Facilitating Early Rehabilitation in Acute Stroke Patients Using an Occupational Therapy Assistant Dan Bonython & Georgie Hyder Royal Adelaide Hospital Central Adelaide Local Health Network
Introduction > Stroke patients in the acute setting generally spend 53% of their therapeutic day resting in bed and a further 28% of their time sitting with minimal to nil physical activity. Bernhardt et al. (2004
Introduction > Earlier and more aggressive therapies are associated with better outcomes Horn et al. (2005
Introduction So why the disparity? > Limited resources and staffing levels. > Healthcare system is challenged to provide an adequate number of appropriately skilled health care workers. Lizarondo et al. (2010)
Introduction Why do stroke patients benefit from Occupational Therapy? > Occupational therapy plays an integral part in the rehabilitation of stroke patients Horn et al. (2005) > Consistent Occupational Therapy is associated with significantly improved functional outcome and greater rates of discharge home Legg et al. (2007)
Introduction Aim of the study > To evaluate the effectiveness of using an Occupational Therapy Assistant to provide earlier and more intensive rehabilitation to acute stroke patients by measuring functional performance and quality of life outcomes.
Introduction Case Study Introducing Mrs Butler > 60 year old female > Presents to Emergency Department with a left upper limb weakness
Case Study OT sees the patient on day 2 Intensive therapy recommended Who s going to assist with the therapy?? >The patient? >The family? >Nursing staff?
Method Research Design > A non-blinded, parallel-group superiority study > Ethics approval granted by the Royal Adelaide Hospital Research Ethics Committee. > Admission and discharge assessments Setting and Participants > Royal Adelaide Hospital, Stroke Unit > Participants >18; Stroke Unit; Stroke diagnosis N = 52 (26 control, 26 intervention)
Method Control > Standard Occupational Therapy intervention Intervention > Standard Occupational Therapy intervention > Daily Occupational Therapy Assistant therapy Personal activities of daily living Upper limb therapy Functional mobility
Method Outcome measures > Primary: Modified Barthel s Index (MBI) Objective measure 10 items scored on a 5 point scale Total score out of 100 >Secondary: EuroQol EQ-5D-3L (EQ-5D) Subjective measure Five dimensions Visual analogue scale > Other: Length of stay; discharge destination
Improvement in Mean MBI Score Results 4 3.5 3 2.5 2 1.5 1 0.5 0 Modified Barthel Index Intervention Control Activity of Daily Living
Improvement in Mean MBI score Results 25 20 Modified Bathel Index Scores 20.6 15 10 10.1 Intervention Control 5 0 Total score
Back to Mrs Smith > If in the intervention group: Capacity to see her daily to perform prom UL exercises Resulted in multiple positive outcomes Had a head start on therapy in rehab > If in control group OT able to see her briefly a couple of times a week Very limited input from family and nursing staff Some spontaneous improvements
Results Quality of life measure > Improved VAS scores for control and Intervention however no significant difference between groups Length of stay and discharge destination > No significant difference between groups
Discussion Limitations > Non-randomised allocation > Non-blinded examiners and subjects > High exclusion rate > Missed data > Changed therapist
Discussion > More evidence is needed > Investigation on the longer term effects on the stroke population > The monetary effect on the health care system > Occupational Therapist vs Occupational Therapy Assistant
Mrs Smith Back to Mrs Smith one last time > Able to reach her rehab goals earlier
Acknowledgements > Royal Adelaide Hospital Allied Health, Pharmacy and Nursing Clinical Research Grant > Data Management and Analysis Centre, University of Adelaide > Occupational Therapy Department, Royal Adelaide Hospital > Royal Adelaide Hospital Stroke Unit
References > Bernhardt, J., Dewey, H., Thrift, A. & Donnan, G. (2004). Inactive and alone: physical activity within the first 14 days of acute stroke unit care. Stroke, 35, 1005-1009 > Cadilhac, D.A., Carter, R., Thrift, A.G., Dewey, H.M. (2009). Estimating the long-term costs of ischemic (IS) and hemorrhagic (ICH) stroke for Australia: new evidence derived from the North East Melbourne Stroke Incidence Study (NEMESIS). Stroke, 40, 915 21. > Horn, S.D., DeJong, G., Smout, R.J., Gassaway, J., James, R. & Conroy, B. (2005). Stroke rehabilitation patients, practice, and outcomes: Is earlier and more aggressive therapy better? Archives of Physical Medicine and Rehabilitation, 86 (Suppl 2), S101 S114.(Legg et al. 2007). > Legg, L., Drummond, A., Leonardi-Bee, J., Gladman, J.R.F., Corr, S., Donkervoort, M. et a l. (2007). Occupational Therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomised trials. British Medical Journal, 335, 922 930. > Lizarondo, L., Kumar, S., Hyde, L. & Skidmore, D. (2010). Allied health assistants and what they do: a systematic review of the literature. Journal of Multidisciplinary Healthcare, 3, 143-153.