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Bridging Evidence into Practice

GINA DUBUISSON PT,CSRS

dubuisson@verizon.net

GDubuisson@jfkhealth.org

OBJECTIVES

1. Participants will be able to identify the most effective

patient care setting for improved outcomes post-stroke, based on current evidence.

2. Participants will be able to identify the most effective

interventions for post-stroke gait and functional mobility deficits, based on current evidence.

3. Participants will be able to design a treatment plan for

patients post-stroke, using practical approaches to evidence based interventions.

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STROKE STATISTICS

1. Each year approximately 795,000 people have their first

or a recurrent stroke.

2. It is the fourth leading cause of death and leading cause

of long term disability in adults.

3. For Medicare patients discharged from the hospital

after stroke, ≈45% return directly home, 24% are

discharged to inpatient rehabilitation facilities, and 31% are discharged to skilled nursing facilities (Go, Mozaffarian, Roger 2014)

STROKE STATISTICS

A study of ischemic stroke survivors who were ≥ 65, found that 6 months post stroke:

1. 50% had some hemiparesis

2. 30% were unable to walk without some assistance

3. 26% were dependent in activities of daily living

4. 26% were institutionalized in a nursing home

A survey of stroke survivors in 21 states found that only about 30 % received out-patient rehabilitation (Go, Mozaffarian, Roger 2014)

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Evidence on Stroke Rehabilitation

What is the most effective type of care post-stroke ?

Specified Acute Stroke Care and Stroke Rehabilitation programs have been shown to be most effective in the treatment of stroke

Strong level 1a evidence that dedicated acute care stroke units-

1.Reduce the need for institutionalization

2. Show a reduction in death rates from stroke and reduce the likelihood of death

3. Reduce the likelihood of dependency post stroke

(Teasell, Hussein 2013; www.guideline.gov).

Evidence on Stroke Rehabilitation

Patients admitted to an acute and then in-patient rehabilitation stroke unit

Strong level 1 a evidence of:

1. reduced rate of death 2. reduced rate of dependency, 3. decreased hospital length of stay, 4. decreased need for institutionalization, 5. improved functional outcomes.

Patients admitted to subacute stroke units

Strong level 1a evidence of reduction in mortality and dependency when compared to a general rehab unit.

(Teasell, Hussein 2013; www.guideline.gov).

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More on Stroke Specific Rehabilitation

• For mild strokes- no evidence that specialized stroke care

makes a difference in outcomes

• For moderately severe strokes- treatment on stroke unit

improves functional outcomes but not mortality.

• In severe strokes- treatment on a stroke unit does reduce

mortality but does not improve outcomes or need for

institutionalization.

(Teasell, Hussein 2013; www.guideline.gov).

Evidence on Predictors for

Outcomes

1. Severity

2. Age

3. Balance- A study by Veerbeek in 2011 looked at non-ambulatory patients 72 hours post stroke. Those that had good sitting balance and some hip and knee recovery had increased chance of becoming ambulating independently in 6 months versus those who could not. Many other studies point to the importance of trunk control and sitting balance as predictors of good outcomes.

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Evidence on Interventions

1. Therapeutic Exercise

2. NDT and PNF

3. Task Specific Training

4. Orthosis

5. Other beneficial activity

1. Therapeutic Exercise

Cardiovascular training

• Multiple health and government organizations are now recommending cardiovascular training for stroke patients to prevent secondary complications and to improve overall function

• Several RCTs have shown positive outcomes in VO2 peak aerobic capacity, walking speed and endurance

• 1 RCT found improvement in balance

• No direct correlation with improvement in ADL or functional outcomes have been shown (Teasell et al 2013)

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Therapeutic ExerciseStrength training

Mixed outcomes, some showed positive and some showed no long term benefits related to basic resistance training (Teasell et al 2013).

Balance training

Stroke is the leading risk factor for falls in older adults, 6x more likely to fall. Improved balance has been shown to be a strong predictor of increased distance walked post-stroke (Pohl, Perera, Duncan et al 2004).

Strong level 1a evidence that balance training improves functional outcomes post-stroke. In particular, improved sitting balance shows a high correlation to improved outcomes(Veerbeek, Wegen, Wel 2011, Teasell et al 2013)

Bridging Evidence into Practice

1. Cardiovascular

I. Seated for more involved patients

II. Best with UE use, but only if no sublux and some pain-free

AROM at shoulder and elbow. May need assistance with grip.

III. Treadmill and cross training for less involved

2. Strength

I. Maintain ankle ROM for improved transfers

II. Trunk ROM and strength for postural alignment, balance and

mobility. Eg. Push/pull, resistance in all directions

III. Hip extension and knee flex ROM and strength

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Bridging Evidence into Practice

3. Balance

I. Assess and address somatosensory, visual and

vestibular components then increase difficulty by

adding cognitive and dual task activity.

