an integrated therapeutic approach to intensive upper limb ... · intensive upper limb...
TRANSCRIPT
An Integrated Therapeutic Approach to
Intensive Upper Limb Rehabilitation
Kate Kelly & Fran Brander
Consultant Occupational Therapist & Consultant Physiotherapist,
The National Hospital for Neurology and Neurosurgery
Queen Square
[email protected] ; [email protected]
7th Northern Ireland Stroke Conference
Tuesday 12th June 2018
Aim of talk
Discuss the Impact of Intensity on UL Recovery
Describe the Queen Square UL Programme
Demographics & Clinical Characteristics on Admission
Interventions
What’s in the Black Box
Results
Patient Experience
Summary
Upper limb treatment – how much are we
giving?
People are still INACTIVE and
ALONE after stroke
WHAT? HOW MUCH? WHEN?
People with stroke should receive at least 45 minutes of each appropriate therapy every day, at a
frequency that enables them to meet their rehabilitation goals, and for as long as they are willing and
capable of participating and showing measurable benefit from treatment.
Royal College of Physicians – National Clinical Guideline for Stroke
• Average stay in ASU = 17 Days
• 17 days*35 mins*74% =
7.3 hours in total
• Only 10-25% of sessions ‘active’
SSNAP data
?• Reduce long-term dependency, admission to
institutional care, length of admission (by 6 days)
• No clear differences in ADLs, subjective health
status or mood
• No evidence that services without co-ordinated
MDT input have any benefit (may cause harm)
July 2017
Stroke – post-stroke care
JAMA. 2016;315(6):571-581
Upper limb treatment – early
30 hours over 10 weeks
• Patients ~46 days post-stroke
• Mean baseline FM-UL = 41 +/- 9 (mild-mod)
• UL training 3 hours/week for 10 weeks
✗
300 hours over 12 weeks
Upper limb treatment
✔
• Mean baseline FM-UL 15-35
(mod-severe)
• Arm training
• Patients ~40 days post-stroke
• Mean baseline FM-UL 6-8 (severe)
• Arm training 1, 2, 3 hrs/day, 5 days/wk,
6 wks
90 hours over 6 weeks
Upper limb treatment
✔
+ 11.5 pts FM-UL
1 hr/day = 30 hours 2 hrs/day = 60 hours 3 hrs/day = 90 hours
Upper limb treatment – chronic
• Mean baseline ARAT 10-48
• 1-hour sessions, 4 days/week for 8
weeks = 32 hrs (active time 14-30 hours)
• Groups - 3200, 6400, 9600, or 10,800
reps
• “We are skeptical that patients could
achieve another order of magnitude of
dose in the context of a traditional
therapy session”
ΔARAT = 0.4/week = 3.2 ΔARAT = 0.05/week = 0.4
ΔARAT = 0.31/week = 2.5 ΔARAT = 0.66/week = 5.3
32 hours over 8 weeks✗
In total each patient receives 100 hours upper limb oriented therapy
over 3 weeks.
Daily treatment consists of:
• 2 hours each of OT and PT including analysis of movement and
tasks, treatment of impairment and re-education of motor control
within functional tasks.
• 2 hours of tailored, individualised interventions, including repetitive
practice with a rehabilitation assistant, sensory retraining, adjuncts
to therapy such as robotics, dynamic and functional orthoses and
neuromuscular electrical stimulation and group work.
• Patients are encouraged to work on cardiovascular fitness during
the programme.
• Education, self-efficacy and goal setting are integral components of
the programme.
