Addressing inactivity after stroke: The Collaborative Rehabilitation in Acute Stroke (CREATE) study.

Create protocols for 100% recovery and inactivity wouldn't exist. SOLVE THE CORRECT PROBLEM! Your survivor would be too busy counting reps and looking forward to recovery. DO YOU NOT UNDERSTAND?

 Addressing inactivity after stroke: The Collaborative Rehabilitation in Acute Stroke (CREATE) study.

Fiona Jones1*, Karolina Gombert-1, Stephanie Honey2, Geoffrey Cloud3,4, Ruth Harris5, Alastair
Macdonald6, Christopher McKevitt7, Glenn Robert4, David Clarke2
1Faculty of Health, Social Care and Education. Kingston University & St George’s, University of
London. UK.
2Leeds Institute of Health Sciences. University of Leeds, UK
3Alfred Health, Melbourne, Australia.
4 Department of Clinical Neurosciences, Central Clinical School, Monash University, Melbourne,
Australia
5Faculty of Nursing, Midwifery and Palliative Care, King’s College London. UK.
6School of Design, Glasgow School of Art. UK.
7School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King’s
College London. UK.
*Corresponding author.
Corresponding author contact details: f.jones@sgul.kingston.ac.uk
Keywords. Stroke, inactivity, co-design.
Word Count
Tables and Figures
Table 1 Timings of data collection and the methods used
Table 2 Excerpts from analysis of field notes and interviews and how priorities were shaped
Table 3 Demographic details patient participants
Table 4 Staff participants
Table 5 Carer participants
Table 6 Co-design group characteristics
Table 7 Co-design groups in each site
Table 8Impact of co-designed changes
Table 9- Pre and post implementation Behavioural Mapping data
Figure 1 Showing Accelerated and Full Experienced-based Co-design with pre and post
implementation data Collection
brought to you by COREView metadata, citation and similar papers at core.ac.uk
provided by Kingston University Research Repository
Background: Stroke patients are often inactive outside of structured therapy sessions – an enduring
international challenge despite large scale organisational changes, national guidelines and
performance targets. We examined whether Experienced-based Co-design (EBCD) - an improvement
methodology- could address inactivity in stroke units.
Aims: To evaluate the feasibility and impact of patients, carers and staff co-designing and
implementing improvements to increase supervised and independent therapeutic patient activity in
stroke units and to compare use of full and accelerated EBCD cycles.
Methods: Mixed-methods case comparison in four stroke units in England.
Results: Interviews n=156 patients, staff and carers, ethnographic observations –n=365 hours,
behavioural mapping n=68 patients, and self-report surveys n=182 patients pre and post
implementation of EBCD improvement cycles.
Three priority areas emerged 1) ‘Space’ (environment) 2) ‘Activity opportunities’ and 3)
‘Communication’. More than 40 improvements were co-designed and implemented to address these
priorities across participating units. Post-implementation interview and ethnographic observational
data confirmed use of new social spaces and increased activity opportunities. However, staff
interactions remained largely task-driven with limited focus on enabling patient activity. Behavioural
mapping indicated some increases in social, cognitive and physical activity post-implementation but
was variable across sites. Survey responses rates were low at 12-38% and inconclusive.
Conclusion It was feasible to implement EBCD in stroke units. This resulted in multiple
improvements in stroke unit environments and increased activity opportunities but minimal change
in recorded activity levels. There was no discernible difference in experience or outcome between
full and accelerated EBCD; this methodology could be used across hospital stroke units to assist staff
and other stakeholders to co-design and implement improvement plans.

Addressing inactivity after stroke: The Collaborative Rehabilitation in Acute Stroke (CREATE) study

If you want to increase activity post stroke there are two possibilities I see:

1. Have your doctor stop the 5 causes of the neuronal cascade of death in the first week. That would save billions of neurons. I only lost 5.4 billion neurons that first week because my doctor did nothing that first week. At $1000 a neuron that should have cost the hospital 5.4 trillion dollars. That would concentrate the hospital leadership.

