Transcript Slide 1

Is intensity of therapy important?
Dr Derick T Wade,
Professor in Neurological Rehabilitation,
Oxford Centre for Enablement,
Windmill Road, OXFORD OX3 7HE, UK
Tel: +44-(0)1865-737310
Fax: +44-(0)1865-737309
email: [email protected]
Why is intensity of therapy
important?
• The questions
does rehabilitation alter outcome?
how is rehabilitation quantified for funding?
• are translated into
is outcome related to the face-to-face time therapist
spends with patient?
how much face-to-face time did the therapist spend
treating the patient?
National Clinical Guideline for
Stroke. 3rd edition. 2008
Recommendation 3.13.1.A
• “Patients should undergo as much therapy
appropriate to their needs as they are willing
and able to tolerate, and in the early stages
they should receive a minimum of 45 minutes
daily of each therapy that is required. “
• No comment on time involved in any
other activities.
Content
• What is rehabilitation?
A process with many activities
• What is therapy (treatment)?
Any actions undertaken by therapists?
Process of teaching a patient an activity?
• What improves patient function?
Time with the therapist practicing?
Other therapist actions/other practice?
Messages
• Rehabilitation is not synonymous with
therapy.
• Therapists (team members) do much more
than give therapy.
• Rehabilitation process should be
separated from rehabilitation actions:
In research studies and papers
When considering resources needed and used
The clinical context
• Patients present with problems they
and/or others attribute to a health
problem
• Rehabilitation works within a holistic,
biopsychosocial model of illness
The holistic biopsychosocial model
Pathology
Impairment
Abnormal organ structure
or function; disease/damage
Symptoms & signs experienced
Impairments of function implied
Personal context
experience, expectation, attitude, choice, belief, disease label
Temporal context
stage in life; stage in illness
Social context
Expectations, attitudes, beliefs etc
of others
Participation
Patient roles; Others’ roles
Physical context
Objects and structures:
Peri-personal, general
Activities
Behaviour; goal-directed actions
Illness is:
• A dysfunction within the whole system
Traditionally secondary to pathology (disease
of or damage to an organ)
Better considered secondary to mismatch
between:
• Demands made on person
– By self (personal context), others (social context),
environment (physical context), bodily needs
• Capacity of person to maintain equilibrium in face
of challenge
– Capacity depends on whole person, and may be limited
in many ways
Medical approach
• Medical care only considers pathology
Diagnosis, cure/control, implications
• Uses bio-medical model of illness
Low attention to anything other than
• Pathology
• Somatic distress (pain)
Not recognise other causes of illness
Not consider importance of other factors
Patient goals usually to:
• Achieve satisfying social functions (roles)
• Be able to respond and adapt to changing
circumstances
• Be free of emotional and somatic distress
• Only concerned with pathology as one of
many potential limiting factors
Rehabilitation approach
• Considers whole situation
Using holistic biopsychosocial illness model
• Focuses on
Patient problems, wishes etc
Patient activities in first instance
• Goals are to
Optimise social function, adaptability
Minimise distress
Rehabilitation: a problem-solving process
Assessment to
• Formulate (analyse and understand) situation
• Determine potential goals and actions
Goal setting to:
• Set short-, medium-, and log-term goals
Actions to:
• Preserve patient safety and well-being (support)
• Change situation (‘treatments’)
Evaluation to:
• Compare change against goals
• Identify new/altered goals/actions
Rehabilitation activities
• Collecting & analysing data (assessment)
• Setting goals
• Undertaking actions to
Preserve safety and well-being
Alter situation / achieve goals
• Monitor change and progress
Transfer care to another service/patient
Rehabilitation actions - 1
• Two types:
support: care needed to maintain status quo
• Often the major resource
treatment: action expected to affect change
• Treatments are multi-focal (i.e. affect
several factors)
Any level:
• pathology, impairment, activities, participation
Any context:
• personal, physical, social
Rehabilitation actions - 2
• Often prolonged in time
• May be mutually inter-dependent
Botulinum toxin and physiotherapy
Giving wheelchair, adapting house and
teaching how to use it
• Order also may be important
• Difficult to describe, classify or quantify
Best by domain of WHO ICF?
