, burden reduction, and team work. The poster session demonstrated the work completed so far as the Wellness Champion program is expanded to faculty and staff across U of U Health.
University of Utah Health: Wellness Champion Poster Session 2017University of Utah
Improving Wellness: 40 Champions, 20 Projects and 12-months of Progress: The Wellness and Integrative Health’s Resiliency Center, Accelerate, and the Spencer S. Eccles Health Sciences Library presented a Faculty Wellness Poster Session. Each department in the School of Medicine highlighted the past year’s Wellness Champion projects, which are focused on personal resilience, burden reduction, and team work. The poster session demonstrates work completed so far as the Wellness Champion program is expanded to faculty and staff across U of U Health.
MedicalResearch.com: Exclusive Interviews with Medical Research and Health Care Researchers from Major and Specialty Medical Research Journals and Meetings
8. Recovery Oriented Services in Mental Health and Addiction Management.pdfKingsleyOkonoda
Recovery from mental illness involves much more than recovery from the illness itself. People with mental illness(es) may have to recover from the stigma that they incorporated into their very being; from the iatrogenic effects of treatment settings; from the lack of recent opportunities for self-determination; from the negative side effects of unemployment; and crushed dreams.
JTC - What Is Psychotherapy? by Anne BurkeAnne Burke
Johnstown Therapy Centre - What Is Psychotherapy?
An introduction to Psychotherapy & Counselling at the Johnstown Therapy Centre in Dun Laoghaire, Co. Dublin.
What is the future of personal brain health? SharpBrains
Accelerating innovation is poised to enable systematic brain health self-monitoring and self-care, which in turn can transform what it means to live healthy and fulfilling lives. What concrete steps can individuals take to manage and enhance brain health and heal illness throughout the various stages of life?
- Chair: Alvaro Fernandez, CEO of SharpBrains, YGL Class of 2012
- Barbara Arrowsmith Young, author of The Woman Who Changed Her Brain
- Alexandra Morehouse, VP Brand Management at Kaiser Permanente
This session took place at the 2013 SharpBrains Virtual Summit: http://sharpbrains.com/summit-2013/agenda/
University of Utah Health Improving Wellness: 40 Champions, 20 Projects, 12 M...University of Utah
On December 14, 2017, the Wellness & Integrative Health’s Resiliency Center, Accelerate, and the Spencer S. Eccles Health Sciences Library will presented a Faculty Wellness Poster Session. Each department in the School of Medicine highlighted the past year’s Wellness Champion projects, which were focused on personal resilience, burden reduction, and team work. The poster session demonstrated the work completed so far as the Wellness Champion program is expanded to faculty and staff across U of U Health.
University of Utah Health: Wellness Champion Poster Session 2017University of Utah
Improving Wellness: 40 Champions, 20 Projects and 12-months of Progress: The Wellness and Integrative Health’s Resiliency Center, Accelerate, and the Spencer S. Eccles Health Sciences Library presented a Faculty Wellness Poster Session. Each department in the School of Medicine highlighted the past year’s Wellness Champion projects, which are focused on personal resilience, burden reduction, and team work. The poster session demonstrates work completed so far as the Wellness Champion program is expanded to faculty and staff across U of U Health.
MedicalResearch.com: Exclusive Interviews with Medical Research and Health Care Researchers from Major and Specialty Medical Research Journals and Meetings
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Are There Any Natural Remedies To Treat Syphilis.pdf
Take_Charge_extended_presentation_slides.pptx
1. TAKING CHARGE AFTER STROKE
Harry McNaughton
Medical Research Institute of New Zealand
1
2. People who achieve amazing things dream of amazing
things
2
What the person with stroke can do for themselves, is
as much as anything clinicians can do to them
Take Charge puts the person with stroke in the driving
seat – where they belong
Take Charge aims for transformation: from a stroke person
to a person who happens to have had a stroke
Intrinsic motivation is a necessary condition for
successful rehabilitation
3. Take Charge is effective
The first time an intervention has been shown to be effective (at the level of
participation, independence, quality of life) in the community phase of stroke
rehabilitation
Response: How can this be possible?
