20 Years in Stroke Rehabilitation: Trials, Tribulations and Tomorrow

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1 20 Years in Stroke Rehabilitation: Trials, Tribulations and Tomorrow Julie Bernhardt Assoc Prof, Director AVERT Very Early Rehabilitation Program, National Stroke Research Institute and School of Physiotherapy, La Trobe University National Stroke Research Institute

2 Trials Outline Stroke rehabilitation research Changes over recent years Quality, funding and new directions Tribulations Challenges faced by clinicians Improving care with tight resources Accessing & staying abreast of evidence Changing practice in the face of new evidence Controlling / leading change Tomorrow What might rehabilitation look like in the future? Take home messages

3 What is Stroke Rehabilitation?..neurological rehabilitation, a scientific adolescent which, as is the way with adolescents, has precocious spending habits Pomeroy & Tallis,, 2002 Rehabilitation costs in the first year after stroke estimated at AUD $ 166 million Dewey et al, 2001

4 Looking Back

5 Looking Back Service provision Post acute in separate facility Outpatient services on discharge Therapy departments close to ward Woodwork valued as an occupational pursuit, patients in long enough to use it!

6 Stroke Rehabilitation Audit, Mount Royal Hospital (1989) Rehab Length of Stay Time from stroke onset to admission to rehabilitation 22.0 days (SD 17.2) *blxxxy acute hosp Stroke rehabilitation average LOS 84.9 days (SD 66.0) Outcome: 75% home, 7.5% Hostel, 16% NH

7 Stroke Rehabilitation Audit, North West Hospital (1995) Rehab Length of Stay Time from stroke onset to admission to rehabilitation 17.6 days 22.0 days Stroke rehabilitation average LOS 54.9 days (SD 32.5) 54.9 days Outcome: 77.2% home, 9.6% Hostel, 13.3% NH

8 Rehab Length of Stay Time from stroke onset to admission to rehabilitation 14.2 days 17.6 days Stroke rehabilitation average LOS 34.9 days (SD 16.5) 84.9 days Outcome: 80.2% home, 9.6% Hostel, 12.0% NH

9 Number of Rehabilitation Beds LOS

10 What else has changed?

11 Rehabilitation Environment Ward Gym

12 How Active Rehabilitation? Author Subjects Location Active therapy Tinson, Rehab 62 min/day Lincoln, SU 46 min/day Mackey, Rehab 45% doing nothing Esmonde, Rehab 33% in therapy, (50% non therapy time doing nothing) Ada, Gym 66% time inactive when alone Bernhardt, SU 24 min/day 53% time inactive, 60% alone Tay, Rehab 21% in therapy 72% day in bedroom

13 What s s Changed? Changed Facilities Models Equipment Paperwork Patient access LOS When rehab starts Same Patient activity MDT Routines (hours) Case conferences No continuum care

14 Number of Rehabilitation Beds 80 Redevelopment LOS Losses / gains

15 Rehabilitation Environments Lost in redevelopment(s) Patient dining area in ward Therapy areas close to ward Nursing / therapist combined staff rooms Close proximity between OT / PT / SP No evidence of benefit BUT No one listened to the clinicians

16 Stroke Rehabilitation Now Fewer inpatient beds but greater diversity in models of care Starts sooner (Day 1!) / shorter LOS? Greater opportunity / imperative to be Evidence based Greater use of technologies Gait labs FES, treadmill training Other equipment typically before evidence

17 Who and what leads change? Administrators, DHS, architects WE SHOULD

18 Trials Outline Stroke rehabilitation research Changes over recent years Quality, funding and new directions Tribulations Challenges faced by clinicians Improving care with tight resources Accessing & staying abreast of evidence Changing practice in the face of new evidence Controlling / leading change Tomorrow What might rehabilitation look like in the future? Take home messages

19 Evidence Based Practice is Good Clinical Practice Clinical expertise (becomes out of date) External evidence (may not be available) Patients views Clinical problem

20 Finding the Evidence I cant find any stroke rehabilitation evidence!

21 Stroke Research Cumulative number of reports of trials Only a small proportion Level 1 or 2 Evidence Clinical effectiveness Measuring outcome Publication year Systematic reviews RCT

22 Stroke Rehabilitation Research PEDro OTseeker Clinical practice guidelines 12 - Systematic reviews RCT s related to stroke ~300 ~300 High proportion are low quality effectiveness trials leading to conclusion Unknown effectiveness

23 Stroke Rehabilitation Efficacy Trials Often too small we expect to have a huge benefit! Unrealistic!! Intervention not detailed / monitored No follow up Use of multiple outcome measures (each trial is different) Do not address possible harms

24 Rehabilitation Benefit If only we could randomise to groups: rehabilitation versus no rehabilitation Some rehabilitation Rehabilitation setting A versus versus More rehabilitation Rehabilitation setting B

25 What benefit might we expect? (Hankey & Warlow,, 1999) Stroke units* Aspirin* tpa* Absolute risk red* 5.6% 1.2% 6.3% NNT Approx cost? Nil added $83 $36,000 *Risk of death / dependency * Level 1 evidence (hard outcome)

