An Integrated Therapeutic Approach to

Intensive Upper Limb Rehabilitation

Kate Kelly & Fran Brander

Consultant Occupational Therapist & Consultant Physiotherapist,

The National Hospital for Neurology and Neurosurgery

Queen Square

kate.kelly4@nhs.net ; fran.brander@nhs.net

7th Northern Ireland Stroke Conference

Tuesday 12th June 2018

Aim of talk

Discuss the Impact of Intensity on UL Recovery

Describe the Queen Square UL Programme

Demographics & Clinical Characteristics on Admission

Interventions

What’s in the Black Box

Results

Patient Experience

Summary

Upper limb treatment – how much are we

giving?

People are still INACTIVE and

ALONE after stroke

WHAT? HOW MUCH? WHEN?

People with stroke should receive at least 45 minutes of each appropriate therapy every day, at a

frequency that enables them to meet their rehabilitation goals, and for as long as they are willing and

capable of participating and showing measurable benefit from treatment.

Royal College of Physicians – National Clinical Guideline for Stroke

• Average stay in ASU = 17 Days

• 17 days*35 mins*74% =

7.3 hours in total

• Only 10-25% of sessions ‘active’

SSNAP data

?• Reduce long-term dependency, admission to

institutional care, length of admission (by 6 days)

• No clear differences in ADLs, subjective health

status or mood

• No evidence that services without co-ordinated

MDT input have any benefit (may cause harm)

July 2017

Stroke – post-stroke care

JAMA. 2016;315(6):571-581

Upper limb treatment – early

30 hours over 10 weeks

• Patients ~46 days post-stroke

• Mean baseline FM-UL = 41 +/- 9 (mild-mod)

• UL training 3 hours/week for 10 weeks

✗

300 hours over 12 weeks

Upper limb treatment

✔

• Mean baseline FM-UL 15-35

(mod-severe)

• Arm training

• Patients ~40 days post-stroke

• Mean baseline FM-UL 6-8 (severe)

• Arm training 1, 2, 3 hrs/day, 5 days/wk,

6 wks

90 hours over 6 weeks

Upper limb treatment

✔

+ 11.5 pts FM-UL

1 hr/day = 30 hours 2 hrs/day = 60 hours 3 hrs/day = 90 hours

Upper limb treatment – chronic

• Mean baseline ARAT 10-48

• 1-hour sessions, 4 days/week for 8

weeks = 32 hrs (active time 14-30 hours)

• Groups - 3200, 6400, 9600, or 10,800

reps

• “We are skeptical that patients could

achieve another order of magnitude of

dose in the context of a traditional

therapy session”

ΔARAT = 0.4/week = 3.2 ΔARAT = 0.05/week = 0.4

ΔARAT = 0.31/week = 2.5 ΔARAT = 0.66/week = 5.3

32 hours over 8 weeks✗

In total each patient receives 100 hours upper limb oriented therapy

over 3 weeks.

Daily treatment consists of:

• 2 hours each of OT and PT including analysis of movement and

tasks, treatment of impairment and re-education of motor control

within functional tasks.

• 2 hours of tailored, individualised interventions, including repetitive

practice with a rehabilitation assistant, sensory retraining, adjuncts

to therapy such as robotics, dynamic and functional orthoses and

neuromuscular electrical stimulation and group work.

• Patients are encouraged to work on cardiovascular fitness during

the programme.

• Education, self-efficacy and goal setting are integral components of

the programme.

Treatment – Queen Square Programme

Time Monday Tuesday Wednesday Thursday Friday Time

7:45 7:45

8:00 8:008:15 8:15

8:30 8:30

8:45 8:45

9:00 Occupational Therapy Occupational Therapy Occupational Therapy Amadeo Rehab Assistant Group 9:00

9:15 Occupational Therapy Occupational Therapy Occupational Therapy Amadeo Rehab Assistant Group 9:15

9:30 Occupational Therapy Occupational Therapy Occupational Therapy Occupational Therapy Occupational Therapy 9:30

9:45 Cardio Independent Exercises Cardio Occupational Therapy Occupational Therapy 9:45

10:00 Cardio Independent Exercises Independent Exercises Occupational Therapy Occupational Therapy 10:00

10:15 Sensory Programme Independent Exercises Independent Exercises Physiotherapy Occupational Therapy 10:15

