4/8/2013. Nancy Flinn, OTR/L PhD Director of Outcome and Research Courage Center

Transcription

1 Nancy Flinn, OTR/L PhD Director of Outcome and Research Courage Center Courage Center has incentive contracts with a number of payers They pay us extra if we achieve targeted outcomes The outcomes need to improve each year We have a rigorous outcome measurement program Mayo Portland Adaptability Inventory brain injury and stroke Spinal Cord Injury Measure III spinal cord injury Pediatric Evaluation of Disability Inventory Peds Oswestry low back pain These measures are the basis of the incentive contracts Intensive Treatment has been implemented across many Courage Center sites and has been effective in improving client outcomes BIG and LOUD for persons with Parkinson's Disease Modified Constraint Induced Movement Treatment for persons with stroke and brain injury Activity Based Locomotor Exercise for persons with SCI and brain injury/stroke Peds Intensive therapy 1

2 We decided to implement intensive intervention across therapies and Health, Wellness and Fitness programs Staff was very familiar with the principles, because intensive intervention had been the topic of multiple Journal Clubs in the last 2 years And many staff had been trained to use the principles in the intensive programs we were running Because we had been talking about intensive intervention, the staff knew about it But even with encouragement, few staff had implemented the strategies Here are the key studies that supported the process. A series of projects compared intensive models of practice to usual and standard care The outcomes were not quite what was expected. 222 individuals with ischemic stroke Compared CIMT to usual and customary treatment No intensity of treatment match Measured Motor Activity Log (MAL) and Wolf Motor Function Test (WMFT) Wolf, S. L., Winstein, C. J., Miller, J. P. et al. (2006). Effect of Constraint induced movement Therapy on Upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA 296(17),

3 106 subjects with incomplete SCI within 8 weeks of injury Two groups of incomplete SCI treatment Control group over ground training Experimental group body weight supported treadmill They received 12 weeks of equal time of BWSTT or control Maximum number of sessions would have been 60 (five sessions weekly for 12 weeks) Results: No significant differences were found between treatment groups at entry or at 6 months for FIM- Locomotion or walking speed and distance Dobkin, Apple, Barbeau, et al., (2006). Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology, 66,

4 The two groups were treated at different facilities Principles of treatment were Progressively increase task difficulty Be repetitive Maintain attention of subjects Reinforce successful skill acquisition This matched the intensity of the two groups. So, intensity of practice was the factor, not equipment or technique. Multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper limb impairment 6 months or more after stroke Three research arms Intensive robot-assisted therapy Intensive comparison therapy Standard and usual care Intensive comparison and intensive robot-assisted therapy did better than standard and usual care, but no different from each other. Lo, Guarino, Richards, Haselkorn, et al., (2010). Robot-assisted therapy for long-term upper-limb impairment after stroke. New England journal of Medicine, 361, Intensive and Robotic intervention was done 36 hours over 12 weeks. Usual and standard care not defined or tracked. 4

5 This project was funded at $13 million and running over 11 years. 408 participants who had a stroke 2 months earlier Three treatment arms Intensive treadmill training with body weight support 2 months after the stroke Intensive treadmill training with BWS 6 months after stroke Exercise program at home managed by a PT 2 months after the stroke Each intervention included 36 sessions of 90 minutes for 12 to 16 weeks. Duncan, Sullivan, Behrman, Azen, Su, et al., (2011). Body-Weight-supported Treadmill Rehabilitation after Stroke. New England Journal of Medicine, 364(21) No significant differences between locomotor treadmill training and intensive home PT. Early therapy better than later therapy All groups increased in gait speed, endurance 57.6% of all participants reported a fall, and 6% had an injurious fall Home treatment focused on progressive strength and balance training 5