26 Langhorne (SUTC), ESC, 2005 Types of Stroke Units Type Admission Discharge Features Acute, intensive Acute, semi-intensive intensive Comprehensive Rehabilitation Acute (hours) Acute (hours) Acute (hours) Delayed Days Days High nurse staffing Life support facilities Close physiological monitoring Days weeks Acute care / rehabilitation Conventional staffing Weeks Rehabilitation Mobile team in hospital Variable Days-weeks Medical / allied health advice Mixed rehabilitation Variable Weeks Mixed patient group Rehabilitation

27 Death Death of or dependency by end by of scheduled follow follow up up 29 Trials, 6536 patients Langhorne (SUTC), ESC, 2005

28 Stroke Rehabilitation Efficacy Trials Often too small we expect to have a huge benefit! Unrealistic!! Intervention not detailed / monitored No follow up Use of multiple outcome measures (each trial is different) Do not address possible harms

29 Why Are Rehabilitation Trials Different? Drug trials* Patient passive Dose straightforward (may be single dose) Double blinding easy Placebo/dose controlled Outcomes simple Confounding variables Costs limited Rehab intervention trials Patient active participant Complex provider / patient interaction Double blinding often impossible Difficult to ensure uniform dose Outcomes made complex Confounding variables Costs high (salaries) Funded by DRUG companies Funded by?????? *Gold standard methods

30 AVERT Large, multi-centre (10 sites) randomised controlled trial of very early rehabilitation versus standard care Best practice RCT methods like a drug trial Hard outcomes (death/disability) with long term follow up (12 months) Multi-disciplinary n > 2000 patients (to detect 7% benefit) 2.8 Million $$ to complete

31 How Do We Improve our Research Base?

32 How Do We Improve Research? Better training opportunities for allied health & nurses Consider cost of interventions Tackle strategic, important, clinical questions Adequate Funding!!! Work collaboratively across disciplines Support research at all levels Student placements Grants

33 Little Funding in the Grand Scheme $ million % All Stroke Rehab 2.7% 0.6% NHMRC, 2005

34 Trials Outline Stroke rehabilitation research Changes over recent years Quality, funding and new directions Tribulations Challenges faced by clinicians Improving care with tight resources Accessing & staying abreast of evidence Changing practice in the face of new evidence Controlling / leading change Tomorrow What might rehabilitation look like in the future? Take home messages

35 Good Clinical Practice Clinical expertise (becomes out of date) External evidence Patients views Clinical problem

36 Who Knows the Evidence?

37 Why Don t t We Change Practice Ability When There is Evidence? Lack of confidence in validity of research findings Lack of confidence in their ability to read and understand research Opportunity Insufficient time to keep up to date Implementation Difficulty making change happen Pollock et al, Clin Rehab, 2000

38 National Stroke Foundation Acute guidelines for stroke (2003) 20 Guidelines supported by Level 1, 2 evidence Rehabilitation and recovery guidelines for stroke (August 2005) The most comprehensive in the world Consumer versions in progress

39 a systematic, accessible, and transparent database of the evidence of effectiveness of interventions in stroke care Lynn Legg

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50 Implementation: Knowing the Evidence Is Not Enough! We have to change our practice Getting started Simple measures of care Access clinical guidelines and try to implement even 1 guideline How will you know you have been successful?

51 Imperatives to Change Cost of rehabilitation Mounting evidence for and against interventions Not only need to adopt those of proven efficacy, must discard those that are ineffective Pressure from consumers Consumer guidelines for best practice stroke care coming soon!

52 Trials Outline Stroke rehabilitation research Changes over recent years Quality, funding and new directions Tribulations Challenges faced by clinicians Improving care with tight resources Accessing & staying abreast of evidence Changing practice in the face of new evidence Controlling / leading change Tomorrow What might rehabilitation look like in the future? Take home messages

53 EBP Stroke Rehabilitation in the Future? Evidence based decision tree Standardised assessment recording tool Best practice care for stroke patients

54 Foundations for a Great Future Thriving multidisciplinary research teams Staff retention Support models for rural and remote facilities No clinician / researcher divide Adequate funding for stroke care / research Range of effective service delivery models (acute+rehab) Better patient outcomes Strong multidisciplinary teams Patients / carers as active participants Removal of ineffective interventions

55 Take Home Messages Stroke rehabilitation has changed radically in 20 years & will continue to do so Evidence to guide practice is more accessible now than ever and MUST be adopted We must lead the change or be led Researchers / clinicians / consumers must work side by side

56 Sugar Plum Fairies Patient Christmas Concert, Mount Royal Hospital 1991

57 Thank you

58 AVERT Phase 3 Very Early Rehab + Standard Care Group n = 1012 Arrive hospital, screened, recruited < 24 hrs Stroke First intervention, < 24 hrs Nurse / PT model Day 7 Ax Day 14 Ax 3 month Ax 1 o outcome 6, 12 month Ax Stratified (NIHSS), blocked randomisation Usual care until discharge Standard Care Group n = 1012 Blinded outcome assessor 1 o outcome death / disability 2 o outcomes complications AQoL, function, costs of care, time to walking

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