My job today:
1. Show how it is possible for Take Charge to be effective
2. Get you excited about using Take Charge (using it will convince you)
3. Remind us all to keep the person with stroke at the centre – person-centred care
• Some practical issues
• Questions
3
4. The Take Charge team: 2005-2020
4
Matire
Viv
Tom John
Carl
Judith
Will
Mark
Anna R
Geoff
Api
Anna M
Alan
Harry
Kath
6. Personal factors
• gender, age
• social background, education, profession
• past and current experience
• coping styles
• overall behaviour pattern
• character
• ‘and other factors that influence how disability is experienced by the individual’
•Intrinsic motivation is a necessary condition for
successful rehabilitation
6
7. The Engine
= My Sense of self
‘Who I really am as a person’
The Fuel
= My
Intrinsic
motivation
Fuel ingredients:
AMP-C
Autonomy – I have choices
Mastery – I can do this
Purpose – Where I want to go
Connectedness – My support crew
The Other bits
9. Intrinsic vs extrinsic motivation
9
• For full story: self-determination theory, Deci & Ryan (full
references are in the IJS paper)
• Simple version
• Intrinsic motivation – internal, personal, your fuel
• Extrinsic motivation – external incentive (cash, praise, award)
someone else pushing your car
10. Julia
• 54 years old
• Successful businesswoman
• Husband and 2 teenage children
• Significant stroke with R hemiparesis and aphasia
• Thrombolysed @ 2.5 hours without significant change
• Transferred to rehab ward Day 7, needing 2 assistants to transfer safely
10
12. Julia was intrinsically motivated. She had:
1. A sense of Purpose focussed beyond the stroke itself
2. A very strong sense of Autonomy
3. A strong sense of competence/Mastery
4. Connectedness
The Take Charge intervention
tries to spark, or support, intrinsic motivation
for all people with stroke
12
13. Better ability to Take Charge = better outcomes?
Ability to Take Charge
With the
Take Charge
intervention
Better outcomes
13
Number
of
people
JULIA
14. How Take Charge was delivered in the Taking Charge after Stroke
(TaCAS) trial
Looking beyond the stroke
• Intervention at around 3-16 weeks following stroke, community-
living people (not institutional care)
• Either one or two sessions, 6 weeks apart, session ~ 60 mins
• Trained facilitator
• Baseline assessment (ADL, IADL, QoL, independence, risk factors)
• Make a Connection
• Listen, don’t speak
• Reflect: All the ideas from person with stroke and family
• Unlimited time – generally about 60 minutes
• Independent from usual rehabilitation team
14
15. Delivering Take Charge: Up to 60% eligible
15%
15%
35%
25%
10% Dead
Institution
Home dependent
Home independent (not recovered)
Home independent (recovered)
Take Charge
15
16. My stroke
Me
Who I really am
My stroke
What Taking Charge is all about
16
A stroke person
A person who happens
to have had a stroke
21. Maori and Pacific Stroke Study n = 172 RCT,
80% follow-up
Taking Charge after Stroke Study n = 400
RCT, >99% follow-up
N = 572
SF36 measures
health-related
quality of life.
MCID of the PCS
in stroke = 2-3
21
Quality of life
22. Independence
Modified Rankin Score
(mRS) measures
‘functional outcome’;
scores 0-2 =
independent; 3-5
increasing levels of
dependence
NNT for 1 more person
to be independent at 12
months = 7.9
22
24. “But we are doing this already”
• Probably not
• Review:
• Rosewilliam S, Roskell C, Pandyan A. (2011).