6 New treatment mechanisms with or without technology CIMT, PBWSTT, UE Robotics are not significantly better than more traditional treatment at the same intensity. But, technology may be an easier way to get repetitions, particularly for ambulation of larger or lower functioning patients. ABLE Constraint induced movement treatment BIG GRASP Peds Intensive Therapists who used these programs have common responses: they have been surprised at how hard their clients were able to work. they were have been surprised by how fast clients improved They been surprised at the amount of improvement they saw in their clients They have enjoyed working in these programs because clients make these unexpected gains They all focus on driving central nervous system reorganization, or plasticity, through activity. This whole approach is a big change from the neural systems we learned about when I was in school This new approach to activity based therapy is being applied more broadly, and grew out of constraint induced movement treatment in the 80 s 23 6

7 To drive plasticity in the central nervous system, you need to implement a program that includes a number of characteristics. 1. Use it or lose it use practice to drive specific brain function 2. Use it and improve it training that drives a specific brain function can lead to an enhancement of that function 3. Specificity the nature of the training dictates the nature of the plasticity 4. Repetition matters induction of plasticity requires sufficient repetition 5. Intensity matters induction of plasticity requires sufficient training intensity Kleim, Jones (2008). Principles of Experience-Dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research. 51, S225-S Time matters different forms of plasticity occurs at different times during training 7. Salience matters the training experience must be sufficiently meaningful to induce plasticity 8. Age matters plasticity is easier in younger brains 9. Transference plasticity in response to one training experience can enhance the acquisition of similar behaviors 10. Interference plasticity in response to one experience can interfere with the acquisition of other behaviors Neural circuits not actively engaged in task performance for an extended period of time start to degrade. Not using circuitry because it isn t working can cause that circuitry to degrade further The cortical real estate that isn t being used by that task may be get taken over by another task (TBI in young children) 7

8 Plasticity can be induced in specific portions of the brain through extended training. Is treatment focused on improving specific impaired function? Choose tasks that are the just right challenge. Have client do specific tasks and upgrade frequently, either in the clinic or as their home program. Is the client engaged in recognizable functional activities that activate damaged portions of the brain? Use more realistic activities so that the client can see the relevance. Choose tasks that are difficult for the client (if they are succeeding 80 to 90%, it is too easy; if they are failing more than 50%, it is too hard) Choose tasks that are not compensatory. Have the client perform difficult tasks when they are not in therapy (i.e. home program that is targeted to improvement and that they are doing.) Have the client perform common difficult activities multiple times during a day for their home program. Complex tasks generalize to simpler tasks; simple tasks do not generalize to complex tasks. Training induces improved circuitry Including increasing the number of synaptic responses And increasing dendritic growth and synaptogenesis on the ipsilateral side 8

9 Choose tasks that are the just right challenge. Have client do specific tasks and upgrade frequently, either in the clinic or as their home program. Requires acquisition of a skill and continued practice Practice required until the task is approaching automatic status How will we know if the task is becoming automatic? Dual task Easy to retrieve task Fluid performance Practice must include focus on improving impaired function; practice of unskilled or unimpaired movements does not promote plasticity. Practice must be on the margin of skilled performance. Is the client focused on challenging activities, at the very edge of the client s ability? Avoid use of compensatory movements or skills, unless you have specifically decided that compensation is needed. Practice tasks that are difficult and challenging, at the edge of the client s ability. Upgrade tasks frequently as clients make gains. The client should complete full tasks (i.e. reach, grasp, manipulate, release) 9

