Transcript What Should I Be Doing?

TREATMENT
RECOMMENDATIONS
FOR MANAGING THE POST
STROKE UPPER LIMB
7 YEARS LATER:
HAS ANYTHING CHANGED?
Susan Barreca, MSc. PT
[email protected]
Focus of today’s talk
 Examine the uptake of the treatment
recommendations of the 2001 Consensus Panel
by revisiting the same questions:
What is the most effective way for individuals to
regain function in their paretic upper limb?
Who benefits most?
 Discuss the controversy around the Panel’s
premises that there should be different treatment
goals for individuals whose arms and hands are
at varying levels of motor impairment
Consensus panel members
Funded by Ministry of Health and Long-Term Care of Ontario &
Heart and Stroke Foundation of Ontario
Panel Members
 Dr. Steve Wolf
 Dr. Richard Bohannon
 Dr. Susan Fasoli
 Prof. Ann Charness
 Dr. Vlasta Hajek
 Prof. Kelley Gowland
 Maria Huijbregts
 Jeremy Griffiths
Moderator
Mary Ann O’Brien
Methodologist
Dr. Andy Willan
Consensus exercise process
 Thorough literature review
 Conducted series of meta-analyses
 Developed 6 common clinical scenarios
 Used Chedoke McMaster Stages
 Sackett’s level of evidence (1-IV)
 Formulated treatment recommendations
 Panel voted independently by e-mail
 Recommendations underwent external review
Critical appraisal of studies
Downs, S.Black,N. Epidemiol Community Health, 1998 (27 items)
Inter-rater reliability (n= 3),R2=0.90, 2-tailed,
p=0.002 on 8 observations chosen at random
 RCTs (n=45)
18.8/27 (4.3)
95% CI (10.2, 27)
 COHORTS (n=29)
11.8/27 (3.7)
95% CI (4,19)
 6 SYSTEMATIC REVIEWS (Oxman Guyatt Index)
Evaluation of Consensus Exercise
 Scored 80% by independent SCORE reviewers
using AGREE
 Awarded highest standards of excellence by
Physiotherapy Evidence Based Database
(PedRO) http://www.pedrp.fhs.usyd.edu/index.htl
 Placed on the CMA Infobase Web
http://mdm.ca/cpgs/search/english/results.asp
 Supported by Ottawa Panel Evidence Based
Clinical Practice Guidelines (Topics in Stroke Rehab,
2006)
Effective interventions
 Electrical stimulation (Z= 2.44) & EMG-NMS of
wrist (Z=3.43), ES for shoulder (Z=2.65) [ Wanga,
2002; Popovic, 2003; Kimberly, 2004; Ring &
Rosenthal, 2005; Alon, 2007]
 Constraint-induced movement therapy (Z=9.71)
Suputtitada, 2004; Brogardh & Bengt, 2006, Wolf et al,
2007]
 Sensory-motor retraining including robotic therapy
(Z=4.78) [Fasoli, 2004; Hesse, 2005: Volpe, 2004;
Sawaki, 2006]
Effective interventions
 Home exercises over no treatment (Z=2.22)
 Movement+elevation for hand edema (Z=3.2)
 Shoulder strapping decreasing pain (Z=6.11)
 OT + imagery (Z=3.34) [Dijkerman, 2004, Lui, 2005]
 Repetitive training (Z=2.07): [French, 2007 appears
unsupported]
Interventions not shown effective
• NDT no better than other treatments (Z = 1.49) [Langhammer & Stanghelle, 2003; Van Vliet,
2005; Platz, 2005, Desroisier, 2005]
• Biofeedback alone (7/7) Systematic Review
[Armagan,2003, Hemmen & Seelmen, 2007]
• Low TENS on motor performance (Z=1.33)
or spasticity (Z=1.52)
• Additional training at 6 months (Z=1.56)
[Duncan, 2003; Pang, 2005]
What do we mean by upper limb
‘functional recovery’?
