Aweb-basedinterventionforupperlimbrehabilitationfollowingstroke

JaneBurridgeProf.ofRestorativeNeuroscienceUniversityofSouthamptonUKjhb1@soton.ac.uk

ThispresentationpresentsindependentresearchfundedbytheNationalInstituteforHealthResearch(NIHR)underitsResearchforPatientBenefit(RfPB)(Grant

Reference#PB-PG-0909-20145).Theviewsexpressedarethoseoftheauthorsandnotnecessarilythoseofthe

NHS,theNIHRortheDepartmentofHealth.

Howcantheinternetincreaseintensityofpractice?

Whatthistalkisabout

• Thewaystrokerehabilitationismoving(intheUK…)• Evidenceforintensityofpractice• Rationaleandpotentialbenefitsofrehabilitationtechnologies

• Anexamplefromourcurrentresearch:– Web-basedsupportprogrammeforhome-basedupperlimbrehabilitation

Futuremodelofstrokerehabilitation

• Driveforcost-effectiverehabilitation• Targetingrecovery• Changeinattitudesfromdependencetoindependence

• EarlySupportedDischarge(ESD)• Rehabilitationathome• Improvingassessment

Intensity

• Agameoftennis:– 5strokes/point– 10points/game– 10games/set– 3 sets/match

• =750strokes/match• Howmanyrepetitionsinatherapysession?

• In(human)strokerehabilitationthetypicalnumberofrepetitionsinasessionis30(Langetal,2009)

• Inanimals,changesinprimarymotorcortexsynapticdensityoccurafter400(butnot60)reaches(Remple etal,2001)

• Mighttherebea‘threshold’abovewhichULuseimprovesandbelowwhichitdecreases(Schweighofer etal,2009)

• Canthenumberbeincreasedbyprovidingothersupporttoenablemovementorgivingmotivatingfeedback?

Isthereevidencetosupport‘increaseddose’?

ThedoseofULtreatmentafterstrokeisunacceptablylow

• Patientsdoverylittleinhospital

• JulieBernhardtreportedthatpatientsareonlyactive13%oftheday.AndALONE60%oftheday

• Notthebestenvironmenttopromoteneuroplasticity

• Animalstudies- need400-600repsofreachtasks

• Onaveragepatientsachieve32repsinatherapysession

• Strongevidencethathighdoseoftherapyiseffective

• Incorporatinghighintensityofrepetitivetaskpractice

• Variedandgoalorientated

Is More Better? Using Metadata to Explore Dose–Response Relationships in Stroke Rehabilitation

Keith R. Lohse, PhD; Catherine E. Lang, PT, PhD; Lara A. Boyd, PT, PhD

• Usedregressionmodelstopredictimprovementoffunction

• 30studies1750participants• Increasedtimescheduledwasapredictorofclinicallymeaningfulimprovement

• Irrespectiveoftimepost-stroke

Stroke2014;45:2053-2058

…...Buthowcanweachievetherequiredintensityinroutineclinicalpractice?

Withinthenext10yearsrehabilitationtechnologieswillusedroutinelyinclinicalpractice

Rationalefortechnologies

Whatourpatientstellus..

‘Recoveringfromstrokeislikewatchingpaintdry– itsdifficulttokeepmotivatedwhenyoudon’tseemtobeimproving’

Whatarethekeydeterminantsofaneffectivemotortrainingprogram?

• Intensity?• Repetition?• Taskspecificfunctionaltraining?• Providingfeedbacktopatient?• Alternating/changingtasks?

Constraint-InducedMovementTherapy

(CIMT)

LifeGuidePlatform• DevelopedinSouthampton- fundedbytheUKResearchCouncil• Tomotivateandsupportbehavioralchangee.g.drugaddiction,

obesity• Softwaretocreateweb-basedinteractivetherapiesthat:– Givepersonalizedadviceandguidancebasedontheuser'sanswerstoquestions

– Supportuserstoplan,chartandchecktheirprogress– Sendsupportingmessagestousersintheformofpersonalizedemailsortexts

– Storeandtransmitdatasecurely

LifeCIT- RationaleandAims

• CIThasasoundneurophysiologybase• HasbeenshowntobeeffectiveBUT• Iscostlyintermsofcontacttime• Evidenceforefficacyasahome-basedintervention• Butfeedbackhasshownpotentialproblemswithadherenceand

motivation• LifeCITsupportshome-basedCIT

LifeCITMethodology

• STAGE1:Co-designwithpatients,carersandtherapistsinaclinical/homeenvironment– Webpagesincludingdesigningaprogrammeofassessment,activities,

games,feedbackandsupport– Interaction,communicationandfeedbacksupportfromtherapists,

friendsandfamily• STAGE2:PragmaticRCT(n=30)withstrokepatientsfollowingdischargefrom

hospitalto:– Testfeasibilityandidentifyproblems– Assesseffectonupperlimbfunctionandqualityoflife– Estimateeffectsizecomparedwithusualcare– Monitoradherence

LifeCIT:Philosophy

• NOT:‘Thisiswhatyouneedtodo….’ Givinginstructions– thetherapistisincharge

• BUT: ‘Whatdoyouwanttobeabletodo?’Thepatienttakesthelead– thesystem(LifeCIT)supportsandguides

• Usingthisapproachweaimtoencourageself-efficacyandindependenceratherthancomplianceanddependence

Phase1:DevelopmentofPrototype1

• Meetingswiththerapists(6siteseachn=1-6)usingpower-pointslidesillustratingmock-upsoftheproposedwebsite– Therapistsmadesuggestionsaboutcontentofthewebsitee.g.exercises,games,activitiesatdifferentlevels