10 Simple engaging a neural circuit is not enough learning and relearning of new behavior is necessary for lasting neural changes (rats require several days of training to get increased # of synapses, strength, and cortical map reorganization) How much repetition? Until the individual is consistently using the skill outside of therapy without cues or reminders. Animals that did 400 repetitions a day got neural reorganization, while those that got 60 repetitions a day did not. It may be that early intensity actually causes more damage to the brain (this is in the first days post injury how many is not clear) The same intervention at 2 weeks post caused improved function Repetition drives plasticity, to get the subjects over the hump to a stage of automaticity or easily accessible movement. Neural plasticity is induced through high levels of repetition, in animal research in the range of 400 reps. Is the client practicing tasks to automaticity, where the activity is easily accessible in a variety of environments? How many repetitions do I have my client do on each task within a treatment session? Are there enough repetitions of each task to get instantiation of the synapses? Have the client perform multiple repetitions of a few targeted tasks. Home exercise programs should be designed to include multiple repetitions of tasks, and designed to be performed. Can this client participate in fitness program to build more repetitions? The client should continue repetitions until they are of an automatic nature easy to initiate, consistent, occurring in daily activity on a routine basis. (client could go from performing the activity during therapy, to home program, to incorporated into daily activity.) Have the client perform the task faster. Dual task practice also builds intensity. 10

11 Program developed as a home program for stroke survivors. High repetitions Evidence based program, patients can perform independently Neural plastic change is a process, not an event. There are cascades of neuronal reactions to brain damage that occur over the weeks or months following a BI. If clients are learning compensatory techniques, then relearning of adaptive responses may have to overcome those other processes to be effective A brain injury results in a cascade of biochemical changes in the brain, and response to intervention is greatest when as soon as possible. Is my intervention occurring in the early or late post-stroke period? Is there anything that I can do to make the treatment occur earlier? Emphasize to clients that NOW is the best time for therapy. Consider changing the pattern of therapy appointments 3 times a week for 4 weeks, rather than 12 appointments tapered over 6 or 7 weeks. Consider that time is important, so delays may impact outcomes (i.e. scheduling, transportation problems, etc.) 11

12 Individuals evaluate an event in terms of importance in order for it to be encoded (learn to recognize a tone paired with food, but no other specific tone) Emotions modulate the strength of memory consolidation People will learn tasks that are rewarding or meaningful Plasticity within brain function is dependent upon the salience or meaningfulness of the experience Is the activity I am using with my client meaningful to my client? Could I make this activity more meaningful (through motivational interviewing techniques)? Choose activities that are meaningful to clients. Use measures that will identify meaningful tasks (COPM, Patient Specific Functional Scale, etc.) Make sure that the relevance of activities is clear to patients. Use motivational interviewing to engage clients in their work. I am going to ask you to identify important activities that you are unable to do or are having difficulty with as a result of your problem Unable to Able to perform perform activity activity at same level as before injury or problem Activity Date Date Follow Follow -up -up Stratford (1995) Assessing disability and change on individual patients: A report of a patient-specific measure. Physiotherapy Canada 47:

13 Plasticity is reduced with aging It may be that aging is analogous to an insidious brain insult However, the aging brain is also clearly responsive to experience, although the changes may be less profound or slower Problematic in young children Younger brains are more plastic than older brains. Work in Peds? The ability of plasticity within one set of neural circuits to promote plasticity in other circuits Can use repetitive transcranial magnetic stimulation or peripheral electrical stimulation Exercise may also support plasticity now linked with increased neurotrophic factors in animals, improved cognitive function in humans Exercise in general can increase neurotrophins that promote neuronal grown and survival of vulnerable neurons in the SCI and other brain regions. Is my client doing enough general exercise to drive neural plasticity and transference? Is my client a candidate for a fitness program to increase his overall function? 13

14 Increase the amount of general activity your client is participating in. Teach your client about the importance of fitness at this time and in the future. Increase the repetition of exercise and activity build a routine of activity for the client to participate within their daily routine Stimulation applied outside of training experience, can disrupt the memory consolidation process, or induce plasticity that is not shaped by behavior Compensatory behaviors may be easier to perform that adaptive responses, and thus performed more than adaptive behaviors, and inhibit the development of those adaptive behaviors Early skill training focused on the sound limb (in rats) greatly decreased the effect of later training on the impaired forelimb. Brain injury clients develop compensatory strategies that are easier to perform than more difficult but ultimately more effective strategies acquired in rehab. These ineffective strategies may limit recovery of higher level skills. Am I working on compensatory strategies, rather than on primary recovery? Is that appropriate under these particular circumstance? Identify compensatory strategies that your client is using, and consciously address whether that is appropriate or not. Move clients away from compensatory strategies if possible. 14