A systematic review and synthesis of the
quantitative and qualitative evidence behind
patient-centered goal setting in stroke
rehabilitation. Clin Rehabil, 2011;25,:501–14
The clipboard test
24
25. Traditional goal-setting vs Take Charge
Traditional Goal setting Take Charge
Generic goals tailored to the individual Completely personal
Structured Loosely structured
Teacher/coach/counsellor Reflecting the person’s own thoughts
Clinician talking Facilitator listening, not talking
Focus on what is do-able Focus on what the person wants
Complete plan of future action No written plan at the end of a session is OK
‘SMART’
(Specific/Measurable/Achievable/Realistic/Timed)
Anti-SMART
Time limited (often 45 min) No time limit (often 45 – 90 minutes)
25
26. Take Charge is anti-SMART
• S - specific
• M - measurable
• A - achievable
• R - realistic (relevant)
• T - time-related
26
27. Take Charge
Improving
intrinsic
motivation
SF36 ↑10%
FAI ↑10%
Independence ↑ 8%
Barthel ↑3%
£100
27
Activity
limitation
Participation
restriction
Environment
STROKE
or other
health
condition
Quality of life
and
independence
Personal factors
Personal factors
Body
structure
& function
28. Number needed to treat (NNT) for death or independence
Stroke unit care 20 (mainly deaths prevented)
Aspirin acutely 100
IV tPA within 3 hours 10
Mechanical thrombectomy 5
Take Charge 8 (independence)
28
29. Why stroke rehabilitation is so important
Your next 1000 people admitted to hospital with stroke: Benefit of treatments on
death/dependence
Stroke unit care 50 (NNT = 20, 100% eligible)
Aspirin acutely 9
IV tPA within 3 hours 12
Mechanical thrombectomy 5 (current) – 15 (potential)
Hemicraniectomy
for malignant MCA infarction 5 (mainly deaths avoided)
Take Charge 62 (NNT = 8, 50-60% eligible)
(in addition to best stroke rehab)
29
30. Sufficient evidence to change clinical practice?
Level 1a evidence of benefit for independence in stroke
• Benefit at 6 months, sustained at 12 months
• Dose effect
• Effective in both ethnic-minority and ethnic-majority populations
• No harm
• Cheap
• Training easy
• [Cost saving, not yet published]
30
31. Practical issues
• Which patients and how many sessions
• Integrate with current rehabilitation services or ‘add-on’?
• The facilitator
• Good listener
• Maybe not a rehabilitation clinician
• Older person?
• Training: this webinar + read the training manual is sufficient – email any questions. Skype or
Zoom session for bigger groups? Get in touch.
• Training/ booklet modification if necessary
• Materials all free on the website: www.mrinz.ac.nz/programmes/stroke
• Send us any translations so that we can post these for others (German, Estonian, Russian
underway)
31
32. 32
People who achieve amazing things dream of amazing
things
What the person with stroke can do for themselves, is
as much as anything clinicians can do to them
Take Charge puts the person with stroke in the driving
seat – where they belong
Take Charge aims for transformation: from a stroke person
to a person who happens to have had a stroke
Intrinsic motivation is a necessary condition for
successful rehabilitation
33. Experience Take Charge for yourself
• Materials free to download and modify
• www.mrinz.ac.nz/programmes/stroke
• 3 different ways to think about using Take Charge to enhance stroke outcomes
33
Julia
34. Research potential!
• Take Charge
• More sessions?
• Timing of first intervention?
• Conditions other than stroke?
• International study?
• Using Take Charge to enhance new therapy interventions
• Alternatives to Take Charge?
• Better measures of ‘intrinsic motivation’, outcome
34
35. Contacts and links
• Harry McNaughton
• Stroke department, Royal Derby Hospital
• Harry.mcnaughton@nhs.net
• Harry.mcnaughton@mrinz.ac.nz
• Take Charge booklet and training manual
• www.mrinz.ac.nz/programmes/stroke
• Main paper
results: https://doi.org/10.1177/1747493020915144
35
36. “But what did they do after Take Charge?”
