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Stroke is a Chronic Disease : A Need to Narrow the Gaps and Expand The Continuum of Care. Post-Acute Stroke Care. Pamela W Duncan PhD, FAPTA, FAHA Professor Division of Doctor of Physical Therapy Duke University . Stroke Care . Community. Stroke. Hyper acute. Acute.

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Stroke is a Chronic Disease : A Need to Narrow the Gaps and Expand The Continuum of Care

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    1. Stroke is a Chronic Disease : A Need to Narrow the Gaps and Expand The Continuum of Care Post-Acute Stroke Care Pamela W Duncan PhD, FAPTA, FAHA Professor Division of Doctor of Physical Therapy Duke University

    2. Stroke Care Community Stroke Hyper acute Acute Rehab

    3. Paul Coverdell Registry - NC • 13, 283 discharges with 92% NIH stroke scale > 4 • Mean acute stay 4.9 days , Median 3 days • 47% discharged directly home to self care

    4. Paul Coverdell Registry - NC • 13% discharged to SNF • 12 % discharged to Home Health • 14% discharged to IRF

    5. Several Important Messages from AHA/ASA Decade of Stroke

    6. Stroke is Preventable Major campaigns including Power to End Stroke MESSAGE 1

    7. Message 2 Stroke is an emergency CALL 911

    8. Quality of Stroke Care Matters GET with the Guidelines for Stroke Paul Coverdell Registries Developed Quality Measures for Stroke Care JACHO Centers of Excellence For Acute Stroke Care MESSAGE 3

    9. Stroke Care Stroke Hyper acute Acute

    10. Problem Stroke is a chronic condition with multiple risk factors for continued decline in health, functional status and quality of life Secondary risk factors e.g. Hypertension, Atria Fibrillation (Anticoagulation), Diabetes), Smoking, Obesity, and Decreased Physical Activity Post-Acute Stroke Care

    11. Existing data suggest that fewer than 50% of individuals with stroke have their risk factors assessed, treated or controlled 90% of individuals who are overweight at initial evaluation remain overweight 51% of individuals who are hypertensive have BP under control Smokers do not quit smoking Few participate in exercise program AHA Physical Activity and Exercise Recommendations- 2004 Post-Acute Stroke Care

    12. Bushnell et al: AVAIL DATA • Only 75% of individuals persist with secondary prevention medications

    13. Depression is under diagnosed and under treated • Ghost SS, Williams LS et al: Medical Care 2005

    14. Depression Depression is major barrier to engaging in exercise and recovery programs Incidence of Depression range from 18 to 68% Screen for Depression- Geriatric Depression Measure, BECK Depression Inventory, or the CESD 14

    15. % 15

    16. Effects of Post-Stroke Depression –HUGE Reduces Probability of Independence in ADLS Increases Time to Recovery 16

    17. Physical Activity In Individuals With Mild Stroke less than half of age matched individuals • Rand et al Stroke 2009

    18. Death and Re-hospitalizationsBravata DM et al Stroke 2007 • Over 53% of Medicare stroke survivors die or are readmitted to the hospital at least once during the first year after stroke • 27.2 % one readmission • 13.2 % dead –one readmission • 12.9 % dead

    19. Northern Manhattan Stroke ProjectDhamoon et al Stroke 2009 The proportion of patients with functional independence after stroke declines annually for up to 5 years, Greatest in those with no insurance and Medicaid Independent of age, stroke severity Even among those without recurrent stroke or MI

    20. MMWR- November 2009Paul Coverdell Registry Across 4 States 49 % of all stroke survivors from Paul Coverdell registry are discharged requiring assistance or dependent in ambulation

    21. Problem FALLS e.g. >50% stroke patients unable to walk at hospital discharge Impaired ambulation → falls, fall injuries, hospital readmission, SNF placement Decrease cardiovascular function- deconditioning Limited Social Participation Post-Acute Stroke Care

    22. Whitson, Duncan et al: JAGS 2006 Increase fractures rates in FRG 4-7 ( moderately Impaired- those who return to the community) ..first year

    23. Kaplan-Meier Results: Time to first fracture 2.7% 4.7% Estimated 1-Year Fracture Rate: 2.7% (95% CI 2.3-3.1%) Estimated 2-Year Fracture Rate: 4.7% (95% CI 4.1-5.3%)