– Reviewedcurrentlyusedexercisesheetsforpatientsofdifferentlevelsofability

– Discussedcommunicationbetweentherapists,patientsandcarers

• DesignedandbuiltfirstprototypeLifeCITwebsite

Phase1:Prototype2.Developedviathink-aloudstudieswith12sub-acute(<12weeks)patientsinhospitalandathome

Developmentsbasedonobservedpatients’behaviornavigatingthewebsiteandsimultaneousoralfeedback

• Websitenavigation:– avoidmultiplemenuoptions- linearprogressionthroughthepages

– noscrolling– allinformationononepage

• Clarityofinstructions:– minimaltextandavoidingambiguity– motivationallanguageandillustrationse.g.‘congratulations’‘useitorloseit’

– Instructionsviavideowithavoice-overratherthantext

• Simplifiedcomputergames

FinalVersionoftheWebsite

https://pips.ecs.soton.ac.uk/player/play/LifeCIT_demo

EnterauserID:2numbersand2lettersPW:anythingyoulike!

UsingtheMotorActivityLog(MAL)

• Personalized:acriticalfactorinmotivationandadherence

• Activitiesthatinteresttheindividual• Relatetopersonalobjectives• Attherightlevelofability• TheMALisusedtoassesswhatthepatient‘cando’andthedataisthenusedtopersonalizethewebpages

Choosingactivities

Laterintheday…..

Doesa3-weekLifeCITinterventionimproveupperlimbfunctionandmaintainedatsix-monthfollow-up?

• Feasibilitystudy- PragmaticpilotRCT• Patientsrecruitedondischargefromhospital7daysto3

monthspoststrokeandasecondcohortpost16weeks• SelectioncriteriaincludedsafetyusingCITathome,>10°

wristmovementand>2.4ontheMAL• Mainoutcomemeasures:WMFTandMAL(Baseline,post

interventionandsix-monthfollowup)• PosttreatmentinterviewswiththepatientswhousedLifeCIT

Results

Participants• Screened:N=83(60didnotmeetinginclusioncriteria4 declined(3couldnotuseacomputer)

• Recruited:ControlN=8TreatmentN=11

• Drop-outs:1 duringtheintervention(secondstroke),2 missed6-monthassessment(1frozenshoulderand1unabletocontact)

SummaryofadherencedatarecordedontheLifeCITWebsite

Activity Mean (SD) Min-Max

Time the Mitt was worn each day (hours) 4.8 (2.6) 1.4–8.4

Total reported activity time / day (hours) 3.2 (1.7) 0.6–5.9

Number of activities completed / day 8.9 (4.9) 2.5–15.6

Days activity reported (max 21, target 15) 13.6 (2.1) 11-18

BetweenGroupdifferencesformainoutcomemeasures

OutcomeMeasure Meandifferencebetweengroups

ANCOVAP-Value(95%CI)

MAL/AOUBaselinetoendoftreatmentScore- 0-5

1.00* <0.003**(0.43-1.57)

MAL/AOUBaselinetofollow-up 0.25 0.64(0.95-1.44)

MAL/QOUBaselinetoendoftreatmentScore0-5

0.89* <0.003**(0.36-1.40)

MAL/QOUBaselinetofollow-up 0.46 0.42(0.80-1.71)

WMFT(FAS)BaselinetoendoftreatmentScore0-5

0.45* <0.001**(0.24-0.65)

WMFT(FAS)Baselinetofollow-up 0.50* 0.15(-0.24-1.24)

*MinimumClinicallyImportantDifferences(MCID):**betweengroupsigP<0.05MAL:10%(i.e.0.5)(VanderLeeStroke2003) - acutestrokeWMFT(FAS)0.2-0.4(Keh-chung NNR2009)

Whattheparticipantshadtosay…

Keyfactorsthatchangedbehaviourwere:

• Usingtheonlinesystem• UsingtheC-MIT• Componentsofthetherapy:Activitiesofdailyliving/functionalgoalswerekeyforeveryone

• AdaptingovertimetofrustrationsofwearingtheC-Mitt

• Seeingfunctionalgain• FamilySupportandsocialencouragement

Summary

• UseofLifeCITathomeisfeasibleandwellacceptedbyusers(100%retentionduringthetrial).

• Upperextremityfunctioninsub-acuteandchronicstrokepatientsimprovedfollowingathree-weekinterventionandatasix-monthfollow-up.

• Only1 participantdeclinedtotakepartbecausetheydidnot/couldnotuseacomputer

• Excellentadherence• Positivefeedback

Development• LifeCIThasnowbeendevelopedtobeusefulforlowerfunctioningpatientswhowouldnotbesuitableforusingCIT

• Web-basedInteractiveSupportforrecoveryofthearmandhandafterStrokE (WISE)

• PhaseIIImulti-centretrialStrokeWISE withstandardcare(HTA)

Conclusions• Technologies,especiallythoseexploitingtele-healtharelikelytobecomenormalpractice

• Toaugmentconventionalpractice• Toimprovecost-effectiveness• Currentlythereisalackofevidence• Motivation,selfmanagementandindependencearekeyfactorsinrehabilitation

• Co-designwithALLusersiskeytoacceptance– itmustbeverysimpleforpatients

Acknowledgements• Co-applicants:Ann-MarieHughes,LucyYardley,MarkWeal,

DamianJenkinson,MarkMullee• Healtheconomist:JeremyJones• Researchers:ClaireMeagher,SeanEwings,SebastienPollet,

CarolinaGonclaves andClaudiaAlt• FreddieNashandTomLeese,6th FormComputerScience

studentsfromBishopWordsworthSchool,Salisbury• Patientsandcarers• TrialSteeringCommittee– chairedbyDr TobyBlack

Thankyou

Questions?