15 How do we actually change the clinical practice of our therapists? There are barriers to making changes Insurers aren t going to pay us more for this work. How do we apply these principles? How do therapists change their practice? How will we know if this worked? Skilled therapists work in automatic ways. Insurers have not embraced intensive practice when it is defined as frequency of treatment or total treatment. But some characteristics of intensity are not related to frequency of treatment. Beyond programs such as BIG, LOUD, ABLE, peds intensive, CIMT, how can it be applied to other treatment? There is good evidence that actually changing practice is difficult Not enough to just tell people to do it Need to create a structure to promote change Reward changes Give concrete evidence that change is occurring Give concrete evidence that change is good/worth it Courage staff is skilled and experienced They have extensive experience with a specific challenging population Based on the literature, professionals tend to use techniques they learned in the first couple of years of their practice We are expert in these techniques These techniques are relatively automatic We know what to expect from them We are comfortable with using familiar techniques We all believe they are the best possible techniques we could use 60 15

16 Courage Center has Clinical Practice Groups for each diagnostic group, and we decided to use those as part of the implementation We have had extensive conversations about intensive interventions over the last 2 years, so it was not new We selected representatives from each site and each discipline and each Clinical Practice Group to participate in an Intensive Intervention Implementation Team, to design the implementation The III Team met every other week for 2 months, sometimes in person and sometimes by phone The III Team designed the implementation tools and piloted strategies and evaluation measures Cheat sheet matrix of the literature, so people could pull the articles and read them if they wanted, but could also see a summary of the findings. Self-Assessment for staff to identify where they were in the change process Cheat Sheet, a laminated card with specific strategies The III Team served as links back to the Clinical Practice Groups The III Team piloted these strategies and came back with feedback. Then each of the Clinical Practice Groups were brought on board, made familiar with the materials, and with their roles It was explicitly stated that their job was to take charge of the implementation of the program Then I went to each site and to some departments to launch the program They were introduced to the materials and expectations. Our long-term outcome measurement will be through the organizational outcome measures We wanted a more proximal measure to look at what was happening during implementation. We looked at formal measures, and identified the Borg scale. But it looks at physical exertion, which was not appropriate for interventions that were more cognitively based. 16

17 We asked therapists to rate how much effort their client was putting forth on a 10 point scale. We asked them to ask their clients how much effort they were putting forth on a 10 point scale. We collected this information on all the clients our therapists saw over a 2 day period in October, and then again in early February. Ask the client: How much effort did you put forth during this session? This includes both physical effort and thinking I didn t work at all You are shooting for patient effort of 5 to 8. I couldn t do one more thing We asked staff to spend 10 minutes going through the Self-Assessment, identifying strategies they are using and strategies they are not using. Pick a single strategy and practice it until it is close to automatic. Pick one or two clients, then integrate as many strategies as you can. Use Cheat Sheet for each treatment, adding intensity to each treatment. 17

18 Reps Work: rest ratio Heart rate Weight Respiratory rate Rate of perceived exertion Increased ROM Addition of divided attention Increase cognitive challenge with physical activity Faster performance Increase incline Duration of activity Increase resistance Modify HEP- (with any of the above, decreased # of exercises with increased repetitions) Use of grids etc to increase accountability with HEP Instability of surfaces Increase dynamic / busy environments Variety of positions Increase saliencemake interventions ultimately important and meaningful. Have the conversation with the client you should be working really hard! Increase communication and consistency between fitness/ PT/ OT/ SLP etc to be consistent and increase reps total etc. Decrease cues and assistance Use of tools like IM, wii, games, and metronome to easily increase repetitions Multitasking Ask clients what is meaningful, how they can carry it through into real life We re not good at them (so they don t work well to start off) It doesn t feel comfortable We don t know what to expect It s hard to change a habit, change requires conscious effort But we asked our staff to do it Take some time to reflect on your practice (using the Self-Assessment) 2. Identify opportunities to integrate intensity into your daily treatment 3. Select one strategy to implement, and implement it in a planful way 4. Evaluate your outcomes 5. Talk with your co-workers about what you are doing and how it is going 6. Repeat When we start talking about intensity, the first thought people have is increasing time. That s really not in the scope of this project We can t staff it Insurance won t cover it It s not the focus of this project Our goal is to change the way we deliver treatment within their standard schedule of therapy