We don’t know for sure. So much unknown about the psychology of recovery from illness – likely to
be very individual
• Not more face-to-face rehab
• (In my opinion) It’s not about ‘more therapy’ (compare what we know about elite athletes,
musicians, students studying – more about motivation, focus, engagement)
Some insights from qualitative study (unpublished)
• Permission to do my own thing
• Rebel against paternalistic doctors and therapists ‘one size fits all’, ‘scripted’
• Therapists ‘obsessed with safety’ – I’m not allowed to take risks (compare Julia)
• Felt properly listened to for the first time
• Came to a better understanding of ‘who I really am’
• Better focussed on what is really important (to me)
• Working out a plan over time – booklet helped with ‘big ideas’ and simple structure to ‘get on’
• Alan's story
36
37. Permission to take risks and fail
Michael Jordan, the greatest basketballer to play the game
"I've missed more than 9,000 shots in my career. I've lost almost 300 games.
Twenty-six times, I've been trusted to take the game winning shot and missed.
I've failed over and over and over again in my life”
37
38. From the facilitators’ perspective
• Judith’s story ‘I was going to say that …
• Privilege to share the stories of people with stroke in their own homes
• Therapists turned facilitators
• ‘so hard not to say anything’
• ‘so wanted to ‘help’ but you told me not to!’
• ‘amazing to see the look on their face when they started to talk about what they really
wanted’
• ‘They said ‘no-one has ever asked me questions like this before’. How can that be
possible?’
• ‘The first session was a wash out but the second was amazing’
38
39. What’s in a phrase?
• Self-management (SM) vs self-directed rehab (SDR)
• Depends on resources available
• ‘DIY’ (SM) vs employing the top mechanical engineers for your car (SDR)
• But some things always better done yourself (eg risk factor management?)
• Who is driving the car?
• Take Charge vs intrinsic motivation
• Take Charge is the name of the intervention
• People with stroke can relate to it
• The person with stroke is undoubtedly the subject not the object
• You can’t ‘do’ Take Charge ‘to’ someone, only ‘with’ someone
• Intrinsic motivation describes the underlying principle
• Possibly more confusing to use with people with stroke
• Possible confusion with motivational interviewing
39
40. Take Charge for every day
• Inpatients – I say to all patients and families: ‘the 3 most important things for a
better outcome are’
• A Dream for the future - ‘know where you want to be going’ (= Purpose) + Belief (= Mastery)
• An Attitude (= Autonomy)
• Permission to misbehave (like ‘Julia’)
• A Person in your corner (= Connectedness) – Paul Farmer’s ‘accompagnateur’
• Outpatients/GP: I ask:
• ‘What do you dream about for the future?’
• ‘What is your biggest fear?’
40
41. Take Charge: timing
• Stroke dogma: 95% of motor recovery complete by 12 weeks – ‘plateau’ effect
• So how can an intervention at 3-16 weeks improve outcomes at 12 months?
6 weeks
Motor
recovery
‘Normality’ narrative
‘Live life whatever’ narrative
Take Charge intervention
41
Editor's Notes
Kia ora koutou katoa. Greetings from the indigenous people of Aotearoa New Zealand.
So there is level 1a evidence from 2 moderately large randomised controlled trials that Take Charge is effective in the community phase of stroke rehabilitation. The main results of the 2nd trial and the meta-analysis of the 2 trials are available, open access, in this month’s International Journal of Stroke. I am not going to go over those results today in any detail.
A common response to these results has been disbelief. How can an intervention, not started until an average 6 weeks after stroke, that involves one or two sessions of about 60 minutes of talking and no physical therapy, possibly have an impact on important outcomes at 12 months after the stroke?
So I mainly want to address this disbelief, and convince you that interventions like Take Charge can be effective. A good way to convince you is to start using the intervention yourself and see what happens.
I will cover a few practical issues with using the intervention. Feel free to jot down questions as we go and I will try and answer as many of them as I can at the end. My contact details are on the last slide so even if we run out of time contact me on email or twitter and I will get back to you.
This was a team effort over many years. Thanks to all the investigators, researchers and back room team at MRINZ.
