Transcript Document

Post-Acute Stroke Care
Stroke is a Chronic Disease : A
Need to Narrow the Gaps and
Expand The Continuum of Care
Pamela W Duncan PhD, FAPTA, FAHA
Professor
Division of Doctor of Physical Therapy
Duke University
1
Stroke Care
Stroke
Hyper
acute
Acute
Rehab
Community
2
Paul Coverdell Registry - NC



13, 283 discharges with 92% NIH
stroke scale > 4
Mean acute stay 4.9 days , Median 3
days
47% discharged directly home to self
care
Paul Coverdell Registry - NC

13% discharged to SNF

12 % discharged to Home Health

14% discharged to IRF
Decade of Stroke

Several Important Messages from
AHA/ASA
5
MESSAGE 1

Stroke is Preventable
• Major campaigns including Power to End
Stroke
6
Message 2
Stroke is an
emergency
 CALL 911

MESSAGE 3

Quality of Stroke Care Matters

GET with the Guidelines for Stroke

Paul Coverdell Registries

Developed Quality Measures for Stroke Care

JACHO Centers of Excellence For Acute Stroke
Care
8
Stroke Care
Stroke
Hyper
acute
Acute
9
Post-Acute Stroke Care

Problem
• Stroke is a chronic condition with
multiple risk factors for continued
decline in health, functional status and
quality of life
• Secondary risk factors

e.g. Hypertension, Atria Fibrillation
(Anticoagulation), Diabetes), Smoking, Obesity,
and Decreased Physical Activity

10
Post-Acute Stroke Care
Existing data suggest that fewer
than 50% of individuals with stroke
have their risk factors assessed,
treated or controlled
 90% of individuals who are overweight
at initial evaluation remain overweight
 51% of individuals who are
hypertensive have BP under control
 Smokers do not quit smoking
 Few participate in exercise program
• AHA Physical Activity and Exercise
Recommendations- 2004
11
Bushnell et al: AVAIL DATA

Only 75% of individuals persist with
secondary prevention medications

Depression is under diagnosed and
under treated

Ghost SS, Williams LS et al:
Medical Care 2005
Depression



Depression is major barrier to
engaging in exercise and recovery
programs
Incidence of Depression range from
18 to 68%
Screen for Depression• Geriatric Depression Measure, BECK
Depression Inventory, or the CESD
14
Barthel > 90 at 3 Months
%
100
90
Normal
80
Depressive
70
60
50
40
30
20
10
0
1.6 - 2.4
2.8 - 3.6
Orpington Scale Ranges
> 3.6
15
Effects of Post-Stroke Depression
–HUGE


Reduces Probability of Independence
in ADLS
Increases Time to Recovery
16

Physical Activity In Individuals With
Mild Stroke less than half of age
matched individuals
 Rand et al Stroke 2009
Death and Re-hospitalizations
Bravata DM et al Stroke 2007

Over 53% of Medicare stroke
survivors die or are readmitted to
the hospital at least once during the
first year after stroke
• 27.2 % one readmission
• 13.2 % dead –one readmission
• 12.9 % dead
Northern Manhattan Stroke Project
Dhamoon et al Stroke 2009
The proportion of patients with functional
independence after stroke declines
annually for up to 5 years,
Greatest in those with no insurance and
Medicaid
Independent of age, stroke severity
Even among those without recurrent stroke
or MI
MMWR- November 2009
Paul Coverdell Registry Across 4
States

49 % of all stroke survivors from
Paul Coverdell registry are
discharged requiring assistance or
dependent in ambulation
20
Post-Acute Stroke Care

Problem
• FALLS




e.g. >50% stroke patients unable to walk at
hospital discharge
Impaired ambulation → falls, fall injuries,
hospital readmission, SNF placement
Decrease cardiovascular functiondeconditioning
Limited Social Participation
21
Whitson, Duncan et al: JAGS 2006