2. Have EXACT STROKE PROTOCOLS WITH EXACT REPETITIONS THAT DELIVERS 100% RECOVERY. With that motivation to exercise would not be a problem. Survivors would be too busy counting and exercising to sit on their butts.

Your solution is incorrect because it is just a guideline NOT a protocol. So NO DEFINED OUTCOME.

Addressing inactivity after stroke: The Collaborative Rehabilitation in Acute Stroke (CREATE) studyj

Show all authors

Fiona Jones, Karolina Gombert-, Stephanie Honey, ...

First Published November 2, 2020 Research Article 

https://doi.org/10.1177/1747493020969367

Article information

   

Abstract

Background

Stroke patients are often inactive outside of structured therapy sessions – an enduring international challenge despite large scale organizational changes, national guidelines and performance targets. We examined whether experienced-based co-design (EBCD) – an improvement methodology – could address inactivity in stroke units.

Aims

To evaluate the feasibility and impact of patients, carers, and staff co-designing and implementing improvements to increase supervised and independent therapeutic patient activity in stroke units and to compare use of full and accelerated EBCD cycles.

Methods

Mixed-methods case comparison in four stroke units in England.

Results

Interviews were held with 156 patients, staff, and carers in total; ethnographic observations for 364 hours, behavioral mapping of 68 patients, and self-report surveys from 179 patients, pre- and post-implementation of EBCD improvement cycles.

Three priority areas emerged: (1) ‘Space’ (environment); (2) ‘Activity opportunities’ and (3) ‘Communication’. More than 40 improvements were co-designed and implemented to address these priorities across participating units. Post-implementation interview and ethnographic observational data confirmed use of new social spaces and increased activity opportunities. However, staff interactions remained largely task-driven with limited focus on enabling patient activity. Behavioral mapping indicated some increases in social, cognitive, and physical activity post-implementation, but was variable across sites. Survey responses rates were low at 12–38% and inconclusive.

Conclusion

It was feasible to implement EBCD in stroke units. This resulted in multiple improvements in stroke unit environments and increased activity opportunities but minimal change in recorded activity levels. There was no discernible difference in experience or outcome between full and accelerated EBCD; this methodology could be used across hospital stroke units to assist staff and other stakeholders to co-design and implement improvement plans.

Keywords Stroke, inactivity, co-design

Introduction

Evidence that increasing the frequency and intensity of stroke rehabilitation can improve outcomes has driven numerous international guidelines and other major developments in hospital-based stroke care to achieve larger doses of therapy provided over seven days.^1,2 However, outside of the scheduled therapy, inactivity is common and observational studies show stroke patients can be inactive and alone for more than 60% of waking hours, an issue largely unchanged for decades.^3,4

There is now more understanding that rehabilitation intensity and outcomes cannot be improved by national targets alone – the stroke unit environment and how time is spent outside of scheduled face-to-face therapy are of critical consideration. Attempts to address inactivity have had mixed results. Dose-driven interventions including circuit class therapy and seven-day therapy have increased therapy provision but not patient activity outside of sessions.⁵ Some progress has been made by applying environmental enrichment evidence from animal models.⁶ Studies conducted in Australia have utilized controlled pre- and post-designs and evaluated the impact of more stimulating environments on inpatient activity.^3,7 Behavior mapping showed an increase in activity levels across all domains and some changes were sustained at six months post intervention. However, the environmental enrichment was driven by the perspectives of researchers and professionals without patient and carer involvement and no specific quality improvement (QI) methodology. Improvement research is now recognized to be critical to ‘cumulate, synthesize and scale learning’ to expedite the translation of evidence into practice.⁸ We believed that a robust QI methodology could address the intractable issue of patient inactivity.

Across healthcare internationally, there is increasing evidence of improvement methodologies which involve patients and staff working collaboratively to help co-design solutions and deliver healthcare services.⁹ Experience-based co-design (EBCD) is an approach which enables staff and patients to co-design services in partnership. Experiences are gathered from patients and staff through in-depth interviewing, observations and group discussions, to identify key ‘touch points’ or emotionally positive or negative issues. An edited ‘trigger’ film is created from patient interviews to convey experiences of the service. Staff and patients are then brought together to explore the findings and to work in small groups to identify, co-design and implement activities that will improve the service or the care pathway.^10,11 EBCD now has widespread use and led to improvements across multiple healthcare settings, including acute hospitals – but can lack detailed evaluation of feasibility and impact.¹² To date EBCD has not been used as an improvement method in stroke units to address inactivity.

