Integrating Evidence into Clinical Practice in Stroke Rehabilitation: The Forgotten Revolution
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Integrating Evidence into Clinical Practice in Stroke Rehabilitation: The Forgotten Revolution Robert Teasell MD FRCPC Professor and Chair-Chief Physical Medicine & Rehabilitation. Objectives. Understand the evidence for why stroke rehabilitation works

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Integrating Evidence into Clinical Practice in Stroke Rehabilitation: The Forgotten RevolutionRobert Teasell MD FRCPC Professor and Chair-ChiefPhysical Medicine & Rehabilitation


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Objectives Rehabilitation: The Forgotten Revolution

  • Understand the evidence for why stroke rehabilitation works

  • Appreciate the gaps between real-life practice and the evidence

  • Build support for evidence-based practice and innovation


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The Forgotten Revolution in Stroke Rehabilitation Rehabilitation: The Forgotten Revolution

  • Stroke rehab works!

  • Once stroke occurs rehab offers best opportunity for improving outcomes

  • Confluence of animal and clinical evidence (almost 500 RCTs) points to efficacy and benefits of investing in stroke rehab

  • Demand for stroke rehab is increasing

  • Good care saves money and improves lives

  • Stroke rehab should be transforming!


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The Forgotten Revolution in Stroke Rehabilitation Rehabilitation: The Forgotten Revolution

  • Evidence is being ignored

  • We have an antiquated and increasingly inadequate system

  • Stroke rehab not changed in 4 decades

  • Undervalued and organized in an ad hoc fashion

  • Not rehabilitating at the right time, in the right place with the right treatment

  • Need system change and reinvestment!


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PSROP (Post-Stroke Rehabilitation Outcomes Project) Rehabilitation: The Forgotten Revolution

  • Study of 7 stroke rehab centers (6 in United States, n=1161; 1 in New Zealand, n=130)

  • Comprehensive study of stroke rehabilitation examining the “black box”

  • Compare with IBM Data of Canadian Centers (most in Ontario)


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Comparing US to Canada Rehabilitation: The Forgotten Revolution


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What do the PSROP (U.S.) Centers Do Differently? (FIM efficiency 2.5X)

  • Pts get admitted to specialized inter-disciplinary stroke rehab units

  • Admitted earlier and more disabled

  • More intensive therapy (incl. W/E)

  • Less time in assessments

  • Move to high level tasks early

  • Well developed outpatient services

  • Apply best-evidence to save money!



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Meta analysis of RCTs efficiency 2.5X)

29 trials (6536 patients)

  • Mortality at 1 year 0.86 (0.71-0.94)

  • Death or dependence 0.78 (0.68-0.89)

  • Death or institution 0.80 (0.71-0.90)

    Independent of age and gender

    Trials primarily acute-subacute rehab or subacute rehab


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Indredavik et al. (1990) efficiency 2.5X)(Combined acute-subacute stroke unit)

  • Randomized 220 acute strokes to Stroke Unit or General Medical Unit

  • Maintained treatment for 6 weeks

  • Outcomes: home vs institution, mortality, Barthel index - at 6 and 52 weeks, 5 and 10 years


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Indredavik et al. (1990) at 6 weeks efficiency 2.5X)

Significant benefit still seen at 10 years


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Ronning and Guldvog (1998) (Subacute rehab unit) efficiency 2.5X)

  • Randomized Controlled Trial

  • n = 251 stroke patients

  • Inpatient rehab unit (RU) vs. ad-hoc care in community (CR)


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Ronning and Guldvog (1998) efficiency 2.5X)

Characteristics:

  • Acute stay 10 days – randomized to treatment (rehab) or control (community care)

  • Rehab Unit LOS = 27.8 days

  • Community Care - 40% nursing home, 30% outpatient therapy, 30% no formal rehab treatment


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Ronning and Guldvog (1998) efficiency 2.5X)

Results:

  • 7 month follow-up for all stroke patients

  • Dependent (BI < 75) or dead - 23% vs 38% (p=.01)

  • 39% reduction in worse outcomes with stroke rehab


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R efficiency 2.5X)ønning & Guldvog (1998) Moderate to Severe Strokes

  • Moderate to severe stroke (BI<50) (n=114):

  • 62% CR vs 32% RU dead or dependent (p=.002)

  • 48% reduction in bad outcomes

  • Barthel Index scores - 90 vs. 73 (p=.005)


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R efficiency 2.5X)ønning & Guldvog (1998)Mild Strokes do not benefit from Rehab

BI Score > 50 at time of admission to rehabilitation

NS

100

% Patients

50

NS

NS

NS

0

RU

CR


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Stroke Rehab Units efficiency 2.5X)

  • Specialized interdisciplinary stroke rehabilitation results in improved functional outcomes and less mortality

  • Moderate to severe stroke patients make the greatest improvement

  • Milder strokes can be rehabilitated in community/outpatient setting without negative functional outcomes


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Conclusions on Stroke Rehab Units efficiency 2.5X)

Stroke rehab units associated with:

  • mortality

  • combined outcome of death and dependency

  • institutionalization

  • length of hospital stay


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Conclusions on Stroke Rehab Units efficiency 2.5X)

Subacute Stroke Rehab Units result in:

  • 10 day reduction in inpatient stay

  • 1 in 27 patients treated will not need institutionalization

  • Increased functional outcomes with decrease in informal care costs

    In SWOntario there are only 2 designated stroke rehab units with PT or OT:patient ratios <10:1

    > 50% not admitted to stroke rehab units!


