TREATMENT RECOMMENDATIONS FOR MANAGING THE POST STROKE UPPER LIMB 7 YEARS LATER: HAS ANYTHING CHANGED? Susan Barreca, MSc. PT [email protected].

TREATMENT TREATMENT RECOMMENDATIONS RECOMMENDATIONS

FOR MANAGING THE POST FOR MANAGING THE POST STROKE UPPER LIMBSTROKE UPPER LIMB

7 YEARS LATER:

HAS ANYTHING CHANGED?Susan Barreca, MSc. PT

[email protected]

Focus of today’s talkFocus 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 membersConsensus panel membersFunded by Ministry of Health and Long-Term Care of Funded by Ministry of Health and Long-Term Care of Ontario & Heart and Stroke Foundation of OntarioOntario & 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

ModeratorMary Ann O’Brien

MethodologistDr. Andy Willan

Consensus exercise Consensus exercise processprocess

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 studiesCritical appraisal of studies Downs, S.Black,N. Epidemiol Community Health, 1998 Downs, S.Black,N. Epidemiol Community Health, 1998

(27 items)(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 Evaluation of Consensus ExerciseExercise

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 interventionsEffective 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 interventionsEffective interventions

Home exercises over no treatment (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]

• 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 (Additional training at 6 months (Z=1.56) [Duncan, 2003; Pang, 2005]

Interventions not shown effective

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

Emphasis on FunctionFunction is a complex activity optimallycharacterized by efficiencyin accomplishing a taskgoal in a relevant environment

Craik, 1992

Emphasis on RecoveryRecovery 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 Premise1:Therapeutic goals for the arm & hand Stage 4 for the arm & hand Stage 4 or higheror higherProvide 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 & handproper 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 Definition of upper limb functionfunction

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 elementsKey elements 

Arm & Hand Function

  Reaching including

transport & trunk control

Visual RegardEye & Hand

motor coordination

Grip, grasp, release to

environmentaldemands

  Motor, Sensory & Cognitiveprocesses with 2 separate controlsystems for reach & grasp

Anticipatory & in-hand

manipulation

Since our recommendationsSince 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 Why different remedial goals for the arm & hand goals for the arm & hand Stage 3 or less may not be Stage 3 or less may not be readily acceptedreadily 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 valuesProfessional 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

ResponseResponse

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)

ResponseResponse

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)

ResponseResponse

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 moderateimpairments improved Duncan, 2004; Winstein, 2004; Pang,

2006 (n=92, 64, 63 respectively)

Prediction validity in the Prediction validity in the absence of a prognostic absence of a prognostic inception cohortinception cohort study 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 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 Nikopoulou-Symrni & Nikipoulos, 2007

Longitudinal Prospective Longitudinal Prospective StudyStudy

Kwakkel & Kollen, 2007Kwakkel & 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 Stratification beginning but classification may be classification may be misleadingmisleading 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) 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) 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 Profile of Chedoke rehab patientspatients

14.36

(11.51,17.21)

71.96

(16.7)

57.50

(19.0)

Hand > 4

(n=54)

8.55

(5.18,11.92)

28.93

(22.0)

20.68

(13.2)

Hand < 3

(n=74)

13.29

(10.53,16.04)

68.98

(20.7)

55.62

(20.7)

Arm > 4

(n=50)

9.53 (6.16,12.91) 95%CI

33.06

(24.8)

23.77

(17.0)

Arm < 3

(n=78)

clinical significant change, >6.3

D/C CAHAI

range,13- 91

AD CAHAI

range,13- 91

AD CMSA

scale 1-7

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

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

ConcludingConcluding remarks remarks