    24. Results: Total FIM Score and Fracture Risk after Stroke Discharge FIM Score <54 Discharge FIM Score >90 Discharge FIM Score 54-90 Time to first fracture (years)

    25. Results: Total FIM Score at Discharge and Subsequent Fracture Risk Relative Hazard of Fracture FIM Score At Discharge

    26. Conclusions Fracture rates in this stroke cohort are 2-7 times higher than expected population rates Characteristics associated with lower fracture risk after stroke - high cognitive FIM scores - male gender Stroke patients with intermediate functional impairment are more likely to fracture than those with severe or minimal impairment

    27. Phase III, Multi-center (5), Randomized Clinical Trial A Walking Recovery Trial Duncan et al: BMC Neurol. 2007 Nov 8;7:39.Protocol for the Locomotor Experience Applied Post-stroke (LEAPS) trial Locomotor Experience Applied Post-Stroke (LEAPS)

    28. Baseline Characteristics • 408 Community Dwelling Discharged home independent in BADLs • Ambulatory but less than .8 meters/sec • Moderate Stroke • 99.5% Rankin 2,3,4

    29. Baseline at 2 Months Post-stroke Characteristics Mobility • 62 ±12.7 mean age • 45.1% Female • 22.1% Black or African American • 83% Ischemic • 99.5% Modified Rankin 2-4 • 63.8 days post-stroke at randomization • Mean walking speed = 0.38 ± 0.22 m/s • 53.4% severe impairment (< 0.4 m/s) • 46.6% moderate impairment (0.4 < 0.8 m/s) • Median Number of DailySteps 1738 (708-3483)

    30. Timed Walking Tests Practical Application 10 Meter Walk 408 Randomized 2010 0.2 m/s 0.38 m/s -.15 +.15 -.22 +.22 Gait Speed in Meters/Second

    31. Two Month Baselinen = 384 • Number of steps taken in day • 1738 – range 708 to 3483 • How many steps should one take a day for health and fitness

    32. Timed Walking Tests Practical Application 6 Minute Walk 408 randomized LEAPS DATA: Avg. gait distance at 2 Months 125 Meters 332 Meters (1089 ft.) Minimum distance for comm. re-entry --78 +78 Distance in Meters

    33. LEAPS DATASummary of Falls Post Randomization

    34. Risk of Hip/Femur Fracture 34 Pouwels et al: Stroke 2009 2 fold increase of risk of hip fracture Highest risk within 3 months of stroke Need to implement fall risk management in transitions and in community programs

    35. Results Exercise Duration Maximum METs Achieved Group Group 35

    36. 2 months post stroke individuals discharged home ambulatory They do not walk much They have limited aerobic capacity They have high risk for falls and fractures 36

    37. Current Model T PT Walking/ Balance Mobility Limitation (Gradual Onset) Mobility Limitation (Sudden Onset) Age in Years 37

    38. PT Actual Model Walking/ Balance Mobility Limitation (Sudden Onset) Age in Years

    39. Stroke is A CHRONIC Disease 39

    40. Strategies for Optimizing Function Management of Co-morbid Conditions Secondary Risk Factors Recovery not simply neurorehabilitation More aggressive rehabilitation and recovery program- and they may not have to be high-tech 40

    41. Evidence Cochrane Reviews (2003, 2007): Efficacy of extended home-based rehabilitation programs and physiotherapy in improving functional independence following stroke 50% of patients with limited ambulation have meaningful improvement in LE strength and gait velocity with post-acute stroke rehabilitation Stroke patients can improve their cardiovascular function /endurance Post-Acute Stroke Care 41

    42. WALKING AND MOBILITY-WHAT HAVE WE LEARNED IN THE LAST FEW YEARS TO IMPROVE OUTCOMES ? NEW ENGLAND JOURNAL OF MEDICINE MAY 26, 2011 Body-Weight–Supported Treadmill Rehabilitation after Stroke Pamela W. Duncan, P.T., Ph.D., Katherine J. Sullivan, P.T., Ph.D., Andrea L. Behrman, P.T., Ph.D., Stanley P. Azen, Ph.D., Samuel S. Wu, Ph.D., Stephen E. Nadeau, M.D., Bruce H. Dobkin, M.D., Dorian K. Rose, P.T., Ph.D., Julie K. Tilson, D.P.T., Steven Cen, Ph.D., and Sarah K. Hayden, B.S., for the LEAPS Investigative Team