The WHO’s International Classification of Functioning, usually abbreviated to ICF, is a cornerstone of modern rehabilitation theory and practice. I won’t explain it in too much detail. It is our impression that stroke rehab clinicians tend to see this as a linear process, hence my large blue arrows: the stroke affects body structure and function such as arm weakness, which leads to activity limitation, such as difficulty washing and dressing or walking, which in turn restricts participation in life interactions, like work and voluntary activities and study and reduces quality of life. These are modified by environmental and personal factors.
Surveys of community living adults say consistently that it is outcomes at the level of participation, independence and QoL that are valued the most.The focus of hyperacute treatment is to limit the initial damage.
Rehabilitation orthodoxy promotes a concentration on improving basic and advanced activities of daily living, working on the environment to minimise barriers. We know this improves activities of daily living. Unfortunately several large trials aimed at optimising a therapy-led approach on its own, with more therapy, earlier therapy, different types of therapy, robot-assisted therapy, have failed to show significant benefits for people with stroke at the level of independence and quality of life.
The focus of the Take Charge intervention, is on personal factors, which we think deserves a bigger box. In 2 moderately large randomised trials we have shown that people receiving Take Charge , in addition to best hyperacute treatment combined with guideline-recommended best therapy-led rehabilitation, had significantly better levels of independence and quality of life.
Let’s unpack the personal factors box for a minute.
This is how the WHO describes personal factors. The factors in bold strongly influence motivation. Motivation is a difficult concept: hard to measure, no evidence that these personal factors can be manipulated to improve outcomes. So why worry?
So let me make my view clear: Without a motivated person, successful rehabilitation is very difficult. With the Take Charge intervention we have shown that it is possible to manipulate these personal factors to improve outcomes. If we are right, this changes everything.
I want to suggest 3 different ways of looking at Take Charge that may help explain why it works.
The first way asks you to imagine the person with stroke as a car.
The Engine is what defines the car: for the person this is what psychologists call the ‘sense of self’ – who I really am.
The Fuel is what keeps the engine running: for the person this is intrinsic motivation.
The ingredients of the fuel are critical: most important is purpose, then autonomy, mastery and connectedness
All the rest are simply ‘the other bits’, useful but not essential.
Let’s imagine the journey through life of 2 people, both on their way to having a stroke. They both start the journey with a similar amount of fuel.
The upper person has a rich life experience, overcoming adversity and developing resilience, and arrives at the time of stroke with a full tank of fuel, rich with purpose, autonomy and mastery.
The lower person on the other hand goes smoothly through life never really being tested, not quite sure where she or he is headed and arrives at the time of stroke low on fuel, lacking purpose, autonomy and any feeling of mastery.
Although the stroke is likely to temporarily slow down most people, the outcome for the upper person, with a tank full of motivation is likely to be much better than that of the lower one, now completely out of fuel, going nowhere.
Take Charge is an intervention that aims to help the person with stroke top up their fuel: their intrinsic motivation, and improve the trajectory of their recovery.
Intrinsic motivation is from within. You are doing this for yourself. External motivators are bribes of some sort. You are doing it to please other people in some way.
Plenty of empirical evidence from the education and psychology literature tells us that students who are extrinsically motivated do worse than those intrinsically motivated. Of course those of you who have, or have had, teenagers know this already. Any gains from external motivators – financial or otherwise – are usually short term. We need to help the person fill up their own fuel tank, not push their car.
Enough theory. Here is my second illustration of Take Charge. Lets talk about a real person.
Julia had a big stroke with significant motor and language deficits.
This is what the rehab team said about her in the clinical notes and during multidisciplinary team meetings.
Julia was adamant that she was going to get better and wanted to mobilise as much as possible. She was told she could only mobilise with trained staff . When the physios went home and the nurses retired to their work station after 5 o’clock, Julia would get up by herself and try to walk either on her own or with her husband. She had many falls including one in the toilet where she bruised her whole side against the toilet seat.