Increase fractures rates in FRG 4-7 (
moderately Impaired- those who
return to the community) ..first year
22
Kaplan-Meier Results: Time to first
fracture
SURVIVAL PROBABILITY
1.0
2.7%
4.7%
0.9
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
TIME TO FIRST FRACTURE (years)
Estimated 1-Year Fracture Rate: 2.7% (95% CI 2.3-3.1%)
Estimated 2-Year Fracture Rate: 4.7% (95% CI 4.1-5.3%)
23
Results: Total FIM Score and
Fracture Risk after Stroke
1.00
0.99
Discharge FIM Score <54
0.98
Survival Probability
0.97
Discharge FIM Score >90
0.96
0.95
Discharge FIM Score 54-90
0.94
0.93
0.92
0.91
0.90
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
1.1
1.2
Time to F irst F racture
1.3
1.4
1.5
Time to first fracture (years)
1.6
1.7
1.8
1.9
2.0
24
RELATIVE HAZARD
Results: Total FIM Score at
Discharge and Subsequent Fracture
Risk
3.0
2.9
2.8
2.7
2.6
2.5
2.4
2.3
2.2
2.1
2.0
1.9
1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
1.0
0
10
20
30
40
50
60
70
80
90
100
110
120
130
DTO TF IM
FIM Score At Discharge
25
Conclusions



Fracture rates in this stroke cohort are
2-7 times higher than expected
population rates
Characteristics associated with lower
fracture risk after stroke
- high cognitive FIM scores
- male gender
Stroke patients with intermediate
functional impairment are more likely
to fracture than those with severe or
minimal impairment
26
Locomotor Experience Applied
Post-Stroke (LEAPS)
Phase III, Multi-center (5),
Randomized Clinical Trial
A Walking Recovery Trial
Duncan et al: BMC Neurol. 2007 Nov
8;7:39.Protocol for the Locomotor Experience
Applied Post-stroke (LEAPS) trial
27
Baseline Characteristics



408 Community Dwelling Discharged
home independent in BADLs
Ambulatory but less than .8
meters/sec
Moderate Stroke
• 99.5% Rankin 2,3,4
28
Baseline at 2 Months Post-stroke
Characteristics
Mobility
• 45.1% Female
• Mean walking speed =
0.38 ± 0.22 m/s
• 22.1% Black or African
American
• 53.4% severe impairment
(< 0.4 m/s)
• 83% Ischemic
• 46.6% moderate impairment
(0.4 < 0.8 m/s)
• 62 ±12.7 mean age
• 99.5% Modified Rankin 2-4
• 63.8 days post-stroke at
randomization
• Median Number of Daily
Steps 1738 (708-3483)
Timed Walking Tests

Practical
Application
10 Meter Walk
408 Randomized 2010
0.2 m/s
0.38 m/s
-.15
5-30 Day Screen
+.15
-.22
Baseline
Limited
Community
Household
Ambulatory Categories
0
0.2
+.22
0.4
0.6
Community
0.8
1
Crossing Street
1.2
1.4
1.6
30
Gait Speed in Meters/Second
Two Month Baseline
n = 384

Number of steps taken in day
• 1738 – range 708 to 3483
• How many steps should one take a day
for health and fitness
31
Timed Walking Tests

Practical
Application
6 Minute Walk
408 randomized
LEAPS DATA:
Avg. gait distance at 2 Months
125 Meters
--78
0
50
100
332 Meters (1089 ft.)
Minimum distance for
comm. re-entry
+78
150
200
250
300
Distance in Meters
350
400
32
LEAPS DATA
Summary of Falls Post Randomization
N=408
Falls/Participants
612/235
Two Falls or more
139
Serious Injury
28/24
Fractures
21
33
Risk of Hip/Femur Fracture

Pouwels et al: Stroke 2009
2 fold increase of risk of hip fracture
Highest risk within 3 months of
stroke
Need to implement fall risk
management in transitions and in
community programs
34
Results
Exercise Duration
10
M oder at e
Sever e
8
Maximum METs Achieved
5. 4+/ - 2. 0
6
4
5
M oder at e
3. 7+/ - 1. 1*
2
Sever e
* p < 0. 05
0
Group
M oder at el
Sever e
E st i mat ed ME Ts
E xer ci se D ur at i on ( mi n)
6. 5+/ - 2. 4*
4
3. 2+/ - 0. 9
3
2
1
* p < 0. 05
0
Group
M oder at el
35
Sever e
2 months post stroke individuals
discharged home ambulatory

They do not walk much

They have limited aerobic capacity

They have high risk for falls and
fractures
36
Current Model
Walking/
Balance
T
Mobility Limitation
(Gradual Onset)
Mobility Limitation
(Sudden Onset)
PT
Age in Years
37
Actual Model
Walking/
Balance
Mobility Limitation
(Sudden Onset)
PT
Age in Years
38
Stroke is A CHRONIC Disease
39
Strategies for Optimizing Function