10:30 Physiotherapy Sensory Programme Physiotherapy Physiotherapy Rehab Assistant 10:30

10:45 Physiotherapy Cutlery practice Physiotherapy Physiotherapy Rehab Assistant 10:45

11:00 Physiotherapy Cutlery practice Physiotherapy Cardio Amadeo 11:00

11:15 Rehab Assistant Cardio Sensory Programme Cardio Amadeo 11:15

11:30 Rehab Assistant Cardio Armeo Spring Independent Exercises Physiotherapy 11:30

11:45 Rehab Assistant Rehab Assistant Armeo Spring Independent Exercises Physiotherapy 11:45

12:00 Cutlery practice Rehab Assistant Rehab Assistant Cutlery practice Physiotherapy 12:00

12:15 Cutlery practice Rehab Assistant Rehab Assistant Cutlery practice Physiotherapy 12:15

12:30

Lunch Lunch Lunch Lunch Lunch

12:30

12:45 12:45

13:00 13:00

13:15 Joint Physio and OT Cardio Rehab Assistant Physiotherapy Cardio 13:15

13:30 Joint Physio and OT Rehab Assistant Rehab Assistant Physiotherapy Armeo Spring 13:30

13:45 Joint Physio and OT Rehab Assistant Occupational Therapy Physiotherapy Armeo Spring 13:45

14:00 Cardio Amadeo Occupational Therapy Rehab Assistant Occupational Therapy 14:00

14:15 Sensory Programme Amadeo Occupational Therapy Rehab Assistant Occupational Therapy 14:15

14:30 Occupational Therapy Occupational Therapy Cardio Rehab Assistant Group Occupational Therapy 14:30

14:45 Occupational Therapy Occupational Therapy Cardio Rehab Assistant Group Open gym 14:45

15:00 Independent Exercises Occupational Therapy Amadeo Rehab Assistant Group Open gym 15:00

15:15 Independent Exercises Cardio Amadeo Sensory Programme Open gym 15:15

15:30 Independent Exercises Physiotherapy Sensory Programme Occupational Therapy Open gym 15:30

15:45 Independent Exercises Physiotherapy Sensory Programme Occupational Therapy Open gym 15:45

16:00 Physiotherapy Physiotherapy Cutlery practice Occupational Therapy Open gym 16:00

16:15 Physiotherapy Physiotherapy Cutlery practice Occupational Therapy Open gym 16:15

16:30 16:30

16:45 16:45

17:00 17:00

Upper limb treatment – Queen Square

Programme

100 hours over 3 weeks

Upper limb treatment – Queen Square

Programme

• Patients usually require (i) at

least flickers of extension at

the wrist, fingers and/or thumb,

(ii) at least minimal ability in

reaching – but not always

• Patients are ‘admitted’ for 3

weeks of intensive upper limb

oriented therapy.

• 6 week & 6 month follow up

outcome data

Removing Barriers

Video

Treatment Interventions

Videos

Treatment Interventions

Videos

Upper limb treatment – Queen Square

Programme

What’s in the

black box?

Time Repetitions

Upper limb treatment – Queen Square

Programme

100 hours of upper limb therapy over 3 weeks

Median FM-UL 26 pts 34 pts 36 pts 38 pts

N = 175

Median ΔFM-UL 6 pts 8 pts 9 pts

MCID ΔFM-UL = 5-6 pts

Upper limb treatment – Queen Square

Programme

100 hours of upper limb therapy over 3 weeks

Median ARAT 19 pts 27 pts 28 pts 28 pts Median ΔARAT 5 pts 6 pts 8 pts

N = 175 MCID ΔARAT = 5-6 pts

Upper limb treatment – Queen Square

Programme

100 hours of upper limb therapy over 3 weeks

Median CAHAI 40 pts 49 pts 50 pts 51 pts

N = 175

Median ΔCAHAI 9 pts 11 pts 12 pts

MCID ΔCAHAI = 9 ptsN = 175

Focus Groups: Patient Evaluation

Upper limb therapy – summary

• Dose response ‘emerging’ from clinical trials

• Currently we don’t give enough to know what is possible through

motor/behavioural training

• The dose of treatment is critical – more is generally better

• No evidence to say which type of UL therapy is better (hands on

vs. robots vs. self-directed) – but likely each has own value

• Simple task specific training ≠ learning and seems less effective

• Learning required

• Cannot simplify UL rehab to a single protocol based activity

• The challenge is how to increase intensity across the pathway

Upper limb post-stroke therapy

• Prof Nick Ward

• Amanda Strawson

• Ali Norfolk

• Ben Beare

• Dr Kate Hayward

• Fleur Vella

• The UL Team at NHNN

21

Thanks to:

