What a novel idea, asking a patient what their goals are. My doctor would have gotten an earful if he cared at all.
http://www.medscape.com/viewarticle/775929
Even when objective measures of upper-limb rehabilitation after a
stroke failed to show benefit in a
recent treatment trial, patients found satisfaction in their
progress if that progress was assessed on the basis of attainment
of patient-specified goals.
Lisa Shaw, MD, senior research associate in the Institute
for Ageing and Health at Newcastle University in Newcastle upon
Tyne, United Kingdom, pointed out that one third of
patient-driven goals were bimanual, assessing the function of both
hands,
which may have accounted for better outcomes that standard
measures may have missed.
In a test of the use of botulinum toxin-A (BT) along with a
standard upper-limb therapy program, researchers found that on
objective measures of arm function after a stroke, neither
therapy improved function after 1 month. However, patients reported
they were equally satisfied with either therapy when
satisfaction was based on attainment of goals they had chosen
themselves.
Dr. Shaw presented the results here at the 8th World Stroke Congress (WSC).
What Matters to Patients
The original Botulinum Toxin for Upper Limb after Stroke
(BoTULS) trial compared upper-limb therapy alone with therapy plus
BT. It found that using BT improved muscle tone at 1 month
and longer-term, basic arm function tasks, arm strength, and pain.
But it failed to improve arm function overall. BT, which
blocks neuromuscular transmission and thereby induces a prolonged
but temporary paresis, has increasingly been used to reduce
spasticity.
The investigators then asked which therapy goals patients
choose and how attainment of those goals compares with outcomes
on a standard arm function test. They designed a randomized,
controlled clinical trial with blinded observers to look at arm
function as measured by the Action Research Arm Test (ARAT),
consisting of grasp, grip, pinch, and gross movement assessments,
vs patient-centered goal attainment, as assessed by the
Canadian Occupational Performance Measure (COPM) involving performance
and satisfaction.
Participants were adults with upper-limb spasticity and
reduced function at least 1 month after stroke. In both groups, the
average age was 68 years, 65% to 71% of patients were men,
and about 82% of participants had had a thrombotic stroke. The
median time between stroke and trial randomization was 280
days for the control group and 324 days for the BT intervention
group. At baseline, both groups had median ARAT scores of 3
on a scale of 0 to 57. Median COPM scores on a scale of 1 to 10
were 2.0 for both performance and satisfaction in the
intervention group and 1.7 and 1.6, respectively, in the control group.
The interventions were a 1-month upper-limb therapy program
for 1 hour twice weekly with (n =170) or without (n = 162) BT,
at which time outcomes were assessed. BT was injected into
muscles of the hand, wrist, elbow, or shoulder according to the
individual patterns of spasticity.
Treatments focused on 4 set goals and 1 optional goal within the COPM. For ARAT, the focus was on stretching, passive, and
active assisted upper-limb movement; hygiene; positioning; and intensive task-oriented practice.
The most commonly selected goals — by about 90% of each
group — were dressing, washing, and eating and drinking. Participants
chose goals of self-care (66%); productivity, such as
working in the kitchen, managing the household, playing, going to
school,
or writing (19%); and leisure activities (16%). One third of
the goals involved bimanual tasks.
Patient Satisfaction Up Despite Lack of Function
After 1 month, there were no objective differences in the degree of improvement between the BT and control groups. No change
from baseline (change score, 0) on the ARAT occurred in either group (
P = .427). There was a median 2.3-point change from baseline in both the BT and control groups on the COPM performance component
(
P = .535) and a 2.3-point and 2.4-point change, respectively, on the COPM satisfaction component (
P = .342).
Despite the finding that BT did not enhance goal attainment
or arm function compared with standard upper-limb therapy alone,
Dr. Shaw said both the BT and control groups had clinically
relevant improvements of greater than 2 points on the COPM. ARAT
measures are largely unimanual, whereas many COPM measures
involve both of the hands and arms. She said the study highlights
the importance of including patient-specified goals in
rehabilitation studies.
Session moderator Werner Hacke, MD, PhD, MPsych, professor
and chairman of the Department of Neurology at the University of
Heidelberg, Germany, concurred, saying he was not surprised
that the patients felt that they had benefited despite a lack
of objective improvement in arm function.
"It is about caring about the patient, and I believe it doesn't matter what you do," he commented to
Medscape Medical News. "If you care and you have a
positive psychological impact on the patients, they will benefit, and
they feel better. And
then you measure it, and they have not improved, but their
overall feeling is better — and this is what is probably the
most important thing about early rehabilitation — spending
time with the patient, independent of what you do."
He noted that there is no proof that one or another physical
therapy approach is better than another. If "caring" is the
intervention
that makes the patient feel better, Dr. Hacke said this
factor is even stronger in a clinical trial "because there are more
people involved... [and] they have a very strong intention
to help, and that translates."
He found it surprising that arm function was not at all
measurably improved with BT to reduce spasticity because a reduction
in spasticity may make it possible to grasp a cup, for
example. "I would have expected some signal, a trend. And that is
disturbing
that there is not even a trend," he said.
Use the labels in the right column to find what you want. Or you can go thru them one by one, there are only 28,972 posts. Searching is done in the search box in upper left corner. I blog on anything to do with stroke.DO NOT DO ANYTHING SUGGESTED HERE AS I AM NOT MEDICALLY TRAINED, YOUR DOCTOR IS, LISTEN TO THEM. BUT I BET THEY DON'T KNOW HOW TO GET YOU 100% RECOVERED. I DON'T EITHER, BUT HAVE PLENTY OF QUESTIONS FOR YOUR DOCTOR TO ANSWER.
Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.
What this blog is for:
My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.
Wednesday, December 12, 2012
Stroke Rehab Studies Should Consider Patient-Selected Goals
Labels:
botox,
Canada,
COPM,
goal setting,
research
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I could just tear my hair out when researchers use tests that have a poor basement like the ARAT. Tests need good basements to detect change in early recovery over a short period of time. Tests have to be sensitive to small changes to assess the efficacy of a treatment.
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