Management of Co-morbid
Conditions
Secondary Risk Factors
Recovery not simply
neurorehabilitation
More aggressive rehabilitation and
recovery program- and they may not
have to be high-tech
40
Post-Acute Stroke Care
Evidence
• Cochrane Reviews (2003, 2007): Efficacy
of extended home-based rehabilitation
programs and physiotherapy in improving
functional independence following stroke
• 50% of patients with limited ambulation
have meaningful improvement in LE
strength and gait velocity with post-acute
stroke rehabilitation
• Stroke patients can improve their
cardiovascular function /endurance
41
WALKING AND MOBILITY-WHAT HAVE WE
LEARNED IN THE LAST FEW YEARS TO IMPROVE
OUTCOMES ?
NEW ENGLAND JOURNAL OF MEDICINE
MAY 26, 2011
Body-Weight–Supported Treadmill
Rehabilitation after Stroke
Pamela W. Duncan, P.T., Ph.D., Katherine J. Sullivan, P.T., Ph.D.,
Andrea L. Behrman, P.T., Ph.D., Stanley P. Azen, Ph.D., Samuel S. Wu, Ph.D.,
Stephen E. Nadeau, M.D., Bruce H. Dobkin, M.D., Dorian K. Rose, P.T., Ph.D.,
Julie K. Tilson, D.P.T., Steven Cen, Ph.D., and Sarah K. Hayden, B.S.,
for the LEAPS Investigative Team
Multi-site Phase III Randomized Trial of
Physical Therapy Interventions to Improve
Walking Recovery Post-stroke
Pamela W Duncan PhD, PT, FAPTA, FAHA
Principal Investigator
Andrea L Behrman PhD, PT, FAPTA
Co-Principal Investigator
Katherine J Sullivan PhD, PT, FAHA
Co-Principal Investigator
for the LEAPS Investigative Team
Funding from National Institute of
Neurological Disorders and Stroke and
the National Center for Medical
Rehabilitation Research
Trial registration: NCT00243919
Why a Trial in Walking Recovery?
• Stroke mortality is decreasing, yet stroke remains the leading
cause of acquired disability in adults.
Roger VL, et al. Heart Disease and Stroke Statistics – 2011 Update: a Report from the American Heart Association.
Heidenreich J et al. Circulation 2011;123:e18-209
• Two-thirds of individuals with stroke have significant
limitations in walking.
•
Jorgensen HS, et al. Recovery of Walking Function in Stroke Patients: The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995; 76(1):27-32
• 75% of stroke survivors fall within six months of the stroke.
Weerdesteyn V, et al. Falls in Individuals with Stroke. JRRD 2008; 45(8):1195-2014
• Hip fracture risk is doubled after a stroke.
Pouwels S, et al. Risk of Hip/Femur Fracture after Stroke. Stroke 2009; 40:3281-3285
Walking Speed Predicts Levels of
Function and Survival
Perry J, et al. Classification of Walking Handicap in the Stroke Population. Stroke
1995; 26:982-989
Schmid A, et al. Improvements in Speed-based Gait Classifications are Meaningful.
Stroke 2007; 38:2096-2100
• Community mobility requires walking speed > 0.8 m/s
(0.8 m/sec =1.8 mph)
• Short community walks are feasible at 0.4 - 0.8 m/s
(0.4m/sec=.09 mph)
• Walking is limited to the home at <0.4 m/s
• Walking speed is associated with survival in older
adults
Studenski S, et al. Gait Speed and Survival in Older Adults. JAMA 2011; 305(1):50-58
Why this Trial?
A body weight support and treadmill
system is an emerging modality to improve
walking but there is:
• Limited evidence to support its value
Cochrane Review 2002 & Cochrane Review 2005
• Lack of practice guidelines for training
• Appropriate dosing and timing of interventions
after stroke are unknown
• Growing consensus in clinical practice
• that repetitive and progressive practice of stepping
using supported treadmill systems is effective
• Growing commercial market for BWS treadmill
systems and robotic-assisted treadmill
steppers
Study Goals
LEAPS was designed to determine:
1. If in addition to Usual Care, a walking training program that
includes BWST (LTP) is superior to a home physical
therapy program that focused on structured, progressive
strength and balance exercises (HEP).
2. If the timing of intervention delivery for LTP (Early at 2
months after stroke vs. Late at 6 months after stroke)
effected recovery.
3. If degree of initial walking impairment (Moderate vs. Severe)
effected response to the interventions.
Interventions
1.5 hrs, 3x/wk, 12 wks, structured & progressive programs
Locomotor Training Program
Home Exercise Program
• 20-30 min at 2 mph on TM with BWS
• Strength exercises
• Progression: endurance, speed, BWS,
independence, adaptability
• Balance exercises
• Followed by walking practice off the
treadmill
• 2-3:1 therapist/patient
• Progression: repetitions, activity,
balance challenge, resistance
• Encouragement to walk daily
• 1:1 therapist/patient
Primary Outcome Measure
LEAPS trial definition of “improved functional level of walking ability”
Baseline
Severe
Moderate
< 0.4 m/s
> 0.4 m/s < 0.8 m/s
1 year after stroke
> 0.4 m/s
> 0.8 m/s
Perry J, et al. Classification of Walking Handicap in the Stroke Population. Stroke 1995; 26:982-989
Schmid A, et al. Improvements in Speed-based Gait Classifications are Meaningful. Stroke 2007; 38:2096-2100
Prospective
enrollment
Prospective Enrollment
5 -5-30
45 days
post-stroke
dys post-stroke
Initial
contact
& preliminary
Initial
contact
& preliminary
screening
screening from inpatient rehab
Secondary screening
7 wks post-stroke
Phone call to confirm eligibility
Research Design
Tertiary screen: Exercise tolerance test
Baseline assessments 2 mos post-stroke
Stratification (severe, moderate)
Randomization
Early Locomotor Training
training initiated
@ 2 mos
N = 140
Late Locomotor Training
training initiated
@ 6 mos
N = 140
Control
HEP (C)
training initiated
initiated
training
@
