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					                            1st National Stroke Rehabilitation Conference

                          “Applying Best Evidence to Stroke Rehabilitation”

                                           Winnipeg, Manitoba

                                            Sept 13-14, 2007

The first Stroke Rehabilitation Conference was held this past Sept 13-14, 2007 in Winnipeg Manitoba with
an overwhelming attendance of 350 health care professionals as well as stroke survivors. The focus of this
inaugural conference was “Applying Best Practice Evidence to Stroke Rehabilitation”. The calibre of
speakers and topics certainly illustrated the expertise and level of research that exists in the realms of
stroke rehabilitation. The event was cochaired by Debbie Brown the CEO of the Heart and Stroke
Foundation of Manitoba and Dr. Robert Teasell, an international expert in Stroke Rehabilitation and the
initiator of the development of the Evidence Based Review of Stroke Rehabilitation (EBRSR).

                                                   DAY 1
KEYNOTE SPEAKER: Blueprint for Transforming Stroke Rehabilitation
The speakers were led off with Dr. Teasell‟s opening lecture on “Blueprint for Transforming Stroke
Rehabilitation”. He provided an overview of what the research evidence is recommending in terms of stroke
rehabilitation. The key points were: Stroke rehabilitation units work, need to start treatment early, it must
be intensive, provide and active and stimulating environment, focus on high level meaningful tasks that
challenge patients, limit time spent on assessment and meetings (loss of valuable time), and outpatient
therapy must be available. The evidence is showing us the direction we need to take stroke rehabilitation
toward. For more information read 10th and latest edition of Evidence–Based Review of Stroke
Rehabilitation.


Stroke Rehabilitation Care from a Patient’s Perspective
Carole Laurin, a stroke survivor, described her ongoing journey with living and recovering from stroke. She
emphasized the importance of ongoing comprehensive therapy, need for family involvement, and the
multidisciplinary approach to care. Also how the word “plateau” is discouraging as it denotes an
acceptance of no further recovery. The key she felt, was to provide short term goals, to inspire optimism
and challenges in order to move the stroke survivor forward, in their journey.


SCORE: Barriers to Applying Stroke Rehabilitation Guidelines
Dr. Mark Bayley, Medical Director of Neuro Rehabilitation at Toronto Rehab discussed the Stroke Canada
Optimization of Rehabilitation by Evidence (SCORE) project. This initiative was set up to look at knowledge
translation and identification of research. An expert consensus panel identified a set of Evidence Informed
Practice Recommendations for risk assessment and rehabilitation of the arm and leg post stroke. These
recommendations were piloted in 7 centres across Canada, to identify barriers and facilitators to
implementation of evidence based practice (EBP).
The 6 common barriers that health care professionals face in implementation of EBP were: lack of time,
training/education, patient /provider safety, prioritizing treatment, team functioning and team
communication. SCORE is now progressing to a larger scale implementation in 20 centres across Canada.
Quality of Life Following Stroke
Dr. Sharon Wood-Dauphine an epidemiologist presented “Portraits, Profiles and Predictors of Health Related
Quality of Life Post–Stroke”. She discussed the results of a study on the impact of stroke on function and
heath related quality of life of stroke survivors after their first 2 years post stroke. Findings showed 3-6
moths post stroke, survivors still faced ongoing challenges in both basic and instrumental ADLs, vitality,
mental health, and social roles. There was continued improvement in physical function over the first year.
Age, comorbidity and social resources affected level of recovery.


WORSHOP: Constraint Induced Therapy
Leya Thurman, a clinical specialist in Occupational Therapy, discussed Constraint Induced Movement
Therapy and the program they have at St Boniface General Hospital. Constraint Induced Movement Therapy
CIMT is an intervention designed to work on the affected limb that in some cases has a learned suppression
of movement or learned nonuser. The intervention involves the client practice upper limb tasks with the
affected limb while the other arm is “restrained”. The recent EXCITE trial (Wolfe et al 2006) has shown
favourable results to support use of CIMT.


WORKSHOP: A Step Towards Community Re-engagement Through the Community Stroke Care
Service
Louise Nichol is an occupational therapist with the Winnipeg Regional Health Authority (WRHA) Home Care
Program and is currently the Team Manager for the Community Stroke Care Service(CSCS) initiative. Corine
Poirier is a speech-language pathologist involved with this CSCS pilot project. The CSCS was initiated in
October 2005 and it is a specialized service that provides in-home rehabilitation (OT, PT, SLP) for persons
who have suffered a stroke and are discharged home from hospital. The CSCS incorporates community re-
engagement as one component of rehabilitation for clients. In the context of the CSCS, the term „re-
engagement‟ consists of client centred assessment and intervention that focuses on helping clients resume
desired activities, occupations, and roles in their personally defined „community‟. Rehabilitation assistants
are also used to promote client independence, communication, function and mobility where potential exists
and provide clients an opportunity to practice the skills required to engage in community activities, first with
support, and gradually with increased independence and confidence.