Aims

The Collaborative Rehabilitation in Acute Stroke study (CREATE) aimed to (1) evaluate the feasibility of patients, carers and staff collaborating to develop and implement changes to increase supervised and independent therapeutic patient activity in acute stroke units; and (2) understand if improvements developed by two initial stroke units could be transferred to two further units and implemented within a shortened time frame using an accelerated form of EBCD (AEBCD).

Figure 1 provides an overview of the stages of EBCD and AEBCD, data collected, and cohorts included pre- and post-implementation of improvements. Full EBCD and AEBCD took nine and six months to complete, respectively.

Figure 1. Showing accelerated and full experienced-based co-design with pre- and post-implementation data collection.

 

Cardiorespiratory strain during stroke rehabilitation: Are patients trained enough? A systematic review

Only once did I get my heart rate up, when I was racing against something on a biking machine. Otherwise my therapists were afraid to push me to breathlessness.

Cardiorespiratory strain during stroke rehabilitation: Are patients trained enough? A systematic review

Vicky Girard  ¹ , Hubert Bellavance-Tremblay  ¹ , Gabrielle Gaudet-Drouin  ¹ , Geneviève Lessard  ² , Myriam Dupont  ³ , Marie-Andrée Gagnon  ² , Armelle M Ngueleu  ² , Stéphane Mandigout  ⁴ , Charles Sebiyo Batcho  ⁵

Affiliations

• PMID: 33080374
• DOI: 10.1016/j.rehab.2020.09.007

Abstract

Background: Rehabilitation is a mandatory component of stroke management, aiming to recover functional capacity and independence.(WHY? Because you failed to stop the neuronal cascade of death in the first week? Place the blame for lack of recovery directly on your stroke doctors.) To that end, physical therapy sessions must involve adequate intensity in terms of cardiopulmonary stress to meet the physiological demands of independent living.

Objective: The aim of this systematic review was to determine the current level of cardiopulmonary strain during rehabilitation sessions in stroke patients.

Methods: Three electronic databases (PubMed, CINAHL and Embase.com) were searched to identify observational studies that documented cardiopulmonary strain during rehabilitation sessions in post-stroke patients (last search performed in February 2019). A manual cross-referencing search was also performed. To be included, articles needed to report data related to both cardiopulmonary strain (heart rate, oxygen consumption or energy expenditure) and active therapy time. The methodological quality of each study was assessed with the Evidence-Based Librarianship Critical Appraisal Tool. Data related to both cardiorespiratory strain and active therapy time were extracted from selected articles.

Results: Four of 43 full-text articles assessed for eligibility met the inclusion criteria. Results extracted from these articles suggested that the intensity of rehabilitation sessions was insufficient to induce a cardiopulmonary training effect in a post-stroke context as measured by metabolic stress. Patients were inactive from 21% to 80% of the therapy time. (This is for your therapists to solve.)The Evidence-Based Librarianship tool scores ranged from 65% (15/23) to 91% (21/23), which indicates questionable to good quality.

Conclusion: The current literature on cardiopulmonary solicitation during stroke rehabilitation sessions is poor in terms of both the number of studies available and their methodological quality. Summarized results tend to support previous claims that rehabilitation sessions offered to stroke patients are of suboptimal cardiopulmonary strain, which can interfere with their capacity to regain functional independence.

Keywords: VO2max; active time; cardiorespiratory fitness; heart rate; stroke rehabilitation.

Copyright © 2020 Elsevier Masson SAS. All rights reserved.

 

Physical inactivity, cardiometabolic disease, and risk of dementia: An individual-participant meta-analysis

Too many big words in combinations I didn't understand, so ask your doctor for clarification. 

