Keeping up with the evidence in stroke rehabilitation: new (and newer) developments in the national clinical guideline

Transcription

1 Keeping up with the evidence in stroke rehabilitation: new (and newer) developments in the national clinical guideline Audrey Bowen Stroke Association John Marshall Memorial Professor of Neuropsychological Rehabilitation

2 Outline What changed in the 2016 guideline? What (frustratingly) did not? What s new since the guideline? What s on the horizon?

3 From this...to this

4 A suite of guideline documents Full guideline Easy read Concise guideline

5 Intercollegiate Stroke Working Party Chair ICSWP Prof Tony Rudd CBE National Clinical Director for Stroke ICSWP guideline co-editors Martin James Audrey Bowen Gavin Young

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7 Acknowledgement for all their work RCP Stroke Programme Intercollegiate Stroke Working Party (ICSWP) Members of the ICSWP Sub-group leads & reviewers Lay representatives Peer reviewers

8 questions publish searches revise How is the guideline produced? appraisals public consultation draft recommendations ICSWP consensus

9 Q. Where is rehabilitation in the guideline? Preface includes what s new Key recommendations, Choosing Wisely Chap 1 Introduction Chap 2 Organisation of Services Chap 3 Acute Care Chap 4 Recovery & Rehabilitation??? Chap 5 LT Management, 2 O Prevention Chap 6 Commissioning Services

10 What s new 4/9 topics Key recommendations 12/30 Choosing Wisely 5/10 topics

11 12/30 key recommendations H/ASU resources Ch2 Transfers of care Ch2 Rehab intensity Ch2 Org psychological care Ch2 Care homes Ch2 Early mobilisation Ch3 Work & leisure Ch4 Aphasia assessment Ch4 Hydration and nutrition Ch4 Life after stroke, reviews Ch5 Commission overall service Ch6 Commission specific rehab Ch6

12 Q. Where is rehabilitation in the guideline? Preface includes what s new Key recommendations, Choosing Wisely Chap 1 Introduction Chap 2 Organisation of Services Chap 3 Acute Care Chap 4 Recovery & Rehabilitation Chap 5 LT Management, 2 O Prevention Chap 6 Commissioning Services A. Everywhere & prominent

13 commissioning resources organisation & delivery problems patientcentred guideline

14 Commissioning: what changed? Overall Stroke Services 6.1.1A Commissioning organisations should ensure that their commissioning portfolio includes the whole stroke pathway from prevention (including neurovascular services) through acute care, early rehabilitation, secondary prevention, early supported discharge, community rehabilitation, systematic follow-up, palliative care and long-term support. Rehabilitation Services 6.4.1A Commissioners should commission stroke rehabilitation services in accordance with the recommendations in this guideline to provide: an inpatient stroke unit capable of providing stroke rehabilitation for all people with stroke admitted to hospital; a specialist early supported discharge service to enable people with stroke to receive rehabilitation at home or in a care home; specialist rehabilitation services capable of meeting the specific health, social and vocational needs of people with stroke of all ages; services capable of delivering specialist rehabilitation in out-patient and community settings in liaison with in-patient services.

15 Work: what changed? ADDED C Vocational rehabilitation programmes for people after stroke should include: assessment of potential problems in returning to work, based on the work role and demands from both the employee s and employer s perspectives; an action plan for how problems may be overcome; interventions specifically designed for the individual which may include: vocational counselling and coaching, emotional support, adaptation of the working environment, strategies to compensate for functional limitations in mobility and arm function, and fatigue management; clear communication between primary and secondary care teams and including the person with stroke, to aid benefit claims or to support a return to work.

16 Work: what s on the horizon? RETAKE: RETurn to work After stroke Pragmatic, multicentre RCT with internal pilot, cost-effectiveness evaluation and embedded process evaluation Early Stroke Specialist Vocational Rehabilitation in addition to usual NHS Rehabilitation to usual NHS rehabilitation alone CI, Kate Radford, Starts 1 st July 2017

17 Resources: what changed? SRU should have single MDT including specialists in: medicine; nursing; physiotherapy; occupational therapy; speech and language therapy; dietetics; clin neuropsychology/clin psych; social work; orthoptics; with easy access to...

18 What s new since the guideline? What s on the horizon?

19 Resources What changed? Table 2.1 Recommended staffing levels Psy WTE/5 beds HASU Diet WTE/5 bed ASU What s missing? Community staffing levels??

20 Evidence for: resources recommendations Workforce to provide holistic & compassionate care to patients and families (Francis, 2013) Organised in-patient stroke unit care (Stroke Unit Trialists' Collaboration, 2013) SU minimum staffing levels from observational studies of service reconfigurations & national registries (Ramsay et al, 2015, Turner et al, 2016) SU admission, therapy intensity, psychology QS 1-3 (NICE Quality Standards, 2016)

21 Resources: What s on the horizon? Clark et al 03/17 Cochrane protocol Tyson et al SSNAPIEST

22 Psychological care: what changed? 2.12 Psychological care organisation & delivery A-G A Services for people with stroke should have a comprehensive approach to delivering psychological care that includes specialist clin neuropsych/clin psych input within the multi-disciplinary team. B Services for people with stroke should offer psychological support to all patients regardless of whether they exhibit specific mental health or cognitive difficulties, and use a matched care model to select the level of support appropriate to the person s needs.

23 E Services 4PWS should provide screening for mood & cognitive disturbance within 6wks of stroke (in acute phase of rehab & at transfer of care into post-acute services) & 6 & 12 mths using validated tools & observations over time. F Services for people with stroke should include specialist clin neuropsych/clin psych provision for severe or persistent symptoms of emotional disturbance, mood or cognition. G should consider collaborative care model for management of mod to severe neuropsych problems who not responded to high-intensity psych/pharma. involve collaboration between the GP, primary & secondary physical health services & case management, with supervision from a senior mental health professional & long-term follow-up.