KEYNOTE SPEAKER: Management of Psychological Issues and Community Reintegration
Dr. Duane Bishop is a psychiatrist who works in physical rehabilitation presented on “Community
Reintegration: A Family Matter”. He discussed how the family also influences the recovery process. He also
described an intervention they use, Family Intervention Telephone Tracking or FITT model. The patient
/caregiver are contacted after discharge for a period of 6 months. There are 5 areas that are focused on in
questions: family, mood, function, health and cognition. The idea was to provide support by listening,
facilitating problem solving by the patient and caregivers, and providing further education material as
needed. The outcome was a decreased healthcare utilization and improved quality of life. It was most
effective with depression of caregiver and spouse, and family functioning difficulties.




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Canadian Stroke Strategy Consensus – Guideline for Stroke Rehabilitation
Dr. Patrice Lindsay is the Performance and Standards Specialist for Canadian Stroke Network. She
presented on the process of how the Canadian Stroke Strategy Best Practice Recommendations came into
existence. These recommendations were released in December 2006. The next version will be released in
the fall of 2008. To view the Canadian Best Practice Recommendations for Stroke Care 2006, visit
www.canadianstrokestrategy.ca under Stroke Rehabilitation Recommendations.


Assessment of Dysphagia: TOR-BSST
Dr. Rosemary Martino, Assistant Professor of Speech Language Pathology at the University of Toronto
presented on the need and development of a dysphagia screening tool for stroke patients called the
Toronto Bedside Swallowing Screen Test or TOR-BSST. The TOR-BSST is a valid dysphagia screening took
that can be used by frontline workers who have been trained in the administration of the tool, to identify
those stroke patients who are at risk for swallowing complications and need further workup to be done by a
Speech Language Pathologist.
For more information refer to: http://swallowinglab.uhnres.utoronto.ca



THE RAMON J. HNATYSHYN LECTURE: Getting on with the Rest of Your Life After Stroke
The evening‟s talk was given by Dr. Nancy Mayo a researcher from London, Ontario. She discussed the
issues and resources available in the community for stroke survivors. The research shows that 50% of
stroke survivors lack meaningful activity and do not have enough activity to fill their days 6 months post
stroke. Community based stroke resources are patchy across Canada. Stroke Survivors have identified the
following as what they want from community based programs: physical activity, learning, socialization and
fun, stimulation to continue to develop motivation, mobility, cognitive and language skills, at least 3x a
week with help with transportation. There is little or no funding available for community programs. The
Canadian Stroke Network is looking at developing a program called Mission Possible that can be integrated
into existing community resources that meet the needs of stroke survivors and provide evidence of
improved outcomes.

                                                   Day 2


KEYNOTE SPEAKER: Applying Animal Research to Better Understand Rehabilitation Principles
Dr. Dale Corbett, Tier 1 Canada Research Chair in Stroke and Neuroplasticity and Professor of
Neurosciences at Memorial University, discussed how researchers are attempting to identify and optimally
engage neuroplasticity/reorganization processes, which are important in recovery of function. Some
findings in animal studies indicate task specific training, enriched environments, early intervention are all
important aspect to improving outcomes. An article of interest: Biernaskie, J., Chernenko, G and Corbett,D.
Efficacy of rehabilitation experience declines with time following focal ischemic brain injury, J. Neurosci.,
2004, 24, 1245-1254.



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Exercise Capacity and Cardiovascular Adaptations to Aerobic Training After Stroke
Marilyn MacKay-Lyons, Associate Professor in School of Physiotherapy at Dalhousie University, a clinician,
researcher and educator in neurorehabilitation, presented on the importance of cardiovascular fitness after
stroke. Stroke and cardiac disease share the same risk factors. 75% of patients post stroke have cardiac
disease which can be more disabling than the stroke itself. Cardiovascular fitness after stroke is extremely
important and physical activity is a strong independent predictor of stroke risk. Cardiovascular fitness is
abnormally low in post stroke population. There are issues with fatigue, depression and the increased
energy costs of ADLs. Currently stroke rehabilitation does not include aerobic training. Research shows
that there are positive changes with aerobic exercise post stroke. She outlined recommendations for
aerobic training after stroke.