6TH ANNUAL UPPER LIMB NEUROREHABILITATION

COURSE

TREATING PATIENTS WITH UPPER LIMB DEFICIT:

INTEGRATING RESEARCH INTO PRACTICE

Thursday 28th – Friday 29th June 2018

Speakers include:

Gert Kwakkel, VUMC, Amsterdam, The Netherlands

Nick Ward, University College London

Kate Kelly, The National Hospital for Neurology and Neurosurgery

Fran Brander, The National Hospital for Neurology and Neurosurgery

Jane H Burridge, Southampton University

For more information contact Alkida Domi:02034483476 email: a.domi@nhs.net

• Byblow, W., Schlaug, G., Wittenberg, G., 2016. What’s the Perfect Dose for Practice to Make Perfect? Annals of Neurology 80(3). doi

10.1002/ana.24735

• Connell, L.A., McMahon, N.E., Eng, J.J., Watkins, C.L., 2014. Prescribing upper limb exercises after stroke: a survey of current UK

therapy practice. J Rehabil Med 46, 212–218. doi:10.2340/16501977-1268

• Connell, L.A., McMahon, N.E., Redfern, J., Watkins, C.L., Eng, J.J., 2015. Development of a behaviour change intervention to increase

upper limb exercise in stroke rehabilitation. Implementation Science 10:34. doi:10.1186/s13012-015-0223-3

• Donaldson, C., Tallis, R., Miller, S., Sunderland, A., Lemon, R., Pomeroy, V., 2009. Effects of Conventional Physical Therapy and

Functional Strength Training on Upper Limb Motor Recovery after Stroke; a Randomised Phase II Study. Neurorehabil Neural Repair.

23(4): 389-397.

• Doyle, S. Bennett S, Fasoli SE, McKenna KT (2010) Interventions for sensory impairments in the Upper Limb After Stroke. The

cochrane Collaboration.

• De Jong, L.D., van Wijck, F., Stewart, R.E., Geurts, A.C.H., Dijkstra, P.U., 2017. Content of conventional therapy for the severely

affected arm during subacute rehabilitation after stroke: An analysis of physiotherapy and occupational therapy practice. Physiother Res

Int. doi:10.1002/pri.1683

• Harris, J.E., Eng, J.J., 2010. Strength Training Improves Upper-limb Function in Individuals with Stroke: a Meta-analysis. Stroke

41(1):136-140.

• Hayward, K.S., Barker, R.N., Wiseman, A.H., Brauer, S.G., 2013. Dose and Content of Training Provided to Stroke Survivors with

Severe Upper Limb Disability Undertaking Inpatient Rehabilitation: An Observational Study. Brain Impairment 14, 392–405.

doi:10.1017/BrImp.2013.31

• Hayward, K.S., Brauer, S.G., 2015. Dose of arm activity training during acute and subacute rehabilitation post stroke: a systematic

review of the literature. Clin Rehabil 29, 1234–1243. doi:10.1177/0269215514565395

• Hoffmann, T.C., Glasziou, P.P., Boutron, I., Milne, R., Perera, R., Moher, D., Altman, D.G., Barbour, V., Macdonald, H., Johnston, M.,

Lamb, S.E., Dixon-Woods, M., McCulloch, P., Wyatt, J.C., Chan, A.-W., Michie, S., 2014. Better reporting of interventions: template for

intervention description and replication (TIDieR) checklist and guide. BMJ 348, g1687.

• Kitago, T. and Krakauer, J., 2013. Motor Learning Principles for Neurorehabilitation. Handbook of Clinical Neurology, Vol. 110 (3rd

Series). Neurological Rehabilitation.

