facilitating early rehabilitation in acute stroke patients ... · facilitating early rehabilitation...
TRANSCRIPT
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
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.