II. Modified Clinical Test for Sensory Interactions on

Balance (mCTSIB)

Strength and Balance training

Trunk mobility & strength

Sitting balance/core/ UE wt bearing

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2. NDT and PNF• NDT is most widely studied and compared of all

restorative treatments with a good number of RCTs

• A few studies point to the short term effects on

improvement in movement quality.

• Strong level 1a that Bobath (NDT) is not more effective

than other restorative treatment approaches such as PNF

and Motor Learning protocols(Teasell et al 2013)

• Conflicting level 4 evidence that Motor Learning Approach is better that NDT but moderate level 1b

evidence that Motor Learning approach reduces LOS compared with NDT( Langhammer et al 2000)

• PNF ??? evidence is limited and inconclusive

2. NDT and PNF bridging the evidence

• Evidence that it is not superior, but not that it is ineffective.

• Neuro-facilitation and re-education techniques are important in normalizing movement to improve efficiency and function.

• Use them to improve movement within a functional training task.

• Use them to equalize weight bearing and body symmetry.

• If you are not trained, don’t worry !!

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3. Task Specific TrainingThere is longer lasting cortical reorganization in stroke patients when they are involved in task specific activities (Teasell, Hussein 2013).

• Strong level 1a evidence that task specific gait training can improve gait in stroke patients

• Shown in multiple studies to improve gait speed and endurance

• Practice what is meaningful for the patient. If they need to learn how to walk we have to walk with them as much as possible. Use the existing motor plan to improve function.

Task Specific Training

Review of 7 RCTs performed by English et al looked at task specific training in a circuit training set-up.

All the studies showed positive outcomes for balance, gait

speed and ambulation distance, despite great variation in length of session and time post-stroke (English, Hillier 2011).

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Task Specific Training

Treadmill training without

PBWS

• Limited evidence that treadmill

training without PBWS is more

effective than standard gait training.

• However, studies looking at the

cardiovascular and endurance aspect

show positive results (Macko et al

2005, Langhammer et al 2012, Teasell

et al 2013).

Treadmill training with PBWS

• Mixed results that there is significantly greater benefit. In a review of 7 studies with good PEDroscore and good sample size. Three showed positive results and 4 showed no significant difference (Teasell et al 2013).

• LEAPS trial (480 participants). Multi centre RCT in phase 3, showed no difference in gait speed, ADLs, social participation between the 3 groups (early PBWS, late PBWS, HEP) at 1 year out (Duncan et al 2011).

• More recent studies are pointing towards positive results.

Task specific training and intensity

• According to animal neuroplasticity studies it takes 400-600 repetitions of a task to cause permanent change (Kimberley et al 2010).

• Studies have been performed where intensity focus was on number of repetitions for a specific task not length of session. Three RCT studies looked specifically at sit to stand training performed in addition to traditional therapy. Sessions varied from 15 to 45 mins.

• Results showed positive effects on weight bearing through affected limb, increased independence and balance during sit to stand transfers (Barreca et al 2004; Britton et al; Tung et al 2010).

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Bridging Evidence into Practice

1. Perform gait and transfer training in a meaningful way with high repetitions and increased intensity.

2. Intensity can be addressed by increasing speed over distance which can be used in goal setting. Resisted sit to stands or ambulation.

3. Use treadmill training without PBWS for cardiovascular benefits, increasing repetitions and intensity. Use PBWS in gait training for step length, cadence, weight shift and weight bearing for less involved patients.

Bridging Evidence into Practice

4. Treadmill training with PBWS allows for early mobility of more involved patients and increased task specific practice. Generally at 20-40 % BWS in most studies. Speed should be as close as possible to normal walking speed, 2-3x/ week, for 15-20 mins (http://guideline.gov).

5. If the parallel bars are too restrictive use a hallrail/railing for improved facilitation and handling. Great for Pusher Syndrome and ataxia.

6. Use lift equipment and body weight harness to assist with safety and initial standing to initiate practice earlier.

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Evidence on OrthosesTraditional AFO

Strong evidence that AFO’s improve hemiplegic gait pattern but limited evidence that they improve the parameters of gait (Teasell et al 2013).

FES type orthoses

Strong evidence that FES in conjunction with traditional gait training improves hemiplegic gait by improving DF during swing phase of gait. Research shows direct benefit to improvement of gait speed.

•

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Bridging the Evidence on Orthoses

Traditional AFOs

• Keep supply of plastic and carbon-fiber off-the-shelf

AFOs to trial with patients to improve stability and

confidence during gait training.