• Kuipers K., McKenna, K., 2009. Upper Limb Rehabilitation following Brain Injury: Complex, Multifaceted and Challenging. British Journal

of Occupational Therapy 72(1), 20-28

• Krakauer, J.W., 2006. Motor Learning: its relevance to stroke recovery and neurorehabilitation. Current Opinion in Neurology 19:84-90

References

• Kwakkel, G., 2006. Impact of intensity of practice after stroke: issues for consideration. Disabil Rehabil 28, 823–830.

doi:10.1080/09638280500534861

• Kwakkel, G., Kollen, B.J., van der Grond, J., Prevo, A.J.H., 2003. Probability of regaining dexterity in the flaccid upper limb: impact of

severity of paresis and time since onset in acute stroke. Stroke 34, 2181–2186. doi:10.1161/01.STR.0000087172.16305.CD

• Lang, C.E., Macdonald, J.R., Reisman, D.S., Boyd, L., Jacobson Kimberley, T., Schindler-Ivens, S.M., Hornby, T.G., Ross, S.A.,

Scheets, P.L., 2009. Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil 90,

1692–1698. doi:10.1016/j.apmr.2009.04.005

• Lang, C.E., Strube, M.J., Bland, M.D., Waddell, K.J., Cherry-Allen, K.M., Nudo, R.J., Dromerick, A.W., Birkenmeier, R.L., 2016. Dose

response of task-specific upper limb training in people at least 6 months poststroke: A phase II, single-blind, randomized, controlled

trial. Ann. Neurol. 80, 342–354. doi:10.1002/ana.24734

• Lannin, N., Cusick, A., Hills, C., Kinnear, B., Vogel, K., Matthews, K., Bowring, G., 2016. Upper Limb Motor Trainingusing a Saebo

Orthosis is Feasible for Increasing Task-specific Practice in Hospital after Stroke. Australian Occupational Therapy Journal. 63; 364-

372.l

• Lohse, K.R., Lang, C.E., Boyd, L.A., 2014. Is more better? Using metadata to explore dose-response relationships in stroke

rehabilitation. Stroke 45, 2053–2058. doi:10.1161/STROKEAHA.114.004695

• McCabe, J., Monkiewicz, M., Holcomb, J., Pundik, S., Daly, J.J., 2015. Comparison of Robotics, Functional Electrical Stimulation, and

Motor Learning Methods for Treatment of Persistent Upper Extremity Dysfunction After Stroke: A Randomized Controlled Trial. Archives

of Physical Medicine and Rehabilitation 96, 981–990. doi:10.1016/j.apmr.2014.10.022

• NICE, 2013. Stroke rehabilitation in adults.

• Polatajko, H.J., Townsend, E.A., Craik, J., 2007. Canadian Model of Occupational Performance and Engagement (CMOP-E). Enabling

Occupation II: Advancing an Occupational Vision of Health, Well-being & Justice through Occupation. CAOT Publications ACE. 22-36.

• Royal College of Physicians, 2012. National clinical guideline for stroke.

• Shumway-Cook, A., Woollacott, M.H., 2012. Motor Control: Translating Research Into Clinical Practice. Wolters Kluwer, Lippincott

Williams & Wilkins.

• van Vliet, P., Hunter, S.M., Donaldson, C., Pomeroy, V., 2016. Using the TIDieR Checklist to Standardize the Description of a

Functional Strength Training Intervention for the Upper Limb After Stroke. J Neurol Phys Ther 40, 203–208.

doi:10.1097/NPT.0000000000000133

References

• Veerbeek, j.m., van Wegen, E., van Peppen, R., van der Wees, P.J., Hendricks, E., Rietberg, M., Kwakkel, G. 2014. What is the

Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis.. Plos One 9(2): e87987. doi

10.1371/journal.pone.0087987

• Winstein, C.J., Rose, D.K., Tan, S.M., Lewthwaite, R., Chui, H.C., Azen, S.P., 2004. A Randomised Controlled Comparisonof Upper-

extremity RehabilitationStrategies in Acute Stroke: a Pilot Study of Immediate and Long-term Outcomes. Arch Phys Med Rehabil 85(4):

620-628.

• Winstein, C.J., Wolf, S.L., Dromerick, A.W., Lane, C.J., Nelsen, M.A., Lewthwaite, R., Cen, S.Y., Azen, S.P., Interdisciplinary

Comprehensive Arm Rehabilitation Evaluation (ICARE) Investigative Team, 2016. Effect of a Task-Oriented Rehabilitation Program on

Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial. JAMA 315, 571–581.

doi:10.1001/jama.2016.0276

References