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The Earlier the Better efficiency 2.5X)


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The Earlier the Better efficiency 2.5X)

  • Brain is “primed” to “recover” early in post-stroke period

  • Animal studies suggest there is a time window when brain is “primed” for maximal response to rehab therapies, such that delays are detrimental to recovery

  • Clinical association between early admission to rehab and better outcomes


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Benefit efficiency 2.5X) of Early Therapy in Animals

Methods:

  • Biernaskie et al. (2004) subjected rats to rehab x 5 weeks beginning at 5, 14 and 30 days post small strokes

  • Control animals – social housing


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Benefit of Early Therapy in Animals efficiency 2.5X)

Results:

  • All received 5 weeks of enriched enviornment

  • Day 5 admission marked improvement

  • Day 14 moderate improvement

  • Day 30 no improvement vs. controls

  • Corresponding cortical reorganization in brain around stroke


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Stroke Rehab Should be Started ASAP efficiency 2.5X)

  • Animal studies indicate early rehab is associated with improved recovery; late rehab is not

  • In clinical studies earlier rehab is associated with better functional outcomes

  • Time is Recovery!


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Conclusions on Early Admission efficiency 2.5X)

Early Admission results in:

  • Reduced length of acute care

  • Improved functional outcomes, which reduces informal care needs

  • U.S. admits patients earlier, sicker and more disabled and yet do better

    In Canada waiting lists are common!


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More is Better efficiency 2.5X)


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Use It or Lose It efficiency 2.5X)

Rehab training (enriched environments with animals) increases cortical representation with subsequent functional recovery

In animal studies key factors promoting recovery include increased activity and complex, stimulating environment

Lack of rehab decreases cortical representation and delays recovery


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Role of Intensity of Therapy efficiency 2.5X)

  • Post-stroke rehab increases motor brain reorganization, while lack of rehab reduces reorganization

  • More intensive motor training in animals further increases brain reorganization

  • Clinically, greater intensity of stroke rehab therapies is associated with improved outcomes


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Role of Intensity of Therapy efficiency 2.5X)

  • The greater the intensity of therapies - the better the outcomes

  • Seen to be true for physiotherapy, occupational therapy, aphasia therapy, treadmill training and upper extremity function in selected patients (i.e. CIMT)


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Kalra et al. (1994) efficiency 2.5X)

  • RCT of 146 “middle band” strokes to stroke unit (SU) or gen med (GM) unit

  • Median BI = 4/20 initially in both

  • Stroke Unit - BI = 15 after 6 wks; discharged at 6 wks

  • General Medical Unit - BI = 12 after 12 wks; discharged at 20 wks


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Kalra et al. 1994 efficiency 2.5X)


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Kalra et al. 1994 efficiency 2.5X)


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Kalra et al. 1994 efficiency 2.5X)


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Kalra et al. (1994) efficiency 2.5X)

  • Both groups received same amount of therapy overall

  • Stroke Unit therapy more intensive and specialized - “front loading”

  • Significant differences in cost and outcomes


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Sonoda et al. 2004 efficiency 2.5X)

Methods:

  • Comparative study conventional stroke rehab 5 days/wk vs. full-time integrated treatment (FIT) program 7 days/wk

  • Both groups had similar FIM scores on admission

    Results:

  • FIT group significantly shorter lengths of stay and discharged with higher avg FIM scores and nearly double the FIM efficiency scores


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Intensity of Therapies efficiency 2.5X)

  • Lenze et al. (2004) poor participation in therapy during inpatient rehab was common

  • Associated with less improvement in FIM scores and longer lengths of stay even when controlling for admission FIM scores


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Inactive and Alone efficiency 2.5X)

In a therapeutic day

  • >50% time in bed

  • 28% sitting out of bed

  • 13% in therapeutic activities

  • Alone for 60% of the time

    Contrary to the evidence that increased activity and environmental stimulation is important to neurological recovery

(Inactive and alone, Bernhardt et al, Stroke 2004)


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Conclusions on Intensity of Therapies efficiency 2.5X)

  • More therapy results in improved outcomes and is cost-effective

  • Careful attention to actual amount of therapist-patient time and time spent in activation activities

