Transcript Can physiotherapists predict within 72hours the functional

Eghidemwivbie NT and Schneeweis VA
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Introduction
Importance of early prediction
Research question
Method and materials
Statistics and results
Discussion and conclusion
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Stroke is the third leading cause of death in
the western world (Department of Health and Human Services, 2009)
Due to its disabling nature, predictions of
functional outcomes are necessary
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Stroke units
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Early prediction is important
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Inform patients and relatives
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Plan discharge
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Treatment goals
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How accurate can physiotherapists predict,
within 72 hours after stroke onset and at
hospital discharge, the functional outcome in
terms of dexterity, walking ability, ADLs at six
months and place of living at three and six
months post stroke?
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221 patients
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27 trained assessors
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10 hospitals
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Within 72 hours
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Dexterity
Gait
ADL
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Measured with the Action Research Arm Test
(ARAT)
0-57 points
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Fully functional (=57 points)
Almost fully functional (53-56 points)
Recovered to some extent (10-52 points)
Non functional (0-9 points)
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Measured with the Barthel Index (BI)
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0-20 points
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Complete recovery (19-20 points)
Slightly limited (14-18 points)
Moderately limited (10-13 points)
Severely limited (4-9 points)
Very severely limited (0-3 points)
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Measured with the Functional Ambulation
Categories (FAC)
0-5 points
• Complete recovery on uneven surfaces and slopes
(5 points)
• Almost complete recovery, safe on even surfaces (4
points)
• Only under supervision possible (3 points)
• Only with physical support possible (0-2 points)
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At hospital discharge
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Dexterity
ADL
Gait
Place of living
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At three and six months
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Categorized
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Home
Home with help for basic ADLs
Rehabilitation center
Nursing home
Hospital
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Patients‘ characteristics
Sex (m/f)
Age, years (±SD)
Hemisphere of stroke (L/R)
Type of stroke (OCSP)
TACI
PACI
LACI
CIRS (0-52) (±SD)
MI (0-200)
BFMT upper extremity (0-66)
BFMT lower extremity (0-34)
BFMT Total (0-100)
BBS (0-56)
TCT (0-100)
FAT (0-5)
NIHSS (0-69)
MRS (0-5)
BI (0-20)
FAC (0-5)
ARAT (0-57)
82/104
66.3 (14.1)
81/105
36
62
88
2.56 (2.6)
100.5 (31.0, 151.0)
18.5 (4.0, 53.3)
20.0 (9.0, 29.0)
41.0 (13.8, 79.3)
9.0 (1.0, 39.0)
74 (37.0, 100.0)
0.0 (0.0, 4.0)
8.0 (4.0, 14.0)
4.0 (3.0, 5.0)
7.0 (3.0, 12.8)
1.0 (0.0, 3.0)
1.0 (0.0, 37.0)
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Central tendency and variability statistics
First prediction and
observed outcome
at 6 months
strenght/correlation
Second prediction
and observed
outcome at 6 months
Spearman rank correlation
First Prediction
and observed
outcome
Direction of difference
Second prediction
and observed
outcome
Wilcoxon signed rank test
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p < 0.05
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ARAT
0-57 points
Dexterity
N = 186
AFTER 6 months
BASELINE (within
72 Hours)
≤9
61.3%
10 - 52
27.4%
53 - 56
6.5%
= 57
4.8%
≤≤ 99
30.1%
30.1%
10 - 52
26.9%
53 - 56
10.2%
= 57
32.8%
n=114
n=51
n=12
n=9
n=9
n=56
n=56
n=50
n=19
n=61
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BI
0-20 points
ADLs
N = 185
AFTER 6 months
BASELINE
(within 72
Hours)
≤≤ 33
29.6%
29.6%
n=55
n=55
4-9
32.8%
n=61
10 - 13
16.1%
n=30
14 - 18
14.5%
n=27
19-20
19
- 20
7.0%
n=13
≤≤ 33
3.8%
3.8%
n=7
n=7
4-9
9.1%
n=17
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10 - 13
4.8%
n=9
14 - 18
22.1%
n=41
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19-20
60.2%
n=112
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FAC
0-5 points
Gait
N = 186
AFTER 6 months
BASELINE
(within 72
Hours)
≤2
73.1%
3
10.2%
4
8.6%
5
8.1%
≤≤ 22
12.4%
12.4%
3
4.8%
4
15.1%
5
67.7%
n=136
n=19
n=16
n=15
n=23
n=23
n=9
n=28
n=126
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Accuracy of predictions
Chance
(%)
Predicted at Baseline
Second prediction
%accurate %optimistic %pessimistic %accurate %optimistic
%pessimistic
Outcomes
ARAT (0-57)
25.0
50.54
50.54
28.49
20.97
65.14
25.14
9.72
FAC (0-5)
16.6
64.52
64.52
20.97
14.51
71.43
17.14
11.43
BI (0-20)
25.0
58.92
58.92
26.49
14.59
63.43
22.29
14.28
70.52
16.76
12.72
70.52
15.61
13.87
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Place of living 16.6
at 3 months
Place of living 16.6
at 6 months
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Accuracy level
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Optimism
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Consequences
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Physiotherapists can early predict the
functional outcome in terms of dexterity,
gait, ADL as well as place of living at three
and six months post stroke
Prediction models
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Prof. Dr. Gert Kwakkel and EPOS consortium
Janne Veerbeek and Rinske Nijland
Frank van Hartingsveld
WCF-KNGF
St. Jacob, Zonnehuis en Cordaan/Berkenstede in Amsterdam
Laurens Antonius Binnenweg en Reumaverpleeghuis in Rotterdam
Albert van Koningsbruggen in Utrecht en Wiekendaal in Roosendaal
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Homogenous group
Therapy received
11 patients were discharged within 72 hours
 did not have a second prediction
Variety of clinimetrics
normal setting
Physiotherapists‘ characteristics
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Outcome
Our study
Other studies
Dexterity
Accurate within 72
hours
Kwakkel et al. (2000)
within 2 weeks
Gait
Accurate within 72
hours
Jørgensen et al. (1995)
within 3 weeks
ADL
60%
Duncan et al. (1992)
58%
Place of living
71%
Olai et al. (2006) 78%
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Clinical first-ever stroke in the anterior
(carotid) territory
Above 18 years of age
A hemiparesis within the first 72 hours
Able to follow instructions (either verbally or
non-verbally)
Pre-existent not limited in performing basic
ADLs (Barthel Index >18)
Informed consent.
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47 articles
22 excluded
13 new
found
25 included
in project
plan
9 added
4 excluded
34 included
in the final
article
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