Disclosures How might we do more in research and clinical practice? Catherine Lang PT, PhD Program in Physical Therapy Program in Occupational Therapy Department of Neurology Research Support National Institutes of Health American Heart Association Foundation for Physical Therapy HealthSouth Corporation Barnes Jewish Hospital Foundation Missouri Physical Therapy Association Authorship Lang and Birkenmeier 2013, AOTA Press Inc. Consultant/Advisory Board ASA/AHA/Bugher Foundation Stroke Centers of Excellence NIDRR – Research Centers at Rehabilitation Institute of Chicago Neurolutions, Inc. Program in Physical Therapy Rehabilitation Institute of St. Louis Barnes Jewish Hospital Topics Alex Dromerick Dorothy Edwards Joanne Wagner Kim Waddell Chris Gnip Sara Francois Sage Tarter Hillary Smith Monica Ratner Caitlin Burbank Jenna Washabaugh Katherine Hutson Katherine Poppin Ana Abendschein Brittany Hill Elyse Aufmann Steven Babcock Lisa Simone Erin Lamb Nuo Cheng Danae Vachata Ellen Smith Justin Beebe Dustin Hardwick Jillian MacDonald 1. What is the current status of neurorehabilitation services? 2. How might we better design rehabilitation trials to learn more about dosing? Marc Schieber Michael Urbin Kendra Cherry Sydney Schaefer Jill Seelbach Eliza Prager Stacey DeJong Maggie Bland Rebecca Birkenmeier 3. What could be done to increase amount and intensity ? And is this relevant beyond motor rehabilitation? Ryan Bailey Program in Physical Therapy Program in Physical Therapy 1 Rehabilitation services post stroke If you receive home health services Death, 4% Other, 1% MSW HHA 25 Example: Missouri, USA RN Ave # SLP visits = 4.5 Ave #OT visits = 4.6 Ave. # PT visits = 5.8 SLP OT PT SNF, 12% Home, 28% 0% 20% 40% 60% 80% 100% If you receive outpatient services Voc IRF, 31% Home + services, 23% Data from Brain recovery Core; n = 3689 Need at least 2 services SLP OT Local Regional Likely to return to community living Cannot walk 150 ft (~46 m) x 2 Has source of payment National 15 10 5 0 Stroke TBI UDS data; 12/2010 Acute hospitalization Median LOS = 3 days PT 0% 20% 40% 60% 80% 100% Program in Physical Therapy Regardless of where you are, not much activity occurs outside therapy General activity IRF Average LOS 20 Days Discharge Destination If you get to go to inpatient rehabilitation, you do not get to stay very long anymore Program in Physical Therapy There is not much functional practice within therapy sessions UE activity • Only 51% of sessions addressing the UE had repetitions of purposeful movement 7 stroke units in Melbourne, Australia Bernhardt et al. 2004; 2008 UE use measured with wrist accelerometers for 24 hours Lang et al., 2007 N = 162 observations Program in Physical Therapy Lang et al. 2009 Program in Physical Therapy 2 Lower extremity, gait, & stair repetitions Topics • 84% of sessions addressing the LE had gait repetitions 1. What is the current status of neurorehabilitation services? Services are minimal 2. How might we better design rehabilitation trials to learn more about dosing? 3. What could be done to increase amount and intensity? And is this relevant beyond motor rehabilitation? Lang et al. 2009 Inpt. & Outpt. data ; N = 193 observations; Values are means ± SEs Program in Physical Therapy Traditional pre-post designs are not helpful for understanding dose-response 35 35 30 30 25 25 Consider brief, repeated measures • Measures of actual dose delivered Minutes scheduled ≠ minutes of activity Minutes ≈ Repetitions, for one intervention 3500 20 → 15 10 10 5 5 0 0 PreExperimental 3000 15 Active time, 16.7 PostControl PreExp-D1 Exp-D2 Inactive time, 43.3 PostExp-D3 Exp-D4 Minutes 20 It would require more 2-3x more subjects to get dose information Program in Physical Therapy 2500 2000 1500 1000 500 0 Control2 0 5000 10000 15000 20000 Repetitions ≥4 groups to understand the doseresponse relationship (Ruberg 1995a, 1995b) N = 43 observations, usual care SNF setting, Host et al. 2014 Program in Physical Therapy N = 67 participants in stroke trial Program in Physical Therapy 3 Frequent and accurate measures → closer examination of dose Consider brief, repeated measures • Measures of outcomes Tests that take < 10 minutes Bilaterality of mvt. (n = 27) 2 1.5 Magnitude ratio Wearable sensors to monitor: movement, speech, etc. 1 0.5 0 -0.5 Daily life Therapy session -1 -1.5 -2 Urbin et al, in press & submitted Program in Physical Therapy Program in Physical Therapy People can do more than we/they think Topics Inactive time, 13 1. What is the current status of neurorehabilitation services? Services are minimal Active time, 47 N = 93 observations, more intensive rehab. in SNF 2. How might we better design rehabilitation trials to learn more about dosing? Systematic, frequent measures of what was delivered and outcomes 3. What could be done to increase amount and intensity? And is this relevant beyond motor rehabilitation? Birkenmeier et al. 2010; Waddell et al. 2014; Host et al. 2014, Lenze et. al 2013 Program in Physical Therapy Program in Physical Therapy 4 Increase speed as a way to increase intensity? Robotic gait devices as a manipulation of effort Faster movement = better movement quality Increase effort as a way to increase intensity? Reach trajectory Israel et al. 2006 Aperture trajectory Self-selected Fast Less effort = Worse outcomes? Single session experiment, DeJong et al. 2012 Hornby et al. 2008 Program in Physical Therapy Measure patient performance and share the results Program in Physical Therapy Does all of this apply beyond the motor domain? SIRROWS trial: comparison of feedback vs. no feedback; n = 179 • Cognition and language therapy are readily amenable to ‘coach’ model necessitated by limited availability of services Walking speed at discharge 1 0.9 • Tape and video recorders instead of accelerometers 0.8 0.7 • Example of more practice opportunity: free-water protocol in the IRF setting m/s 0.6 0.5 0.4 0.3 0.2 0.1 0 Feedback No feedback Dobkin et al. 2010 Program in Physical Therapy Program in Physical Therapy 5 Free Water Protocol: Take advantage of the natural opportunity to practice QI project with the Brain Recovery Core A swallowing intervention that allows the patients who are NPO or on thickened liquid diets to receive water NPO at admission (Frazier Free Water Protocol; Holes 1994; Feinberg 1996; Mosheim 2005) N = 69 patients from the database, matching as best as possible FWP (n = 36) Age* Gender Length of time on FWP 27% Standard care group 78% Standard care (n = 33) 58 yrs 45 yrs 44% female 48% female 17 days MASA 140 143 FOIS 2.5 2.1 71% 78% On NPO diet at admit NPO at discharge FWP group 3% 71% Program in Physical Therapy Program in Physical Therapy Topics 1. What is the current status of neurorehabilitation services? Services are minimal 2. How might we better design rehabilitation trials to learn more about dosing? Systematic, frequent measures of what was delivered and outcomes Catherine E. Lang PT, PhD Associate Professor Campus Box 8502 4444 Forest Park St. Louis, MO 63110 (314) 286-1945 [email protected] 3. What could be done to increase amount and intensity? And is this relevant beyond motor rehabilitation? Lots of ways, and yes ©2013 Program in Physical Therapy Program in Physical Therapy 6