Physical inactivity, cardiometabolic disease, and risk of dementia: An individual-participant meta-analysis

BMJ — Kivimäki M, et al. | April 18, 2019

Advertisement

In this meta-analysis of 19 prospective observational cohort studies, researchers ascertained if physical inactivity is a risk factor for dementia, focusing on the role of cardiometabolic disease in this association, and reverse causation bias resulting from changes in physical activity during the preclinical (prodromal) phase of dementia. According to results, physical inactivity was non-significantly linked to dementia among people in whom cardiometabolic disease preceded dementia. Physical inactivity was not related to all-cause dementia or Alzheimer’s disease in analyses that addressed bias due to reverse causation, although an indication of excess dementia risk was noted in a subgroup of physically inactive people who developed the cardiometabolic disease.

• See Also: Risk of incident dementia according to metabolic health and obesity status in late-life: A population-based cohort study

Read the full article on BMJ

Breaking Up Sitting Time After Stroke Study - Australia

Join if you can. With the 85% inactivity that stroke patients have there should also be a study on:

1. action observation, 

2. mirror therapy,

3. thermal therapy, 

4. lucid dreaming 

5. Music therapy

6. Sensation overload 

to determine the efficacy of these interventions. We need protocols not just, 'Hey this seems to work sometimes, but we know nothing about dosing. You'll just have to guess.'  And then your medical staff can blame you for not recovering because you didn't do the therapy right or long enough

Breaking Up Sitting Time After Stroke Study - Australia

BUST-BP-Dose Study

Researchers at the Hunter Medical Research Institute (HMRI) are looking at the effects of reducing long periods of sitting, with regular activity breaks, to improve blood pressure in those who have had a stroke.
The BUST-BP-Dose study will monitor blood pressure and blood sugar levels in people who have had a stroke between 3 months and 10 years ago. The study will look at the amount of short activity breaks needed to improve blood pressure in stroke survivors and reduce their risk of having another stroke.
The study is being supported by a Heart Foundation Vanguard Grant, Hunter Medical Research Institute research support grant and Priority Research Centre for Stroke and Brain Injury research support grant.

Register your interest

To find out more or to register your interest please contact Dr Gary Crowfoot on 02 40420759 (Gary.Crowfoot@newcastle.edu.au) or Mr Paul Mackie on 0420881472 (Paul.I.Mackie@uon.edu.au).

Is early rehabilitation a myth? Physical inactivity in the first week after myocardial infarction and stroke

How inactive are you in the first week after stroke? Your days should be filled with an enriched environment and lots of intense therapy.

Is early rehabilitation a myth? Physical inactivity in the first week after myocardial infarction and stroke

Sarah Lay, Julie Bernhardt, Tanya West, Leonid Churilov, Anthony Dart, Kate Hayes & show all

Pages 1493-1499 | Received 13 May 2015, Accepted 07 Oct 2015, Published online: 18 Dec 2015

• Download citation
• http://dx.doi.org/10.3109/09638288.2015.1106598
• 
  

Select Language​▼

Translator disclaimer

• 
  
• 
  
• 
  
• 
  
• 
  
• 
  
• 
  
• 
  

Abstract

Purpose: To compare physical activity levels of patients in the first week after myocardial infarction (MI) and stroke.  
Method: We conducted an observational study using behavioural mapping. MI patients were consecutively recruited from Alfred Hospital, Melbourne. Data for stroke patients (Royal Perth Hospital or Austin Hospital, Melbourne) were retrieved from an existing database. Patients were observed for 1 min every 10 min from 8 am to 5 pm. At each observation, the patient’s highest level of physical activity, location and people present were recorded. Details of physiotherapy and occupational therapy sessions were recorded by the therapists.  
Results: Proportion of the day spent physically inactive was lower in MI (n = 32, median 48%) than stroke (n  = 125, median 59%) patients, but this difference was not significant in univariate or multivariate (adjusting for age, walking ability and days post-event) regression. Time spent physically active was higher in MI (median 23%) than stroke (median 10%) patients (p = 0.009), but this difference did not survive multivariate adjustment (p = 0.67). More stroke patients (78%) than MI patients (19%) participated in therapy.  
Conclusions: This study provides the first objective data on physical activity levels of acute MI patients. While they were more active than acute stroke patients, the difference was largely attributable to walking ability.