24 Evidence: recommendations for organisation & delivery of psychological care Absence of stroke-specific evidence for stepped care Collaborative care > usual care for depression and anxiety in mental health (Archer et al, 2012) Mostly Working Party consensus, Gillham SIP (2011) & NICE QS (2016)

25 What s not new but should be? general cognition little research apraxia absence of new evidence attention & memory only 1 of sufficient quality executive function & neglect insufficient perception uncertainty anxiety, depression & distress more needed emotionalism not changed

26 What s new since the guideline?

27 ESD: transfers of care from hospital to home 3.8.1E Provide early supported discharge to patients who are able to transfer independently or with the assistance of one person. Early supported discharge should be considered a specialist stroke service and consist of the same intensity and skill mix as available in hospital, without delay in delivery A Hospital in-patients with stroke who have mild to moderate disability should be offered early supported discharge, with treatment at home beginning within 24 hours of discharge. + Recommendations B-E

28 Evidence for: organisation & delivery of ESD ESD reduces dependency & admission to institutional care (Fearon et al, 2012) but some uncertainties about delivery remain NICE guideline (2013b) NICE QS4 (2016) Working Party consensus

29 What s on the horizon? EXTRAS RCT - Helen Rodgers Recruitment closed n= randomised from 21 NHS Trusts ESD + 18 months Final outcome collection September 2017 Results by 2018

30 People in care homes: What changed? Do not routinely provide specialist OT for people who have reached the end of their stroke rehabilitation and are now living in a care home ( Choosing Wisely ). Do offer assessment and activities that might improve quality of life (Sections 2.17 and 5.9).

31 Evidence for: recommendations for people in care homes Rehabilitation for older care home populations MAY slightly reduce disability for some but uncertainty (Crocker et al, 2013) 3mt person-centred, goal-setting by OT/OTA did not benefit disability, mood, QoL (Sackley et al, 2015) Working party consensus

32 Early mobilisation: what changed? B People with acute stroke should be mobilised within 24 hours of stroke onset, unless medically unstable, by an appropriately trained healthcare professional with access to appropriate equipment B Patients with difficulty moving early after stroke who are medically stable should be offered frequent, short daily mobilisations (sitting out of bed, standing or walking) by appropriately trained staff with access to appropriate equipment, typically beginning between 24 and 48 hrs of stroke onset. Mobilisation within 24 hrs of onset should only be for patients who require little or no assistance to mobilise.

33 Evidence for: recommendations for early mobilisation Very early, more frequent, higher dose mobilisation focused on out-of-bed activities led to greater disability at 3mts, no effect on immobility-related complications or walking recovery (AVERT, 2015). Early mobilisation might be best in short, frequent amounts but that hypothesis requires testing (Bernhardt et al, 2016).

34 Consistency across guidelines Removed 3 photos of president s/pm Canada UK US Frequent, out-of-bed activity in very early time frame (within 24 h of onset) not recommended. Mobilization may be reasonable for some with acute stroke in very early time frame and clinical judgment should be used. All patients admitted to hospital with acute stroke should start to be mobilized early (betw 24 h & 48 h of onset)...frequent, short daily mobilisations... typically beginning between 24 and 48 h of onset. Mobilisation within 24 hours of onset should only be for patients who require little or no assistance to mobilise High-dose, very early mobilization within 24 hours of stroke onset can reduce the odds of a favorable outcome at 3 months and is not recommended)

35 Aphasia: very subtle changes Recommendations A People with communication problems after stroke should be assessed by a speech and language therapist to diagnose the problem and to explain the nature and implications to the person, their family/carers and the multidisciplinary team. Reassessment in the first four months should only be undertaken if the results will affect decision-making or are required for mental capacity assessment. B In the first four months after stroke, people with aphasia should be given the opportunity to practise their language and communication with a speech and language therapist or other communication partner as frequently as tolerated. C After the first four months, people with communication problems after stroke should be reviewed to determine their suitability for further treatment with the aim of increasing participation in communication and social activities. This may involve using an assistant or volunteer, family member or communication partner guided by the speech and language therapist, computer-based practice or other impairment-based or functional treatment.

36 Evidence for aphasia Brady et al 2016 updated Cochrane review 57 RCTs, many poor quality 13 RCTs SLT better than no intervention Not at follow up but too few RCTs 5 RCTs no difference SLT vs social support 30 RCTs no difference between interventions Drop outs cloud the evidence Drop out from high intensity but only if early Other evidence of perceived value & impact

37 Aphasia: what s new since?

38 RATS3 Dutch ESJ Feb 17 N=152 Early <85y Intensive vs nothing 1h/d 4/52 ANELT FCET2EC German Lancet Feb 17 N=158 Chronic <71y Intensive vs nothing 10h/w 3/52 ANELT

39 What s on the horizon? UK, N=278, chronic, no upper age limit 3 arm: Self-managed computer therapy vs attention control vs usual care Daily practice encouraged Primary outcome 6/12 words and TOMs Status: collecting outcomes Results 2018

40 What else is new since? Cochrane reviews including: English, Circuit class & mobility June 2017 Mehrholz, assisted training walking, May 2017 Mitchell, dysarthria, Jan 2017 Vloothuis, caregiver mediated exercise, Dec 2016 French, repet. Task training, Nov 2016 Fryer, self-management, Aug 2016 Saunders, fitness training, March 2016

41 Take home messages Rehabilitation is prominent in the guideline Rehabilitation research, bigger & better but Bring them together & aspire to greatness Removed 2 Obama photos and quotes: 2008 campaign speech re we are the change 2014 UN Gen Assembly speech re collective effort