Treatment - pathology
• Pathology
Changing neural plasticity/ability to learn
• Increase – e.g. ?use amphetamines
• Decrease – e.g. avoid sedative and similar drugs
Altering neural structures
• Nerve growth factors etc
• Also note
Making the correct diagnosis (or new one)
Giving or monitoring disease therapy
Treatment - impairment
• Treatments to alter impairments:
Directly (e.g. pain, spasticity)
Indirectly
• Prostheses (replace a lost part/skill)
• Orthoses (support a lost skill)
• Note: impairments may change:
Spontaneously
Secondary to other treatments
• E.g. increased activity
Treatment - activities
• To be discussed
Treatment - participation
• Most interventions to alter social
participation are at other levels
An important supra-ordinal goal for other
goals
• May:
Help patient to adjust social role expectations
Help person move out of sick role (being a
patient)
Role change is important
“The kindest thing anyone could have done for
me would have been to look me square in the eye
and say this clearly:
‘Reynolds Price is dead. Who will you be now?
Who can you be now and how can you get there
double-time’”
Reynolds Price. A whole new life: an illness and a healing.
New York Atheneum 1994
Treatment – physical context
• This involves altering the physical environment
 Peri-personal (clothing, small aids etc)
 Personal (wheelchairs etc)
 Within home (adaptations to stairs etc)
 Within other personal settings (e.g. workplace)
 Further afield (public transport etc)
Treatment – social context
• May wish to act on/alter attitudes,
expectations, behaviours etc of:
Personal others (family, friends, work
colleagues)
Others met (e.g. healthcare staff)
• Also consider:
Broader societal attitudes
Laws, rights, responsibilities
Culture of organisations & systems
Treatment – personal context
• May try to alter or influence:
Expectations, beliefs, attitudes
Self-efficacy, confidence etc
• Involves actions such as:
Providing information
Cognitive behavioural therapy
Contacting others in similar situation
System analysis
• Rehabilitation is a system
Involves many people
Includes many activities
All spread over time
• Systems
Are, to an extent, resistant to ‘degradation’
• Someone else can take over
But deliver an outcome that is greater than the
sum of its parts
At present
• We know that the system works
• We do not know
Which bits are critical
The extent to which one intervention may
affect the outcome of another
Changing activities
• Depends primarily on learning:
How to manage despite impairment
• Techniques
• Strategies etc
Use of equipment
What is possible
How to overcome difficulties
Activities (behaviour)
• Learning (a behaviour) depends upon:
Having adequate skills (i.e. impairment not
too severe)
Goals (motivation of patient)
• Patient must see connection to wanted goals
Confidence/self efficacy
• Belief it can be achieved
Feedback on performance
Change in behaviour
• This depends primarily on amount of
practice:
Repetition (100s of times)
May secondarily alter impairment
• E.g. increase fitness or strength
• Also
Feedback on achievement/failure
Varying situations
Roles of rehabilitation team
• To optimise environment
Structures
People (staff, family)
• To ensure practice is
Safe
Appropriate to abilities
• To teach techniques, strategies etc
• To encourage practice in different settings
In a session a therapist may:
Facilitate practice of an activity directly
Provide support (emotional, social)
Provide information, new knowledge
Practice other activities, indirectly
• E.g. communication
Teach how to use equipment
Teach others how to facilitate safe practice
Organise actions by others
Collect data, set goals etc
Rehabilitation
• Helps patient
Select the most appropriate destination
Travel along best pathway
Make best selection at any junctions
• Makes pathway
safe & easy to follow
Have emergency support network
Therapists
• Participate in team to
Select and adjust pathway
Provide safety net
• Help patient
Overcome particular obstacles safely
Navigate parts of the pathway
Learn new skills to manage travel
Conclusions
• Intensity of practice determines extent of
change in specific, targeted activities
Therapist has a role in facilitating safe practice
• Therapists have many other tasks beyond
practice
• Relationship between rehabilitation input
and outcome unclear
Extent (quantity) probably low relationship
Expertise (quality) likely to be more related
Is intensity of therapy important?
Dr Derick T Wade,
Professor in Neurological Rehabilitation,
Oxford Centre for Enablement,
Windmill Road, OXFORD OX3 7HE, UK
Tel: +44-(0)1865-737310
Fax: +44-(0)1865-737309
email: [email protected]
*** NOT VERY IMPORTANT
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