Treatment – Queen Square Programme
Time Monday Tuesday Wednesday Thursday Friday Time
7:45 7:45
8:00 8:008:15 8:15
8:30 8:30
8:45 8:45
9:00 Occupational Therapy Occupational Therapy Occupational Therapy Amadeo Rehab Assistant Group 9:00
9:15 Occupational Therapy Occupational Therapy Occupational Therapy Amadeo Rehab Assistant Group 9:15
9:30 Occupational Therapy Occupational Therapy Occupational Therapy Occupational Therapy Occupational Therapy 9:30
9:45 Cardio Independent Exercises Cardio Occupational Therapy Occupational Therapy 9:45
10:00 Cardio Independent Exercises Independent Exercises Occupational Therapy Occupational Therapy 10:00
10:15 Sensory Programme Independent Exercises Independent Exercises Physiotherapy Occupational Therapy 10:15
10:30 Physiotherapy Sensory Programme Physiotherapy Physiotherapy Rehab Assistant 10:30
10:45 Physiotherapy Cutlery practice Physiotherapy Physiotherapy Rehab Assistant 10:45
11:00 Physiotherapy Cutlery practice Physiotherapy Cardio Amadeo 11:00
11:15 Rehab Assistant Cardio Sensory Programme Cardio Amadeo 11:15
11:30 Rehab Assistant Cardio Armeo Spring Independent Exercises Physiotherapy 11:30
11:45 Rehab Assistant Rehab Assistant Armeo Spring Independent Exercises Physiotherapy 11:45
12:00 Cutlery practice Rehab Assistant Rehab Assistant Cutlery practice Physiotherapy 12:00
12:15 Cutlery practice Rehab Assistant Rehab Assistant Cutlery practice Physiotherapy 12:15
12:30
Lunch Lunch Lunch Lunch Lunch
12:30
12:45 12:45
13:00 13:00
13:15 Joint Physio and OT Cardio Rehab Assistant Physiotherapy Cardio 13:15
13:30 Joint Physio and OT Rehab Assistant Rehab Assistant Physiotherapy Armeo Spring 13:30
13:45 Joint Physio and OT Rehab Assistant Occupational Therapy Physiotherapy Armeo Spring 13:45
14:00 Cardio Amadeo Occupational Therapy Rehab Assistant Occupational Therapy 14:00
14:15 Sensory Programme Amadeo Occupational Therapy Rehab Assistant Occupational Therapy 14:15
14:30 Occupational Therapy Occupational Therapy Cardio Rehab Assistant Group Occupational Therapy 14:30
14:45 Occupational Therapy Occupational Therapy Cardio Rehab Assistant Group Open gym 14:45
15:00 Independent Exercises Occupational Therapy Amadeo Rehab Assistant Group Open gym 15:00
15:15 Independent Exercises Cardio Amadeo Sensory Programme Open gym 15:15
15:30 Independent Exercises Physiotherapy Sensory Programme Occupational Therapy Open gym 15:30
15:45 Independent Exercises Physiotherapy Sensory Programme Occupational Therapy Open gym 15:45
16:00 Physiotherapy Physiotherapy Cutlery practice Occupational Therapy Open gym 16:00
16:15 Physiotherapy Physiotherapy Cutlery practice Occupational Therapy Open gym 16:15
16:30 16:30
16:45 16:45
17:00 17:00
Upper limb treatment – Queen Square
Programme
100 hours over 3 weeks
Upper limb treatment – Queen Square
Programme
• Patients usually require (i) at
least flickers of extension at
the wrist, fingers and/or thumb,
(ii) at least minimal ability in
reaching – but not always
• Patients are ‘admitted’ for 3
weeks of intensive upper limb
oriented therapy.
• 6 week & 6 month follow up
outcome data
Removing Barriers
Video
Treatment Interventions
Videos
Treatment Interventions
Videos
Upper limb treatment – Queen Square
Programme
What’s in the
black box?
Time Repetitions
Upper limb treatment – Queen Square
Programme
100 hours of upper limb therapy over 3 weeks
Median FM-UL 26 pts 34 pts 36 pts 38 pts
N = 175
Median ΔFM-UL 6 pts 8 pts 9 pts
MCID ΔFM-UL = 5-6 pts
Upper limb treatment – Queen Square
Programme
100 hours of upper limb therapy over 3 weeks
Median ARAT 19 pts 27 pts 28 pts 28 pts Median ΔARAT 5 pts 6 pts 8 pts
N = 175 MCID ΔARAT = 5-6 pts
Upper limb treatment – Queen Square
Programme
100 hours of upper limb therapy over 3 weeks
Median CAHAI 40 pts 49 pts 50 pts 51 pts
N = 175
Median ΔCAHAI 9 pts 11 pts 12 pts
MCID ΔCAHAI = 9 ptsN = 175
Focus Groups: Patient Evaluation
Upper limb therapy – summary
• Dose response ‘emerging’ from clinical trials
• Currently we don’t give enough to know what is possible through
motor/behavioural training
• The dose of treatment is critical – more is generally better
• No evidence to say which type of UL therapy is better (hands on
vs. robots vs. self-directed) – but likely each has own value
• Simple task specific training ≠ learning and seems less effective
• Learning required
• Cannot simplify UL rehab to a single protocol based activity
• The challenge is how to increase intensity across the pathway
Upper limb post-stroke therapy
• Prof Nick Ward
• Amanda Strawson
• Ali Norfolk
• Ben Beare
• Dr Kate Hayward
• Fleur Vella
• The UL Team at NHNN
21
Thanks to:
6TH ANNUAL UPPER LIMB NEUROREHABILITATION
COURSE
TREATING PATIENTS WITH UPPER LIMB DEFICIT:
INTEGRATING RESEARCH INTO PRACTICE
Thursday 28th – Friday 29th June 2018
Speakers include:
Gert Kwakkel, VUMC, Amsterdam, The Netherlands
Nick Ward, University College London
Kate Kelly, The National Hospital for Neurology and Neurosurgery
Fran Brander, The National Hospital for Neurology and Neurosurgery
Jane H Burridge, Southampton University
For more information contact Alkida Domi:02034483476 email: [email protected]
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