Rehabilitation of the Hemiplegic Upper Extremity
Susan Barreca PT, Research Clinician at Hamilton Health Sciences and Associate Professor in School of
Rehabilitation Sciences at McMaster, reviewed the results of the 2001 Consensus Panel on the Management
of the Post-Stroke Arm and Hand. She highlighted prognostic literature for UE recovery and provided clinical
date on recovery. The two best indicators of the potential for recovery from impairments secondary to
infarct are the initial severity of the neurological deficits and the early patterns of improvement. Research
practice gap shows that 30-40% of patients do not receive treatments of proven effectiveness while 20-
25% of patients get care that is not needed or potentially harmful. Stage 4 or higher arm and hands should
have every opportunity to remediate upper limb function. Those at stage 3 or lower treatment should focus
on establishing and maintaining comfort, painfree mobile upper limb, with functional recovery augmented
by compensatory or environmental adaptations. The treatment recommendations of the 2001 Consensus
Panel on the management of the post stroke arm and hand can be found at:
http://profed.heartandstroke.ca/ClientImages/1/PostStrokeArmandHandFinal2002.pdf


WORKSHOP: Visual Field Deficits Assessment and Treatment Using Dynavision Mapping
Systems
Lynda Wolf, Occupational Therapist currently working on her doctorate in Applied Health Studies at
University of Manitoba, outlined the visual deficits and levels at which damage can occur secondary to
stroke. The treatment for visual dysfunction includes interventions to teach the individual to cope with
visual impairment. A treatment modality, the Dynavision Light Board, is currently being used at the
Riverview Health Centre in Winnipeg. Several members of the audience also indicated that facilities across
Canada are using the Dynavision Light Board. It is a computerized light board that is attached to a wall.
The client must reach and touch a red light to turn it off, this prompts another light in another area of the
board to turn on. It can be programmed according to treatment goals. It can be used for attention, field
deficits, arm function and standing balance. Performance Enterprises sells the Dynavision System.


KEYNOTE SPEAKER: Exercise Programs in the Community for Stroke Patients
Janice Eng PhD, Professor at the School of Rehabilitation Science at the University of British Columbia, and
Scientist at the G.F. Strong Rehabilitation Centre, provided an overview on exercise programs with
participants who have chronic strokes. In her research, group exercise programs were designed to be
easily implemented into the community without costly one to one therapeutic ratios, specialized or
expensive equipment. The components included: light aerobic warmup, stretching, functional lower
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extremity strengthening, balance and weight shifting. Results indicated improvements in mobility, gait but
also in health related quality of life. For the guidelines and manual for the Fitness and Mobility Exercise
(FAME) program go to: http://www.strokesurvivors.ca/pdf/FAMEeng.pdf



Driving Post-Stroke
Dr. Shawn Calder Marshall, a specialist in Physical Medicine and Rehabilitation and Associate Professor in
Department of Medicine at Ottawa University and a core investigator for CanDRIVE (Canadian Driving
Research Initiative for Vehicular Safety in the Elderly), reviewed patient, medical and legal issues re: driving
post stroke. Driving is a complex skill requiring physical, cognitive and behavioural attributes. This is a
challenging issue for physician and stroke survivors. Many physicians have little training in making decision
regarding determining fitness to drive post stroke. Of 30% of patients who return to driving, 48% never
went through a driving evaluation and 30%would be considered high volume drivers. Some of the better
test predictors for driving outcomes on a road test are: Trails A and B tests, the Useful Field of View test
(UFOV), and the Rey-Ostereith Complex Figure Design (each tend to challenge multiple cognitive domains).
Jurisdictional reporting requirements vary by province, 7 out of 10 provinces have mandatory physician
reporting requirements with regards to patient fitness to drive. The Canadian Medical Association has
produced some guidelines for decision making regarding return to driving.
Two resources suggested were: Determining Medical Fitness to Operate Motor Vehicles, 7th ed. Canadian
Medical Association Ottawa. ON http://www.cma.ca/index.cfm/ci_id/18223/la_id/1.htm and
Driving and Dementia Tool Kit for family Physicians (Dementia Network of Ottawa-Carleton)
http://63.151.41.176/rgap/dementia/task_force_en.asp


Cognitive Problems Post-Stroke
Dr. Jon Erick Ween, a clinical scientist at Kunin-Lunenfeld Applied Research Unit and the Director of the
Stroke and Cognition Clinic in The Brain Health Centre Clinics, wrapped up the conference with looking at
cognition or “what the brain does”. He identified that focal brain damage can have widespread impact on
multiple functions, brain damage will evolve over time with response to learning, and the richly
interconnected brain provides multiple avenues for recovery. How constraint induced approaches can work
for motor deficits and iconic reading in pure alexia. There is no one good tool for assessing cognition. The
MMSE is not appropriate for the stroke population, the MOCA is only slightly better. He discussed the
development of as integrated, electronic tool for assessment and reporting in stroke care, the Affect,
Behaviour and Cognition Database for Stroke. This tool has been validated against a full neuropsychological
battery. It will be undergoing further validity testing against cognitive tests and radiological data.




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