@ 22 mos
mos
NN == 120
120
Intervention Type: LTP compared to Control (HEP)
Intervention Time: LTP at 2-months or at 6-months post-stroke
Subject Recruitment
• From April 2006 - June 2009
• From 6 inpatient rehabilitation facilities in
Florida and California
 Brooks Rehabilitation Hospital, Jacksonville, FL
 USC PT Associates, Los Angeles, CA and Centinela Freeman Hospital,
Inglewood , CA
 Florida Hospital, Orlando, FL
 Long Beach Memorial Hospital, Long Beach, CA
 Sharp Rehabilitation Center, San Diego, CA
 Rancho Los Amigos National Rehabilitation Center, Los Angeles, CA
Primary Inclusion / Exclusion Criteria
Inclusion
• Age ≥ 18 years
• Stroke within 45 days and
living in the community at 2
months post-stroke
• Residual paresis in the lower
extremity
• Ability to walk 10 feet with no
more than 1-person
assistance
• Self-selected 10 meter walking
speed less than 0.8 m/s
• Physician approval for
participation
• Passed an exercise tolerance
test
Exclusion
• Dependent in ADLs prior to
stroke
• Pre-existing neurological
disorders
• Multiple co-morbidities that
would be contraindications for
exercise programs
• Inability to travel to treatment
site
• Walking equal to or faster
than 0.8 m/s
Baseline at 2 Months Post-stroke
Characteristics
Mobility
• 45.1% Female
• Mean walking speed =
0.38 ± 0.22 m/s
• 22.1% Black or African
American
• 53.4% severe impairment
(< 0.4 m/s)
• 83% Ischemic
• 46.6% moderate impairment
(0.4 < 0.8 m/s)
• 62 ±12.7 mean age
• 99.5% Modified Rankin 2-4
• 63.8 days post-stroke at
randomization
• Median Number of Daily
Steps 1738 (708-3483)
Hypothesis 1
1 year after stroke, both the LTP-early and LTPlate groups would have a higher proportion of
participants who improved functional level of
walking than would the home exercise group
(HEP).
Functional Outcome by Group at 12-months
80
OR and 95% CI:
0.83, (0.50 - 1.39), P=0.481
60
40
53.8%
51.6%
20
50.4%
0
Proportion with Improved
Level of Functional Walking Ability(%)
1.19,
(0.72 - 1.99),
P=0.501
Early-LTP
Late-LTP
HEP
Hypothesis 2
Improvements in walking speed from baseline to 1-year
after stroke for LTP subjects trained at 2 months will be
significantly greater than for subjects trained at 6 months.
Results:
• Early-LTP mean change in comfortable walking speed was
0.23±0.20 m/s
• Late-LTP mean change in comfortable walking speed was
0.24±0.23 m/s
• No significant interaction between baseline severity of walking
impairment and timing of LTP for walking speed at 1 year
Walking speed trajectory by intervention group and severity
at screening, 2-(baseline), 6-, and 12-months post-stroke*
Severe
Moderate
0.4
0.2
Walking Speed (m/s)
0.6
0.8
All
0.0
Early-LTP
Late-LTP
HEP
2mo
6mo
12mo
2mo
6mo
12mo
2mo
6mo
Time
* Screening at 26.0±11.6 days post-stroke. 2-month baseline = point of
randomization. The bars indicate 95% confidence interval.
12mo
Walking speed trajectory by intervention group and severity
at screening, 2-(baseline), 6-, and 12-months post-stroke*
Severe
Moderate
0.4
0.2
Walking Speed (m/s)
0.6
0.8
All
0.0
Early-LTP
Late-LTP
HEP
2mo
6mo
12mo
2mo
6mo
12mo
2mo
6mo
Time
* Screening at 26.0±11.6 days post-stroke. 2-month baseline = point of
randomization. The bars indicate 95% confidence interval.
12mo
Walking Speed at 6 Months
• Six months after stroke, Early-LTP (0.25±0.21
m/s) and HEP (0.23±0.20 m/s) groups had
similar gains in walking speed and both groups
sustained these gains at 1 year.
• The Late-LTP group (which only received usual
care from 2 to 6 months) improved by 0.13±0.14
m/s at 6 months.
Statistically and Clinically Significant Changes in Outcomes
from 2 mos to 12 mos post-stroke
No differences in improvements across treatment groups
HIGHLY clinically relevant improvements
Early-LTP
(n=139)
Late-LTP
(n=143)
HEP
(n=126)
Overall
p-value
Comfortable Walking Speed
(m/sec)
0.23±0.20
0.24±0.23
0.25±0.22
0.67
6 minute Walking Distance (m)
73.2±69.4
79.0±75.1
85.2±72.9
0.45
Step Activity Monitor (SAM) –
Median of average number
steps/day [25th -75th percentile]
858
[-253, 2422]
1022
[-111, 3009]
1471
[435, 3481]
0.10
Stroke Impact Scale (SIS)
Participation
(range = 0-100)
17.1±25.9
13.1±22.0
14.4±20.6
0.38
SIS ADL/IADL (range = 0-100)
9.6±19.5
9.4±17.2
14.5±19.0
0.07
SIS Mobility (range = 0-100)
13.7±21.6
12.0±19.1
14.2±20.3
0.685
1.7±3.9
1.5±3.7
2.5±4.3
0.13
8.0±7.8
5.9±9.1
8.3±8.78
0.06
Item
Fugl-Meyer LE Score
= 0-34)
Berg Score (range = 0-56)
(range
Preplanned Secondary Analysis of 6 Month Outcomes
Late-LTP (usual care) experienced approximately HALF
the improvement of early intervention groups
LTP
(n=139)
HEP
(n=126)
UC
(n=143)
Overall
p-value
Comfortable Walking Speed
(m/sec)
0.25±0.21
0.23±0.20
0.13±0.14
<0.0001
6 minute Walking Distance (m)
81.8±62.8
75.9±69.3
41.0±47.4
<0.0001
1017
[-102, 2209]
1357
[84, 3382]
566
[-362, 2043]
0.0367
11.8±26.7
14.6±22.9
7.7±20.5
0.0384
SIS ADL/IADL (range = 0-100)
9.8±17.2
13.0±16.9
7.0±17.8
0.0516
SIS Mobility (range = 0-100)
15.3±21.4
14.9±20.0
7.0±15.7
0.0006
Fugl-Meyer LE Score
(range = 0-34)
2.2±3.4
2.4±4.1
1.3±3.3
0.1196
Berg Score (range = 0-56)
8.8±8.1
7.9±8.5
5.3±7.0
0.0018
13.8±20.8
15.6±19.4
6.2±20.2
0.0013
Item
Step Activity Monitor (SAM) –
Median of average number
steps/day [25th - 75th percentile]
Stroke Impact Scale (SIS)
Participation (range = 0-100)
Activities Specific Balance
Confidence Score (range=0-100)
Proportion Who Improved Functional Level of Walking
at 6 Months
6-mo outcomes
Proportion change
Gait speed change
What comprises usual care visits in 2-6 mos poststroke for patients with moderate to severe walking