She and her husband were in a constant battle with staff to get more therapy, spend more time at home, practice car transfers. Her main priorities were spending time with her family and getting back to work. She was told countless times ‘you can’t run until you have learned to walk again’
We have all seen patients like Julia. I want you to consider whether Julia, and patients like her, in your opinion, is likely to make a better than average outcome, an average outcome or a worse than average outcome?
Most people agree that she will make a better than average outcome, which she did.
Julia is Taking Charge. She has plenty of fuel in her tank and will make the very most of her rehabilitation
The Take Charge intervention, encourages a person’s own intrinsic motivation – a combination of Purpose, Autonomy, Mastery and Connectedness. 10.30
Our previous qualitative work suggested that there is a Take Charge continuum, not just in stroke but also people with chronic pain and cancer. That work suggested that people more able to take Charge experienced better outcomes.
Julia is already at the extreme end of the Take Charge continuum and could be expected to do better than someone further down this curve.
With the Take Charge intervention we hoped to shift the whole distribution to the right, and by doing so improve average outcomes.
So how did we help people top up their fuel tank? In a sentence we aimed to help them Look beyond their stroke. What we actually did was very simple. There is a lot more detail in the training manual
The training only took half a day. The main message for the facilitators was to listen and shut up. The facilitators were not there to coach, simply to listen and reflect. All ideas were from the person with stroke and their family.
I want to emphasise that this intervention was in addition to evidence-based best practice stroke rehabilitation in the hospital and community.
The Take Charge studies have focussed on people with stroke discharged to community living and who say they are not fully recovered from their stroke.
Here is the third way of looking at Take Charge. This single graphic sums up what we are trying to do. We are aiming for a transformation: from a stroke person on the left, overwhelmed by the effects and baggage of the stroke episode, back into the person they want to be – a person who happens to have a stroke.
The next 3 slides show the first 3 pages of the Take Charge booklet. The whole booklet is available for free download from the mrinz website and I will give you the address at the end. This page tries to work on the 2 circles idea from the previous slide – from a ‘stroke person’ to ‘a person who happens to have had a stroke’. The person with stroke or their family fills in the spaces.
This page continues the idea of thinking beyond the stroke. Dreams, hopes, big picture. Sometimes expressing fears is easier than expressing hopes: ‘I’m afraid I won’t be able to read stories to my grandchildren’ is another way of saying ‘Reading stories to my grandchildren is really important to me’
Sometimes visualising and drawing is easier and more powerful than writing ideas down. The idea of a ‘Best Day’ is borrowed from palliative care and amazing stuff can come out. The person is asked to visualise a place, people and action. The family often gets involved. There are spare sheets in the booklet for more ideas over time.
There are several other sheets covering common issues for people after stroke with a structure that allows them to plan for the future
So briefly to a few numbers about effectiveness.
There have been 2 RCTs, both using the physical component summary of the short form 36 as the primary endpoint, a well-validated measure of health related quality of life. The minimal clinically important difference is somewhat controversial in stroke but possibly around 2-3 points..
The first study was of 172 maori and Pacific people in new zealand, published in 2011
and the second of 400 predominantly white new Zealanders published this month
A pooled difference of almost 4 points with fairly narrow confidence intervals
The modified Rankin scale is probably more familiar to some. As an outcome measure it is often dichotomised with scores of <3 signifying independence and scores of 3 and more, increasing dependence. Any statistically significant difference in independence is considered clinically meaningful.
.
Overall, you only need to expose 8 people with stroke to the Take Charge intervention for 1 more person to be independent at 12 months
There was a statistically significant increase in the PCS with each dose of Take Charge. Doses greater than 2 are yet to be tested.
I have often been told by clinical teams that they do person centred goal setting already. Evidence suggests that this is often not the case.
I have 2 simple tests. Firstly if the process is referred to as ‘patient-centred’ rather than ‘person-centred’ that suggests to me a stroke-centric rather than whole person approach.