  • Minimum of 1 hr/day of each therapy

  • Increasing therapy aids and volunteers

  • Less time charting, assessing and meeting

  • More stimulating environments


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Conclusions on Intensity of Care efficiency 2.5X)

  • Core Therapies of PT, OT and SLP are most sensitive to intensity

  • <20% of total hospital budget spent on core therapies

  • <10% in overall budget = 50% in core therapies

  • Can do weekend therapy and overall therapy intensity

  • Reduce LOS and costs by 30%



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Stroke Rehab Must Be Task-Specific efficiency 2.5X)

  • Functional reorganization of cortex greater for tasks meaningful to animal; repetitive activity not enough

  • Rehab must be task-specific, focusing on tasks important and meaningful to patient

  • Compensatory Approaches result in faster recoveries than Remedial Approaches

  • Trends moving away from Bobath and other NDT forms of treatment because they increase length of stay


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Task-Specific Therapy efficiency 2.5X)

  • In U.S. PSROP centers, patients were given challenging tasks which simulated real-life tasks early on

  • Assessments were kept to bare minimum

  • Task-specific therapy reduce LOS!



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Outpatient Therapy efficiency 2.5X)

  • Outpatient therapy improves short-term functional outcomes

  • Doesn’t seem to matter if it is hospital or home-based

  • Timing (later) and intensity (inevitably less) and insensitive outcome measures make detecting benefit difficult


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Outpatient Therapy efficiency 2.5X)

  • Outpatient therapy reduces hospital stay and reduces rehospitalization

  • 8 week course of outpatient PT and OT, 1 hr each 3 days/wk x 8 wks or 2 days/wk x 12 wks costs $2,000

  • Estimated savings per patient in reduced inpatient costs is $4,000


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Conclusions re Outpatient Therapy efficiency 2.5X)

  • Outpatient therapy reduces costs and is relatively inexpensive

  • First thing cut with budget pressures

  • Reduction in CCAC support

  • U.S. emphasize the importance of outpatient supports

  • Outreach programs also save $


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Community Reintegration efficiency 2.5X)

“Doctor says you can come home when I am up to it.”


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Kalra et al. 2004 efficiency 2.5X)

RCT of 300 patients and caregivers

Formal training of caregivers during patient’s rehab associated with:

  • Less caregiving burden

  • Better psychological outcomes in patients and caregivers

  • Higher quality of life in patients and caregivers

  • Reduced overall costs of health and social care


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Conclusions on Community Supports efficiency 2.5X)

  • Higher levels of social support are associated with greater functional gains, less depression, improved mood and social interaction

  • Predictive of discharge destination

  • Interventions to help access community support-services is associated with increased social activity

  • Important to include caregiver as well in social support interventions


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Conclusions on Community Supports efficiency 2.5X)

  • Evidence of a positive benefit of education; one-on-one more effective than written information

  • Skills training in basic nursing skills for caregivers results in less depression and anxiety and improved quality of life for both caregiver and patient


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Structure of Care efficiency 2.5X)vs Process of Care


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Structure, Process and Outcomes in Stroke Rehab efficiency 2.5X)

  • Hoenig et al. (2002) 2 yr prospective trial of 288 acute strokes in the VA system

  • Examined Structure of Care: systemic organization, staffing expertise and technological sophistication

  • Examined Processes of Care: adherence to AHCPR post-stroke rehabilitation guidelines

  • Studied FIM motor subscale 6 mos post-stroke as Outcome


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Structure, Process and Outcomes in Stroke Rehab efficiency 2.5X)

  • Structure of Care helped to predict Processes of Care but was not directly associated with Outcomes

  • Processes of Care were associated with Outcomes – better adherence to guidelines meant improved outcomes

  • Providing Outcomes information does not change provider behavior

  • Better to measure Processes of Care than Outcomes?


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Dealing with Processes of Care efficiency 2.5X)

  • Staff education is important

  • Over half of the cost of in-patient rehab is nursing care – yet little funding is devoted to Nursing Education

  • Need to specifically teach evidence and guidelines related to stroke rehab care

  • Need to focus on Processes of Care


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Canadian PM&R Consensus on Standards of Care efficiency 2.5X)

  • Early access to specialized interdisciplinary rehab

  • Early assessment for stroke rehab

  • Appropriate intensities of therapies

  • Available outpatient therapy on d/c

  • Appropriate community supports

  • Secondary prevention of stroke


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Summary efficiency 2.5X)

  • Stroke rehabilitation (interdisciplinary specialized team) works

  • Get them in early

  • Treat intensively incl w/e therapy

  • Create stimulating active rehab environ

  • Focus on high level meaningful tasks and challenge patients

  • Limit the number of assessments

  • Outpatient therapy must be available

  • Processes of care are critical


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The End efficiency 2.5X)www.ebrsr.com


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