disability?
For 408 total:
Median number of PT visits = 10.5, [0 to 86 visits)
For LTP
Median number of PT visits = 7, [0-56]
For HEP
Median number of PT visits = 13, [0-86]
For Usual Care only
Median number of PT visits = 11, [0-69]
# of UC PT visits did not have an effect on walking speed outcomes for the
LTP and HEP groups (p=0.287).
# of UC PT visits for UC-only group did have a positive association with
walking speed change adjusting for age and baseline walking speed HEP
groups (p=0.049).
Related Serious Adverse Events
• 10 related serious adverse events
• 9 occurred during intervention
 3 (2.2%) in early LTP
 5 (3.5%) in late LTP
 2 (1.6%) in HEP
Hospitalizations were for
CV symptoms or blurred vision
9 of the 10 participants with related
SAEs returned to intervention
Minor Adverse Events
• 56% of participants reported minor adverse
events
• LTP groups reported more events of dizziness
and faintness during intervention
 Early LTP 7.9%
 Late LTP 5.6%
 HEP 0%
Falls and Falls Rate
The most common minor adverse event was falls
• 57.6% of individuals experienced 1 fall
• 34% experienced multiple falls
• 6% experienced an injurious fall
• More multiple falls in early-LTP group than late-LTP or
HEP (p<0.07)
– Attributable to more multiple fallers in the severe group
receiving early-LTP (p< 0.02)
REHOSPITALIZATIONS- 2 MOS TO 1
YEAR POST STROKE
• ALL 129 (32%)
• ELTP 45 (32.4%)
• LTPT 53 (37.1 %)
• HEP 31 (24.6 %)
• P= 0.09
Conclusions - Primary Analysis
• We did not establish the superiority of locomotor training
that included BWS on a treadmill over rigorous,
progressed, equally dosed, home based physical
therapy.
• The home exercise program had fewer risks.
• The rate of falls suggests that as participants increase
mobility and physical activity they fall more. Clinically,
this suggests that we should partner our mobility training
with more aggressive falls prevention management.
Conclusions - Secondary Analysis
6 months
•
Both programs are effective forms of physical therapy, and at 6 months
both are superior to usual care provided according to current practices.
Patients recover faster and sustain recovery
when the intervention is given early.
•
The patients in the late Locomotor Training Program group made
significant improvements in walking speed, despite the widely held
assumptions and reports that most functional improvements after stroke
are complete by six months.
•
The number needed to treat (NNT) to yield one additional subject
making a transition to a higher functional walking level is 5.8 for HEP
and 5.5 for LTP.
LEAPS: in the context of EBP
For patients in the first year post-stroke who can walk
10 feet but are not walking at speeds >0.8 m/s (1.8
mph):
This randomized trial provides strong and high quality
evidence that:
Structured progressive locomotor training (including
BWSTT) is not superior to an equally rigorous structured
strengthening and balance exercise program for walking
recovery.
Either program is more effective than usual care at 6
months after stroke.
Both interventions have low risks of adverse events, but a
structured exercise program in the home results in fewer
adverse events compared to locomotor training.
HEP May Be More Accessible and Feasible
LTP
HEP
Expensive: BWST system and
treadmill ($50 to $60 K)
2 to 3 physical
therapists/assistants
Inexpensive (resistance bands,
balls, step blocks)
Skill
Requires significant training to
acquire skills
No specialized training required
for physical therapists
Location
Outpatient only
Compliance
Likely less
Home or outpatient
Likely greater when delivered in
the home
Equipment
Staff
1 physical therapist
Cardiovascular Higher heart rate response during
Lower heart rate response
Response
interventions
• More intervention-related
dizziness and faintness
• More multiple falls at 1 year in
E-LTP
Risks
• Related SAEs rare, were CV
related but more observed in
Hypothesis 1:
The functional walking ability (successful recovery of
walking ability, walking speed, endurance) will be greater
with extended training (increasing dose intervals of 12,
24, and 36 sessions) across all intervention groups.
Outcome:
• Across all groups, 43% of completers “leaped” a
functional level of walking ability by 12 sessions.
• 13% more “leaped” by 24 sessions.
• 7% more “leaped” by 30-36 sessions.
75
Getting Beyond the Plateau
J Rimmer- University of Illinois
Rehabilitation
Rehabilitation Setting
Hospital
Rehabilitation Center
Long-Term Care Facility
Outpatient Medical Center
Transitional Setting
University-Based Clinic
Hospital Wellness Facility
Private Clinic
Work-Related Facility
Community Exercise
Community Setting
Home Program
Fitness Center
Recreation Facility
Senior Center
76
Screening for Stroke-Related Impairments
Balance, Gait, Exercise Tolerance
Low risk for Falls
and can Exercise
Independently
Community Wellness
Program
Moderate/High risk for
Falls or cannot Exercise
Independently
Physical Therapy
Evaluation
LE motor control and
sensation, endurance,
balance self-efficacy
Mild
impairment
Supervised Exercise
Program with
PTA/Technician
Moderate
impairment
Physical Therapy
Gait, balance training,
Ther Ex,
orthotic/assistive device
evaluation
77
Community Wellness Programs
• After discharge from formal rehabilitation, many
deficits remain so availability of accessible
community-based wellness programs are essential
•
• Example:
EMPOLI- Community of
PHYSIOTHERAPISTS AND COMMUNITY
PROGRAM
78
Empoli Italy