    43. Multi-site Phase III Randomized Trial of Physical Therapy Interventions to Improve Walking Recovery Post-stroke Pamela W Duncan PhD, PT, FAPTA, FAHA Principal Investigator Andrea L Behrman PhD, PT, FAPTA Co-Principal Investigator Katherine J Sullivan PhD, PT, FAHA Co-Principal Investigator for the LEAPS Investigative Team

    44. Funding from National Institute of Neurological Disorders and Stroke and the National Center for Medical Rehabilitation Research Trial registration: NCT00243919

    45. Why a Trial in Walking Recovery? • Stroke mortality is decreasing, yet stroke remains the leading cause of acquired disability in adults. Roger VL, et al. Heart Disease and Stroke Statistics – 2011 Update: a Report from the American Heart Association. Heidenreich J et al. Circulation 2011;123:e18-209 • Two-thirds of individuals with stroke have significant limitations in walking. • Jorgensen HS, et al. Recovery of Walking Function in Stroke Patients: The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995; 76(1):27-32 • 75% of stroke survivors fall within six months of the stroke. Weerdesteyn V, et al. Falls in Individuals with Stroke. JRRD 2008; 45(8):1195-2014 • Hip fracture risk is doubled after a stroke. Pouwels S, et al. Risk of Hip/Femur Fracture after Stroke. Stroke2009; 40:3281-3285

    46. Walking Speed Predicts Levels of Function and Survival Perry J, et al. Classification of Walking Handicap in the Stroke Population. Stroke 1995; 26:982-989 Schmid A, et al. Improvements in Speed-based Gait Classifications are Meaningful. Stroke 2007; 38:2096-2100 • Community mobility requires walking speed > 0.8 m/s (0.8 m/sec =1.8 mph) • Short community walks are feasible at 0.4 - 0.8 m/s (0.4m/sec=.09 mph) • Walking is limited to the home at <0.4 m/s • Walking speed is associated with survival in older adults Studenski S, et al. Gait Speed and Survival in Older Adults. JAMA 2011; 305(1):50-58

    47. Why this Trial? A body weight support and treadmill system is an emerging modality to improve walking but there is: • Limited evidence to support its value Cochrane Review 2002 & Cochrane Review 2005 • Lack of practice guidelines for training • Appropriate dosing and timing of interventions after stroke are unknown • Growing consensus in clinical practice • that repetitive and progressive practice of stepping using supported treadmill systems is effective • Growing commercial market for BWS treadmill systems and robotic-assisted treadmill steppers

    48. Study Goals LEAPS was designed to determine: • If in addition to Usual Care, a walking training program that includes BWST (LTP) is superior to a home physical therapy program that focused on structured, progressive strength and balance exercises (HEP). • If the timing of intervention delivery for LTP (Early at 2 months after stroke vs. Late at 6 months after stroke) effected recovery. • If degree of initial walking impairment (Moderate vs. Severe) effected response to the interventions.

    49. Interventions1.5 hrs, 3x/wk, 12 wks, structured & progressive programs Locomotor Training Program Home Exercise Program • 20-30 min at 2 mph on TM with BWS • Progression: endurance, speed, BWS, independence, adaptability • Followed by walking practice off the treadmill • 2-3:1 therapist/patient • Strength exercises • Balance exercises • Progression: repetitions, activity, balance challenge, resistance • Encouragement to walk daily • 1:1 therapist/patient

    50. Primary Outcome Measure LEAPS trial definition of “improved functional level of walking ability” Baseline 1 year after stroke Severe > 0.4 m/s < 0.4 m/s > 0.8 m/s Moderate > 0.4 m/s < 0.8 m/s • Perry J, et al. Classification of Walking Handicap in the Stroke Population. Stroke 1995; 26:982-989 Schmid A, et al. Improvements in Speed-based Gait Classifications are Meaningful. Stroke 2007; 38:2096-2100