Emphasis on Function
Function is a complex
activity optimally
characterized by efficiency
in accomplishing a task
goal in a relevant
environment
Craik, 1992
Emphasis on Recovery
Recovery is the ability to
achieve task goals
using effective & efficient
means, but not
necessarily those used
before the injury
Slavin et al, 1988
Premise1:Therapeutic goals for
the arm & hand Stage 4 or higher
Provide every opportunity to reduce motor
impairment & improve function
Sensory motor training (level 1 evidence)
EMG-NMS or ES of wrist/forearm (level l
evidence)
Engage in challenging, repetitive & intense
use of novel tasks in order to acquire the
necessary motor skills (level I evidence)
PREMISE 2: Therapeutic goals for
the arm & hand < Stage 3
Maintain a comfortable, pain-free, mobile arm &
hand
 proper positioning, support (AHCPR), careful
handling (level IV evidence)
 teaching the client to perform self-ranging (Expert
Opinion)
 avoid overhead pulleys (level 11 evidence)
 ES (Level I evidence) may reduce shoulder
subluxation in the short term (mean 5 wks)
Maximize recovery using compensatory &
environmental adaptations
Definition of upper limb function
The arm & hand moves as
an integrated unit in various
directions to stabilize, reach,
grasp & manipulate objects of
various sizes & weights
repeatedly (Barreca et al, 2004)
Key elements
Visual Regard
Eye & Hand
motor
coordination
Motor, Sensory
& Cognitive
processes with 2
separate control
systems for
reach & grasp
Reaching
including
transport &
trunk control
Arm & Hand
Function
Grip, grasp,
release to
environmental
demands
Anticipatory &
in-hand
manipulation
Since our recommendations
 Positive response but many clinicians still practice
only NDT, unfamiliar with FES, EMG- FES, have
difficulty managing shoulder pain, experience time
restraints (SCORE addressing these issues)
 Upper limb research still hot but since 2001…..
 Twice as many studies conducted during chronic
phase post stroke vs. subacute stage
 50% of studies examined new interventions not
readily translated into our current inpatient
rehabilitation practice, e.g. CIT, robotics, virtual
reality
Why different remedial goals for
the arm & hand Stage 3 or less
may not be readily accepted
Personal values
 An individual’s confidence in the findings
 French versus Utilitarian philosophical approach
(equality vs. greatest good for the greatest
number)
 Professional values
Professional values
Inherent flexibility and adaptability of neural system
to respond to many factors
Lack of task specific intensive training to utilize
alternative cortical pathways
Validity of predicting outcomes in the arm & hand
Changes in persons whose upper limb is labeled
severe or chronic
Response
Motor learning texts
 For task orientated training, clients need
some hand muscle activity Carr & Shepherd, 2003;
Shumway-Wollacutt & Cook, 2005
 Recent task specific training studies
 Cochrane review showed statistical
significance for task specific training for the
lower extremity, not the upper limb (French,
2007)
Response
 Relationship of U/L sensory motor impairments to
activity
 U/L strength isometrics of shoulder, elbow,
wrist, grip (n=93) explained 87% variance of
CAHAI, a measure of functional arm & hand
performance (Harris & Eng, 2007)
 Active ROM & isometric force production were the
most common predictors of reaching during first 3
months post stroke (Wagner et al, 2007)
Response
 VECTORS: Phase II trial: CIT x 2 hrs, 6 hrs.
constraint vs. CIT, 3 hrs. 90% constraint, 9.4 days
post-stroke, 22.5 on ARAT: high intensity had worse
scores Dromerick, 2007
 Enhanced Exercise: Only those with moderate
impairments improved Duncan, 2004; Winstein, 2004; Pang,
2006 (n=92, 64, 63 respectively)
Prediction validity in the absence of
a prognostic inception cohort study
Predictors Gowland, 1984
Arm = Initial Arm Stage + weeks post stroke (R2 =.80)
Hand = Initial Hand Stage (R2=.78)
Until the mid 1990’s
Wade et al, 1983, De Weerdt, 1987,
Olsen,1990, Duncan, 1992, Nakayama, 1994




initial motor deficit
lack of finger movement first 3 wks.