Geriatrician- Empoli Helath DistrictManages Community Based Programs and
Rehabilitation
Develop Best Practice Models with His
Rehab Provider
Established Community Based Programs
Established clinically relevant data bases
by measuring outcomes
Support of Italian Health Ministry
79
APA PROJECT:
Start: 10.12.2003
Courses: 251
Regular attendance >4200
APA in ASL 11 - Tuscany
Vinci
Cerreto Guidi
Capraia e Limite
Fucecchio
Montelupo
S. Croce S.A.
Castelfranco
Empoli
Montopoli
Montespertoli
S. Miniato
Castelfiorentino
Montaione
Certaldo
Gambassi
Parkinson (10)
Stroke (29)
Lower Limbs in Water (35)
FP & Chronic Back Pain (177)
80
Coordination Center
Community settings
ultiple providers (no-profit and profit)
81
Low cost covered by the participants
82
Preliminary study - Short Physical Performance Battery
4
Repeated chair standing
Gait
4
2
score
score
3
1
0
0
Baseline
6 Months
Baseline
Baseline
6 Months
(Groups: NS, Phases: NS, G*P: P<0.0001)
6 Months
Baseline
6 Months
(Groups: 0,029, Phases: NS, G*P: NS)
APA group
Balance
4
Control group
12
10
score
3
score
Sumary performance score
2
8
6
4
1
2
0
0
Baseline
6 Months
Baseline
(Groups: NS, Phases: NS, G*P: P<0.0001)
6 Months
Baseline
6 Months
Baseline
6 Months
(Groups: NS, Phases: NS, G*P: P<0.0001)
83
Hamilton Depression Scale – 1 year follow
up Included only individuals with
depressive symptoms (HDS >8)
18
15
12
9
6
3
0
*
Baseline
6 Months
*
12 Months
* t – test, p < 0.016, T0-T6 e T0-T12
No differences between T6 and T12
84
Macko et al: JRRD , 325-328,
2008