19 We d been talking about intensity for a couple of years It isn t doing something new, it s changing how we use the treatment techniques we re using right now How much effort outcome measure prior to start of project, repeated at 2 and 5 months Survey of staff in February and again in April about effects of the project We will look carefully at satisfaction survey to see if there is a change over this time Examine outcome measures for changes Oswestry in March MPAI, SCIM and PEDI in June Correlation between clients and therapists rating of effort r =.60, R 2 =.36 This means that the ~1/3 of the variance in the client score can be predicted from therapist score This means there s not a strong association between client and staff opinions of effort

20 95% of staff reported that it had gone well Clients are making larger, faster and longer lasting gains Focused treatment lead to greater gains Many comments about clients being willing and able to do more reps/wt than previously thought More effective treatment sessions, better HEP compliance I think it's gone very well. It increases efficiency of session as well as targets a specific action to address before moving on to another By focusing both treatment and Home Programs, we are getting better compliance and making greater gains. A patient who had been on and off therapy for a year was asked to perform 100 sit to stands/day for a week. While he had not made gains in transfers for the year, he became independent in standing pivot transfers in a week. The HEP for a child was they she walk everywhere with her Mom and another sibling into the school, to the doctors and therapy, and two other times a day. Within 1 week she was starting to take steps independently Child who had multiple goals with handwriting worked on making circles in multiple situations for a week. Asked her parents to have her copy 25 circles a day. In a week, she was able to write a circle, which she had been a goal for 3 months. Used salience with LBP patient who was very depressed, had to do just one thing every day, making gains, feels like she can do 2 things a day. 20

21 Next Strategies to Try 12 Strategies Implemented use it or lose it repetition salience intensity specificity use it and improve it time matters 0 use it or lose it time matters specificity repetition salience transference use it and improve it I usually pick the task by asking what is one chore, or task at home that is hard for you? then I figure out why, and tackle that. I feel like I am checking in with my clients more and verifying that we are working on techniques and goals that really matter to them, providing more information about why I am making them more a part of the decision making in order for better follow through when they are trying it on their own It has gone well! I have been able to see improvements within sessions and from one session to another at times. I think if I would give any tips it would be to not be afraid to push clients beyond what you think they can handle. Try various ways to increase intensity such as varying exercise Some of time, gains in motor patterns noticeable even before strength gains If one strategy doesn't work, try another! I try to use repetition for an outcome but continue to vary the 35% 30% 25% 20% 15% 10% 5% Client Perception of Client Effort Fall Winter activity to keep interest and motivation high 0%

22 35% 30% 25% 20% 15% 10% 5% 0% Staff Perception of Client Effort Fall Winter The clients who were admitted and discharged before December 1 st had an average change in their Oswestry of 3 points. Those clients admitted and discharged after Dec. 1 st had an average change of 6 points. This is both a clinically and statistically significant difference. Specifically, this was a large change in a group that did not make the same gain as the average clients, so that is also great news. While these outcomes need to be considered preliminary, on a small sample, and only one diagnostic group, it is an early indicator of the outcomes we were hoping for Look for changes in outcomes and satisfaction. Re-survey staff about use and opinions in April/May Finalize plans to support continued use of principles through Orientation Clinical practice groups Occasional activation of the III Team We got 100 pedometers to use with clients across sites collecting some data as to their effectiveness. Questions? Nancy Flinn Nancy.flinn@courage.org 22