.90 correlation bet motor & functional recovery
on day 5 sensory & motor scores predicted 74%
variance at 6 months
Recent prediction studies
Total Fugl-Meyer Motor Score (n=171,17 ±12 SD
days) rehab inpatients Shelton et al, 2001
 in lowest quartile, PPV 0.74: FMA low
 highest quartile, PPV 0.86: FMA high
Regression analyses (n=100,rehab inpts, 2-5 wk.
followed at 2, 6,12 months) Feys et al, 2000
 FMA performance predicted 53-89% variance
Risk adjusted outcomes
 Netherlands physiotherapy van Pappen et al, 2007
 Integrated Model of Clinical Reasoning NikopoulouSymrni & Nikipoulos, 2007
Longitudinal Prospective Study
Kwakkel & Kollen, 2007
 101 persons with ischemic MCA infarct followed
during first year
 Outcome measures: change scores of ARAT, FM arm
& hand, Motricity Index arm & leg, cancellation task,
FM balance
Results of regression analyses
FM hand most important relative factor to predicting
improvement on ARAT, p <0.001 followed by FM Arm,
p<0.001
Time was negatively associated with improvement on
ARAT, p <0.001
Stratification beginning but
classification may be misleading
 Double blind RCT Michaelsen et al, 2007 community
dwelling persons (n=30) classified mild or more severe
Intervention: reach with restrained trunk vs reach
without restraint 3x wk/ 5wks.
Mild (FM > 50/66)
Exp (55.3,3.7) Control (57.0,5.7)
More severe (FM < 50) Exp (41.4, 5.5) C (34.6, 10.5)
FMA scores improved, elbow straighter, but not
function as measured with the TEMPA
Profile of Chedoke rehab patients
AD CMSA
scale 1-7
AD CAHAI
range,13- 91
Arm < 3
(n=78)
Arm > 4
(n=50)
Hand < 3
(n=74)
Hand > 4
(n=54)
23.77
(17.0)
55.62
(20.7)
20.68
(13.2)
57.50
(19.0)
D/C CAHAI clinical significant
range,13- 91 change, >6.3
33.06
(24.8)
68.98
(20.7)
28.93
(22.0)
71.96
(16.7)
9.53
(6.16,12.91) 95%CI
13.29
(10.53,16.04)
8.55
(5.18,11.92)
14.36
(11.51,17.21)
How many clients achieve true
change? (Fischers Exact Test, 2-sided, P= <0.001)
< 6.3
>6.3
ARM < 3
49 (63.6%)
28 (36.4%)
ARM >4
15 (30.6%)
34 (69.4%)
HAND < 3
51 (69.9%)
22 (30.1%)
HAND > 4
13 (24.5%)
40 (75.5%)
Meaningful change? For whom?
 Research-Practice Gap (Schuster et al, 1998; Grol, 2001)
 30-40% patients do not receive treatments of
proven effectiveness
 20-25% patients get care that is not needed or
potentially harmful
In US, two camps
 Altruistic where the individual decides what is
meaningful
Realistic what the healthcare system will bear
Meaningful change? For whom?
 Survey of former patients identified 2 major factors
in recovering arm & hand function: (i) using their
paretic upper limb in daily activities; (ii) not having
enough movement to work with Baker, 2007
 Need to consider how we help patients adjust to
their deficits
“Although hope facilitates positive coping (during
rehab), total denial of possible long term
limitations is a negative strategy during this first
stage of living after stroke” (Sabari, 2001)
Concluding remarks
 This is an exciting time for upper limb research
 Many of the 2001 Consensus Panel treatment
recommendations have been accepted
 Controversy still exists over different therapeutic
goals for individuals with differing levels of motor
impairments
 Defining concepts such as function, recovery,
severity, chronicity would help prevent
misunderstandings and foster universal research
practices