• Allows for earlier mobility and repetitive practice of

appropriate gait patterns.

Bridging the Evidence with Orthoses

FES shows good carry-over.

Start with a traditional FES even in acute rehab.

Begin with functional pre-

gait activities then progress to using a heel switch

during gait training.

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Walkaide-activated by inclinometer and can be used without shoes

Bioness L300- foot switch and sensor attached to shoes. Plus model includes thigh cuff for hamstrings

FES Orthosis

Other Beneficial Interventions

mCIMT Mirror Therapy Mental Imagery

• Extensive research on mCIMT showing positive results.

• Some positive results in research and in practice for others,

but require little one on one time.

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References

Barreca, S., Sigouin, C. S., Lambert, C., & Ansley, B. (2004, 12). Effects of Extra Training on the Ability of Stroke Survivors to Perform an Independent Sit-to-Stand: A Randomized Controlled Trial. Journal of Geriatric Physical Therapy, 27(2), 59-64. doi: 10.1519/00139143-200408000-00004

Britton, E., Harris, N., & Turton, A. (2008, 12). An exploratory randomized controlled trial of assisted practice for improving sit-to-stand in stroke patients in the hospital setting. Clinical Rehabilitation, 22(5), 458-468. doi: 10.1177/0269215507084644

Duncan, P. W., Sullivan, K. J., Behrman, A. L., Azen, S. P., Wu, S. S., Nadeau, S. E., Hayden, S. K. (2011, 01). Body-Weight–Supported Treadmill Rehabilitation after Stroke. New England Journal of Medicine, 364(21), 2026-2036. doi: 10.1056/NEJMoa1010790

English, C., & Hillier, S. (2011, 12). Circuit class therapy for improving mobility after stroke: A systematic review. Journal of Rehabilitation Medicine, 43(7), 565-571. doi: 10.2340/16501977-0824

Garland, S., Willems, D. A., Ivanova, T. D., & Miller, K. J. (2003, 12). Recovery of standing balance and functional mobility after stroke. Archives of Physical Medicine and Rehabilitation, 84(12), 1753-1759. doi: 10.1016/j.apmr.2003.03.002

Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Blaha, M. J., ... Turner, M. B. (2014, 12). Heart Disease and Stroke Statistics--2014 Update: A Report From the American Heart Association. Circulation, 129(3), E28-E292. doi: 10.1161/01.cir.0000441139.02102.80

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ReferencesKimberley, T. J., Samargia, S., Moore, L. G., Shakya, J. K., & Lang, C. E. (2010, 12). Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke. The Journal of Rehabilitation Research and Development, 47(9), 851. doi: 10.1682/JRRD.2010.02.0019

Langhammer, B., & Lindmark, B. (2012, 12). Functional Exercise and Physical Fitness Post Stroke: The Importance of Exercise Maintenance for Motor Control and Physical Fitness after Stroke. Stroke Research and Treatment, 2012, 1-9. doi: 10.1155/2012/864835

Macko, R. F., Ivey, F. M., Forrester, L. W., Hanley, D., Sorkin, J. D., Katzel, L. I., Goldberg, A. P. (2005, 12). Treadmill Exercise Rehabilitation Improves Ambulatory Function and Cardiovascular Fitness in Patients With Chronic Stroke: A Randomized, Controlled Trial. Stroke, 36(10), 2206-2211. doi: 10.1161/01.STR.0000181076.91805.89

Pohl, P. S., Perera, S., Duncan, P.W., Maletsky, R., Whitman, R., Studenski, S. (2004) Gains in distance walking in 3-month follow-up poststroke: what changes? Neurorehabilitation and neural repair, 18(1), 30-36

NGC is a public resource for evidence-based clinical practice guidelines. (n.d.). Retrieved May 28, 2014, from http://guideline.gov/

Teasell, R., Hussein M., (2013) Clinician’s Handbook, Section 4a:Motor Rehabilitation Retrieved May 28, 2014, from http://www.ebrsr.com/

Tung, F. L., Yang, Y. R., Lee, C. C., & Wang, R. Y. (2010, 12). Balance outcomes after additional sit-to-stand training in subjects with stroke: A randomized controlled trial. Clinical Rehabilitation,24(6), 533-542. doi: 10.1177/0269215509360751

Veerbeek, J. M., Wegen, E. E., Wel, B. C., & Kwakkel, G. (2011, 12). Is Accurate Prediction of Gait in Nonambulatory Stroke Patients Possible Within 72 Hours Post stroke?: The EPOS Study. Neurorehabilitation and Neural Repair, 25(3), 268-274. doi: 10.1177/1545968310384271