Adaptive physical activity improves
mobility function and quality of life
in chronic hemiparesis- A MODEL
from ITALY
85
Sustained Model
Walking/
Balance
PT
Community Wellness
Programs/intermittent reassessment
Mobility Limitation
(Sudden Onset)
Age in Years
86
Message 4

We can add quality of life to
stroke survival
What are the implications for
Comprehensive Systems of Care for
Stroke.



Improve transitions in care from acute
care to primary care, rehabilitation, and
community based programs
Expand stroke registries , get with the
guidelines and quality improvement
initiative thru the continuum of care
Case management at community level for
recovery, management of disability,
prevention of secondary complications


Create wellness programs/ physical
activity programs for those with
strokeMOVEMENT MATTERS
Individuals
Health
System
Guiding Principles
1.Empowerment of patients
and families
2.Interdisciplinary and
Community l
Collaborations
3.Evidence informed
practice
4.Accessibility
5.Affordability/Reimbursem
ent
6.Appropriateness of
individuals
7.Sustainability
Reduce Rehosptializations
Improved Functional
Outcome, Improved
Patient Satisfaction
Community
Community Partners and
Programs
Academia / Institutes
Programs & Interventions
Network of Researchers,
Health System Leaders,
Community Partners
Database
Stroke Care Let’s Close the Gap
GET WITH THE GUIDELINES FOR
POST-ACUTE STROKE
Stroke
Acute
Rehab
Community
91