Facilitating Early Rehabilitation

in Acute Stroke Patients Using

an Occupational Therapy

Assistant

Dan Bonython & Georgie Hyder

Royal Adelaide Hospital

Central Adelaide Local Health Network

Introduction

> Stroke patients in the acute setting

generally spend 53% of their therapeutic

day resting in bed and a further 28% of

their time sitting with minimal to nil

physical activity.

Bernhardt et al. (2004

Introduction

> Earlier and more aggressive therapies

are associated with better outcomes

Horn et al. (2005

Introduction

So why the disparity?

> Limited resources and staffing levels.

> Healthcare system is challenged to

provide an adequate number of

appropriately skilled health care workers. Lizarondo et al. (2010)

Introduction

Why do stroke patients benefit from

Occupational Therapy?

> Occupational therapy plays an integral

part in the rehabilitation of stroke patients Horn et al. (2005)

> Consistent Occupational Therapy is

associated with significantly improved

functional outcome and greater rates of

discharge home Legg et al. (2007)

Introduction

Aim of the study

> To evaluate the effectiveness of using an

Occupational Therapy Assistant to

provide earlier and more intensive

rehabilitation to acute stroke patients by

measuring functional performance and

quality of life outcomes.

Introduction – Case Study

Introducing Mrs Butler…

> 60 year old female

> Presents to Emergency Department with

a left upper limb weakness

Case Study

OT sees the patient on day 2

Intensive therapy recommended

Who’s going to assist with the therapy??

>The patient?

>The family?

>Nursing staff?

Method Research Design

> A non-blinded, parallel-group superiority

study

> Ethics approval granted by the Royal

Adelaide Hospital Research Ethics

Committee.

> Admission and discharge assessments

Setting and Participants

> Royal Adelaide Hospital, Stroke Unit

> Participants

• >18; Stroke Unit; Stroke diagnosis

• N = 52 (26 control, 26 intervention)

Method

Control

> Standard Occupational Therapy

intervention

Intervention

> Standard Occupational Therapy

intervention

> Daily Occupational Therapy Assistant

therapy

• Personal activities of daily living

• Upper limb therapy

• Functional mobility

Method Outcome measures

> Primary: Modified Barthel’s Index (MBI)

• Objective measure

• 10 items scored on a 5 point scale

• Total score out of 100

>Secondary: EuroQol EQ-5D-3L (EQ-5D)

• Subjective measure

• Five dimensions

• Visual analogue scale

> Other: Length of stay; discharge

destination

Results

00.5

11.5

22.5

33.5

4

Imp

rove

me

nt

in M

ea

n M

BI

Sco

re

Activity of Daily Living

Modified Barthel Index

Intervention

Control

Results

0

5

10

15

20

25

Total score

Imp

rove

me

nt

in M

ea

n M

BI

sco

re

Modified Bathel Index Scores

Intervention

Control

20.6

10.1

Back to Mrs Smith…

> If in the intervention group:

• Capacity to see her daily to perform pROM UL

exercises

• Resulted in multiple positive outcomes

• Had a head start on therapy in rehab

> If in control group

• OT able to see her briefly a couple of times a

week

• Very limited input from family and nursing staff

• Some spontaneous improvements

Results

Quality of life measure

> Improved VAS scores for control and

Intervention however no significant

difference between groups

Length of stay and discharge destination

> No significant difference between groups

Discussion

Limitations

> Non-randomised allocation

> Non-blinded examiners and subjects

> High exclusion rate

> Missed data

> Changed therapist

Discussion

> More evidence is needed

> Investigation on the longer term effects

on the stroke population

> The monetary effect on the health care

system

> Occupational Therapist vs Occupational

Therapy Assistant

Mrs Smith

Back to Mrs Smith one last time…

> Able to reach her rehab goals earlier

Acknowledgements

> Royal Adelaide Hospital Allied Health,

Pharmacy and Nursing Clinical Research

Grant

> Data Management and Analysis Centre,

University of Adelaide

> Occupational Therapy Department, Royal

Adelaide Hospital

> Royal Adelaide Hospital Stroke Unit

References

> Bernhardt, J., Dewey, H., Thrift, A. & Donnan, G. (2004). Inactive and

alone: physical activity within the first 14 days of acute stroke unit care.

Stroke, 35, 1005-1009

> Cadilhac, D.A., Carter, R., Thrift, A.G., Dewey, H.M. (2009). Estimating

the long-term costs of ischemic (IS) and hemorrhagic (ICH) stroke for

Australia: new evidence derived from the North East Melbourne Stroke

Incidence Study (NEMESIS). Stroke, 40, 915–21.

> Horn, S.D., DeJong, G., Smout, R.J., Gassaway, J., James, R. &

Conroy, B. (2005). Stroke rehabilitation patients, practice, and

outcomes: Is earlier and more aggressive therapy better? Archives of

Physical Medicine and Rehabilitation, 86 (Suppl 2), S101 – S114.(Legg

et al. 2007).

> Legg, L., Drummond, A., Leonardi-Bee, J., Gladman, J.R.F., Corr, S.,

Donkervoort, M. et a l. (2007). Occupational Therapy for patients with

problems in personal activities of daily living after stroke: systematic

review of randomised trials. British Medical Journal, 335, 922 – 930.

> Lizarondo, L., Kumar, S., Hyde, L. & Skidmore, D. (2010). Allied health

assistants and what they do: a systematic review of the literature.

Journal of Multidisciplinary Healthcare, 3, 143-153.