Secondly I ask the therapists ‘who is holding on to the clipboard and pen?’ during goal setting. If it is not the person with stroke, I doubt this is person-centred.
These are the main differences we see between traditional goal setting and Take Charge. This is not intended as criticism – just explaining what is different.
I will highlight 2: in traditional goal setting the clinician generally takes the role of teacher or coach and does most of the talking. For Take Charge we train the facilitators only to reflect the person’s own thoughts and ideas and not to offer any suggestions themselves.
Secondly Take Charge is anti SMART.
SMART goal setting may be good in factories and places where efficiency targets need to be met but we believe SMART goal setting lowers horizons and impedes intrinsic motivation. We want people to be dreaming big – going back to work, starting a new job, watching their grand-daughter’s team play football on Saturday mornings, going on a trip through rural Vietnam – it is not necessary that it be terribly realistic but it is does need to be the authentic dream of the person with stroke
So to summarise what Take Charge could achieve for your people with stroke
To underline the importance of stroke rehabilitation interventions for people with stroke, we can compare the effect of Take Charge to current treatments using the number needed to treat:
Remember this result for Take Charge is in addition to other treatments.
So this is why stroke rehabilitation is so important. If you have an effective treatment and can apply it to a large proportion of people with stroke, the total number of people helped can be considerable
So what do you need to change clinical practice?
In stroke alone, the level of evidence for much of what we do falls below this
Well, to use Take Charge you really only need to make 4 decisions:
Which patients and how many sessions
Will you modify your current practice or add this on
Who will be the facilitator and training them
Modification of the Take Charge booklet if necessary
And so we come back to Runa from Assam, who rehabilitated herself from a severe stroke – a few days in hospital, never saw a physio or an OT. Driven by the need to get back to work as a farmer to support her daughter through school.
So please download the materials and start using Take Charge for yourselves. The intervention isn’t limited to healthcare professionals, or even to stroke. People with stroke can access and use the materials themselves if they wish.
I have given you 3 different ways to think and talk about Take Charge which I hope will be helpful
And of course, Take Charge opens up an enormous potential field for research
End of main presentation. The following slides respond to specific questions from the webinar
Alan’s story: Retired in his 60s. Wife died some years ago with cancer. Glass half full kind of guy. Devoted daughters who live in same town. Major stroke with significant mobility issues after several weeks in hospital. Housebound since stroke. First Take Charge session going badly. During baseline assessment Alan kept saying ‘I’m stuffed’ (ie useless), and ‘the physio knows it is hopeless’. He got to the 3rd page of the booklet ‘My Best day’ and just said ‘What can I do – I’m stuffed’. The facilitator asked, ‘What did you enjoy doing before?’ and he still wasn’t able to answer. One of his daughters reminded him that the thing he liked doing the most since his wife died was to go once a week to the local shopping mall and sit outside a café drinking coffee and watching the world go by. Alan said ‘Well I can’t do that now, can I?’. His daughters took on the challenge and organised a wheelchair taxi to take him to the mall the next week. Alan felt very self-conscious and uncomfortable about the whole thing but went along with it. He was touched by the number of people who came up to him and said ‘we’ve missed you’ and how good it was to see him there after the stroke that they all seemed to know about. He went every week after that. By the time of the 2nd Take Charge session 6 weeks later, there was no difference in his overall mobility but he was a different man. One daughter said ‘He has got his zest for life back’. He filled in a lot more of the booklet and started making concrete plans for the future – ‘I’m not going to live like this for the rest of my life’. Alan was clearly ‘looking beyond his stroke’. Would that have happened without Take Charge? Who knows.
But you could start using Take Charge now. This is what I try and do with every person I see.
Timing may be important. For many people with stroke, the normality narrative (I am going to get back to normal) remains strong in hospital and into the early community phase.
For many but not all people disabled by stroke, eventually a different narrative (making the best of what I’ve got) replaces this.
The timing of the Take Charge intervention might be important in helping people to leave their stroke behind.