• Implications for rehabilitation
• In the first week after myocardial infarction, patients spent about half the day physically inactive (even though 81% were able to walk independently).
• Similar levels of inactivity were seen in a comparable cohort of acute stroke patients, suggesting that environmental factors play an important role.
• There appears to be wide scope for increasing levels of physical rehabilitation after acute cardiovascular events, though optimal timing and dose remain unclear.

Listening to music in the early stages after a stroke can improve patients' recovery - Feb. 2008

How many more years than 7.5 will you give your doctors and hospitals a pass on implementing this stroke recovery tool? Fire them all I say. Incompetence has no place in the stroke world. Absolutely no excuse for this.
http://www.news-medical.net/news/2008/02/20/35390.aspx

Listening to music in the early stages after a stroke can improve patients' recovery, according to new research published online in the medical journal Brain.

Researchers from Finland found that if stroke patients listened to music for a couple of hours a day, their verbal memory and focused attention recovered better and they had a more positive mood than patients who did not listen to anything or who listened to audio books. This is the first time such an effect has been shown in humans and the researchers believe it has important implications for clinical practice.
-As a result of our findings, we suggest that everyday music listening during early stroke recovery offers a valuable addition to the patients' care- especially if other active forms of rehabilitation are not yet feasible at this stage-by providing an individually targeted, easy-to-conduct and inexpensive means to facilitate cognitive and emotional recovery, says Teppo Särkämö, the first author of the study.
Särkämö, a PhD student at the Cognitive Brain Research Unit, Department of Psychology, at the University of Helsinki and at the Helsinki Brain Research Centre, focused on patients who had suffered a stroke of the left or right hemisphere middle cerebral artery (MCA). He and his colleagues recruited 60 patients to the single-blind, randomised, controlled trial between March 2004 and May 2006 and started to work with them as soon as possible after they had been admitted to hospital.
-We thought that it was important to start the listening as soon as possible during the acute post-stroke stage, as the brain can undergo dramatic changes during the first weeks and months of recovery and we know these changes can be enhanced by stimulation from the environment, Särkämö explains.
Most of the patients had problems with movement and with cognitive processes, such as attention and memory, as a result of their stroke. The researchers randomly assigned them to a music listening group, a language group or a control group. During the next two months the music and language groups listened daily to music they chose themselves (in any musical genre, such as pop, classical, jazz or folk) or to audio books respectively, while the control group received no listening material. All groups received standard stroke rehabilitation. The researchers followed and assessed the patients up to six months post-stroke, and 54 patients completed the study.
-We found that three months after the stroke, verbal memory improved from the first week post-stroke by 60 percent in music listeners, by 18 percent in audio book listeners and by 29 percent in non-listeners. Similarly, focused attention-the ability to control and perform mental operations and resolve conflicts among responses-improved by 17 percent in music listeners, but no improvement was observed in audio book listeners and non-listeners. These differences were still essentially the same six months after the stroke, Särkämö says.

In addition, the researchers found that the music listening group experienced less depressed and confused mood than the patients in the control group.
-These differences in cognitive recovery can be directly attributed to the effect of listening to music, says Särkämö. -Furthermore, the fact that most of the music (63 percent) also contained lyrics would suggest that it is the musical component (or the combination of music and voice) that plays a crucial role in the patients' improved recovery.
-I would like to emphasise the fact that this is a novel finding made in a single study that is promising but will have to be replicated and studied further in future studies to better understand the underlying neural mechanisms. Since the result is based on a group study, I would also caution people not to interpret it as evidence that music listening works for every individual patient. Rather than an alternative, music listening should be considered as an addition to other active forms of therapy, such as speech therapy or neuropsychological rehabilitation, Särkämö continues.
The researchers say there may be three neural mechanisms by which music could help to stroke patients to recover:

• Enhanced arousal (alertness), attention and mood, mediated by the dopaminergic mesocorticolimbic system-the part of the nervous system that is implicated in feelings of pleasure, reward, arousal, motivation and memory;

• Directly stimulating the recovery of the damaged areas of the brain;

• Stimulating other more general mechanisms related to brain plasticity – the ability of the brain to repair and renew its neural networks after damage.

