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TREATMENT RECOMMENDATIONS FOR MANAGING THE POST STROKE UPPER LIMB

TREATMENT RECOMMENDATIONS FOR MANAGING THE POST STROKE UPPER LIMB. 7 YEARS LATER: HAS ANYTHING CHANGED? Susan Barreca, MSc. PT Barreca@hhsc.ca. Focus of today’s talk. Examine the uptake of the treatment recommendations of the 2001 Consensus Panel by revisiting the same questions:

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TREATMENT RECOMMENDATIONS FOR MANAGING THE POST STROKE UPPER LIMB

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  1. TREATMENT RECOMMENDATIONS FOR MANAGING THE POST STROKE UPPER LIMB 7 YEARS LATER: HAS ANYTHING CHANGED? Susan Barreca, MSc. PT Barreca@hhsc.ca

  2. 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

  3. 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 panel membersFunded by Ministry of Health and Long-Term Care of Ontario & Heart and Stroke Foundation of Ontario

  4. 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

  5. Critical appraisal of studiesDowns, 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)

  6. 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)

  7. 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]

  8. 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 appearsunsupported]

  9. 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]

  10. 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 What do we mean by upper limb ‘functional recovery’?

  11. 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)

  12. 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

  13. 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)

  14. Key elements Reaching including transport & trunk control Visual Regard Eye & Hand motor coordination Arm & Hand Function Grip, grasp, release to environmental demands Motor, Sensory & Cognitive processes with 2 separate control systems for reach & grasp Anticipatory & in-hand manipulation

  15. 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

  16. 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

  17. 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

  18. Response • Motor learning texts • For task orientated training, clients need some hand muscle activityCarr & 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)

  19. 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)

  20. 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)

  21. 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

  22. Recent prediction studies • Total Fugl-Meyer Motor Score (n=171,17 ±12 SD days) rehab inpatientsShelton 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 physiotherapyvan Pappen et al, 2007 • Integrated Model of Clinical Reasoning Nikopoulou-Symrni & Nikipoulos, 2007

  23. Longitudinal Prospective StudyKwakkel & 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

  24. 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

  25. AD CMSA scale 1-7 AD CAHAI range,13- 91 D/C CAHAI range,13- 91 clinical significant change, >6.3 Arm < 3 (n=78) 23.77 (17.0) 33.06 (24.8) 9.53 (6.16,12.91) 95%CI Arm > 4 (n=50) 55.62 (20.7) 68.98 (20.7) 13.29 (10.53,16.04) Hand < 3 (n=74) 20.68 (13.2) 28.93 (22.0) 8.55 (5.18,11.92) Hand > 4 (n=54) 57.50 (19.0) 71.96 (16.7) 14.36 (11.51,17.21) Profile of Chedoke rehab patients

  26. How many clients achieve true change? (Fischers Exact Test, 2-sided, P= <0.001)

  27. 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 wherethe individual decides what is meaningful • Realistic what the healthcare system will bear

  28. 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)

  29. 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

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