The Hand Hub. Mary P Galea Departments of Medicine and Rehabilitation Medicine (Royal Melbourne Hospital) The University of Melbourne

Transcription

1 The Hand Hub Mary P Galea Departments of Medicine and Rehabilitation Medicine (Royal Melbourne Hospital) The University of Melbourne

2 What prompted this project? 30%-60% of stroke survivors fail to regain functional use of their arm and hand Reduced upper limb function after stroke is associated with poor health-related quality of life and high carer burden Stroke survivors consider their loss of arm function as serious, or more serious, than their impaired walking feel that they have not enough movement to work with' Dissatisfaction with inadequate training possibilities after discharge from hospital Kwakkel et al. 1999; Broeks et al. 1999; Barker et al. 2007; Tyson & Turner 2000; Lai et al. 2002

3 What prompted this project? Low expectations, therefore lower priority given to upper limb training during rehabilitation Insufficient time spent on upper limb activities during rehabilitation (4-10 mins per day) Current dose of intervention is inadequate to drive neural reorganization Kuys et al. 2006; Bernhardt et al. 2007; De Wit et al. 2005; Lang et al. 2009

4 Evidence-practice gap Clinical guidelines for rehabilitation after stroke recommend early, intensive, repetitive, taskoriented training. Current dose of intervention for the upper limb is inadequate National Stroke Foundation, 2010; Lindsay et al. 2010

5 Technology for upper limb rehabilitation Advances in robotics, sensor and game technology can be used to increase practice of upper limb activities Games are more interesting and challenging than physical repetition of tasks in traditional therapy programs Mehrholz et al. 2008

6 Technology for upper limb rehabilitation Robotic devices e.g. Armeo (Hocoma), MIT-Manus Sophisticated algorithms to sense and assist movements of the arm Expensive Coaching devices Neither assist nor resist movement Able to track movement and provide feedback related to the patient s performance through summary statistics, e.g. scores, heat maps Computer games have varying levels of difficulty, and demand different levels of proximal and distal control

7 What did we do? establishment of Hand Hub Comprises several workstations of relatively inexpensive devices ReJoyce (Rehabtronics), Able-X & Able-M (Im-Able) Facilitate activities appropriate for patients with varying levels of severity of arm and hand impairment Equipment available for individual sessions with patients Hand Hub usually operates as group sessions supervised by an OT and an allied health assistant.

8 Processes Discussions with medical and allied health staff to address potential barriers to implementation Obtaining equipment Refurbishment of a dedicated space in the Occupational Therapy department Agreement on processes for referral, intervention and assessment Reorganisation of outpatient clinics to include an Upper Limb Clinic Referral to Upper Limb Clinic by hospital and external clinicians and GPs Assessment procedures: Functional Independence Measure, Arm Activity Measure (ArmA), Goal Attainment Scale, Wolf Motor Function Test (abbreviated), EQ-5D Treatment: minimum 18 sessions (3 times per week for 6 weeks)

9 Able-M and Able-X

10 ReJoyce

11 Evaluation using a Quality Improvement Approach Inclusion criteria: Over 18 years Stroke, MS, brain tumours Assessed as being able to benefit from the program Able to communicate in English Exclusion criteria: Medically unstable Unable to travel to the centre for the program Significant musculo-tendinous or bony restrictions Severe spasticity, significant co-morbidities (end-stage cardiac failure etc.), severe cognitive deficits, or severe receptive dysphasia

12 Intervention and assessment Delivered via individual or group sessions for a period of up to six weeks, additional to the patients regular therapy. Patients were assessed before and after the program using validated measures: Arm Activity Measure (ArmA) Streamlined Wolf Motor Function Test Modified Ashworth Scale EQ-5D FIM

13 Results 92 participants completed both assessments Mean age 57±17 years 58% male 88% with stroke Significant improvement in: Arm function and strength Streamlined Wolf Motor Function Test score Muscle tone on the Modified Ashworth Scale Functional Independence Measure (locomotion, mobility and psychosocial subscales Quality of life (EQ-5D) and overall health

14 What went well? Very positive responses from patients and therapists Enjoyment, motivation and socialisation Increased awareness by therapists and rehabilitation consultants of the need to provide options for early rehabilitation of the upper limb Ongoing issues Limited hours of operation - staffing Service offered more to outpatients than inpatients Demand far greater than what can currently be provided, resulting in a significant wait list Only group programs can be offered for individuals outside of the Hospital s geographical boundaries

15 Key outcomes Increased opportunities for upper limb rehabilitation within a group context, reducing therapist one-on-one time Significant improvements in arm function and quality of life Games are cognitively engaging result in improvements in attention, memory and visual perception Patients must use the affected limb in either unilateral or bilateral tasks, thus reducing the potential for a disuse syndrome The graded nature of the games ensures patients can be increasingly challenged as they improve

16 Lessons learned Need to proactively address barriers to practice change, at both the organizational and individual level e.g. ongoing training of staff and promotion of the service internally and externally Adapt referral and assessment processes to meet key stakeholder needs, e.g. include outpatient access unit staff in the process for developing a clinical referral form Maintain regular communication with all key stakeholders in order to maintain engagement in the change management process

17 Future plans Extension of Hand Hub into ward areas to ensure inpatients receive intervention Tele-rehabilitation rehabilitation for the upper limb Qualitative study exploring experiences, attitudes, knowledge and behaviour of staff in relation to the Hand Hub Cost-effectiveness analysis

18 Acknowledgments Royal Melbourne Hospital Rehabilitation Consultants Prof Fary Khan Dr Alaeldin Elmalik Dr Senen Gonzalez Dr Geoff Abbott Occupational Therapists Colin Steel Marlena Klaic Rebecca Wallace Funding Victorian Department of Health Engineers Arthur Prochazka University of Alberta, Canada - ReJoyce Marcus King - Callaghan Innovation NZ Able-X and Able-M