• Other research has shown that during the first weeks and months after stroke, the patients typically spend about three-quarters of their time each day in non-therapeutic activities, mostly in their rooms, inactive and without interaction, even although this time-window is ideal for rehabilitative training from the point of view of brain plasticity. Our research shows for the first time that listening to music during this crucial period can enhance cognitive recovery and prevent negative mood, and it has the advantage that it is cheap and easy to organise, Särkämö concludes.

Source:

http://www.helsinki.fi/

Inactivity Can Remodel Your Brain: A Sedentary Lifestyle Changes The Shape Of Your Neurons

So is your doctor going to change all the lying around in the hospital not doing therapy?
Article here;

Inactivity Can Remodel Your Brain: A Sedentary Lifestyle Changes The Shape Of Your Neurons
Abstract here; 

Physical (in)activity-dependent structural plasticity in bulbospinal catecholaminergic neurons of rat rostral ventrolateral medulla.

Mischel NA, Llewellyn-Smith IJ, Mueller PJ.

Author information

• Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, 48201.

Abstract

Increased activity of the sympathetic nervous system is thought to play a role in the development and progression of cardiovascular disease. Recent work has shown that physical inactivity versus activity alters neuronal structure in brain regions associated with cardiovascular regulation. Our physiological studies suggest that neurons in the rostral ventrolateral medulla (RVLM) are more responsive to excitation in sedentary versus physically active animals. We hypothesized that enhanced functional responses in the RVLM may be due, in part, to changes in the structure of RVLM neurons that control sympathetic activity. We used retrograde tracing and immunohistochemistry for tyrosine hydroxylase (TH) to identify bulbospinal catecholaminergic (C1) neurons in sedentary and active rats after chronic voluntary wheel-running exercise. We then digitally reconstructed their cell bodies and dendrites at different rostrocaudal levels. The dendritic arbors of spinally projecting TH neurons from sedentary rats were more branched than those of physically active rats (P < 0.05). In sedentary rats, dendritic branching was greater in more rostral versus more caudal bulbospinal C1 neurons, whereas, in physically active rats, dendritic branching was consistent throughout the RVLM. In contrast, cell body size and the number of primary dendrites did not differ between active and inactive animals. We suggest that these structural changes provide an anatomical underpinning for the functional differences observed in our in vivo studies. These inactivity-related structural and functional changes may enhance the overall sensitivity of RVLM neurons to excitatory stimuli and contribute to an increased risk of cardiovascular disease in sedentary individuals. J. Comp. Neurol. 522:499-513, 2014. © 2013 Wiley Periodicals, Inc.

Action observation as a stroke therapy

This has been mentioned in research reports;
here; Jan. 2012

Clinical Relevance of Action Observation in Upper-Limb Stroke Rehabilitation: A Possible Role in Recovery of Functional Dexterity. A Randomized Clinic

 
here; Feb. 2012

Modulating the motor system by action observation: Implications for stroke rehabilitation

1.5 years ago, no excuse not to have this in all clinics,
I can't tell from these if this is only useful for penumbra recovery or also dead-brain recovery.
Regardless your therapy department should have had enough time to find/create hundreds of videos showing different movements.
Creating animated gifs is fairly simple so there is no excuse for not having this available.
There should be no down time in the hospital, if not actively working with a therapist you should be watching videos. Someone has calculated that there really is very little active therapy going on while in the hospital. Why is your doctor wasting your valuable time by not providing action observation videos?
See how much wasted time as reported here:
Inactive and alone: physical activity within the first 14 days of acute stroke
During the therapeutic day, patients spent >50% resting in bed, 28% sitting out of bed, and only 13% engaged in activities with the potential to prevent complications and improve recovery of mobility. Patients were alone >60% of the time.