25.11.2010, Thursday    Rehabilitation and Disability Research Theme

School of Physiotherapy
University of Otago

Recovery of post-stroke patients. Pam Duncan, Duke University

Normal, usual care improves patients considerably during 3 weeks – 6 months post stroke. After that, the usual care has little or no effect on improvement. Patients that are discharge continue steady decline between the rehabilitation sessions. There is hope, and some evidence, that intensive therapy and rehabilitation can flatten the decline, and even lift  the plateau. Some studies discussion on intensive therapy and rehabilitation helps (in theory, and in controlled lab environments). Real life cases suggest that normal rehabilitation does not focuses enough on sufficient level of exercise “stress”:

  • use it or lose it, challenge, active training, circuit training
  • specificity, repetition, intensity, time duration
  • exercise and rehabilitation training must be progressive, challenging, sustainable over long time duration

Tests before and after training. Typical post-stroke performance is 0.15m/s walk speed, and ability to walk <100m. 24 training sessions could push it up to 0.31m/s, and >300m distance.

Typical exercises: walking, steps up and down, standing up, sitting down on chair, going over a ramp.

Typical measures: balance, depression, mobility, participation, activity counts (number of steps per day, distance, number of standing up and sitting down on chair).

EMPOLI, Italian community-driven rehabilitation initiative. The use of Fire Services as venue for exercise and meetings (equipment and staff there, often staff “on call” waiting and doing nothing). The project is now widely accepted and successful (in Italy). But, there was a strong resistance from physiotherapists. Strong evidence that community continuing sustained support for long-term rehabilitation is essential.

Many post stroke patients experience falls (over 51% will have multiple falls in the first year post stroke).

Stroke foundation. Judith Heslop

Formed in 1980 as a not for profit organisation. Provides information and support for stroke patients. Promotes research. 8,000 people a year have stroke, 22 per day. Average age for stroke in NZ: Maori: 55years, non-Maori 65 years old. 2,000 people die each year.

NZ stroke rates declined over the last 30 years by 11%, whereas in the rest of the developed world the decline was by 42%! Pre-stroke warning strokes (TIA) are very serious. 80% of strokes are preventable if the TIA are diagnosed correctly. Most of stroke patients will die or be left with severe disability. Life long rehabilitation and support is needed. Social networking essential to sustain quality of life.

Social isolation, financial difficulties.

Bilateral Isokinematic Training Model.

Pact. Steve Catty.

Mental health and intellectual disabilities. Supports currently 800 people in Otago and Southland.

Age Concern. Margaret Dando.

Founded 60 years ago, serving the need of older people. 10 people of staff in Dunedin, national organisation. Number of projects: fall prevention (Steady as you go), meals on wheels, friendship phoning system, elder abuse and neglect, modified by ACC Tai Chi.

Arthritis New Zealand. David Cox.

Registered charity, non for profit. 500,000 people have arthritis in NZ. 140 different types. No cure. Affects all ages. 25,000 people cannot work due to this illness. www.arthritis.org.nz

MS Otago. Liz Caroll-Lowe (and Tania McGregor)

3,000-4,000 confirmed cases in NZ. Possible vitamin D a major factor in the onset of the disease. Difference between Southland and Auckland is 3x more in the south.

Exercise for Cancer Rehabilitation. Lynnette M Jones

1 in 9 NZ women will experience breast cancer over their lifetime. 85% survive. Treatment-related side-effects are significant. Exercise is a key component of survivership. The evidence is growing. 2,028 articles on exercise and breast cancer. Cancer Treatment has negative effect on many aspects, that can be offset by the positive effects the exercises. Exercising great for bone health, sholder functions, strengths, self-esteem, quality of life, aerobic fitness and muscle strength. Resisdance training lots of positive effects and safe on wide group of participants. Decreases lympdedema, fatigue, pain, depression, anxiety. Exercise: no drug company associated with it, hard to sell; GPs do not prescribe it. Interval training is also great! 3-4min for extremely intensive, and then sit and relax for the rest of 10min. 150min of aerobic exercise is one of the guidelines prescribed bythe American health board.

An example of how stakeholder consultation contributes to research and clinical direction. Cath Smith. Focus on MS. Tapu/cacred, Taonga/precious gift. Research principles: Respect for the people. Face to Face (meeting, discussions). Take care of the people.

Health Promotion for People with Disability. Hilda Mulligan.

Individual, social environment, physical environment all contribute to people participation. It is all about the “fit”: you are either too big with a key to too small doors, or you are too small, with no keys, and cannot reach the door handle. What’s important is to match the social context and environment to enable/empower people. Living well with Parkinson’s: self-management, resource kit (skills, knowledge, self reliance, self efficacy). Sleep patterns study for individuals with severe disability (sleeping systems: special materials, etc).

Citizen Engagement in Research. Sarah Lovell.

Social science background. Disability studies. Social justice studies. Qualitative research and hte social model of disability: considers disability to be a result of society’s failure to account for difference. focus on external factors prohibiting participation in society.

Measuring quality of life

Issues with measuring subjective and objective quality of life. Self-report, assessment by the staff member. There are different indicators taken in mental health (a perceived quality of life), different in post-stroke rehabilitation (e.g. mobility, balance, endurance). Self-reporting tends to quickly adjust and the measure is skewed towards reporting the “middle”. People re-adjust the baseline quickly based on recent events.

Discussion and open question session

Silo health system (each disease in its own pigeon hole). To apply for funding you need to be ell categorized, properly boxed.

Examples of media’s failures

“Cure not Care” – highly criticized by the research community. Commercial entities and big pharma controls the narrative, and marginalises serious aspects of

“Exaskeleton” another example of media overblow of some insignificant issues. The problem with “who controls the narrative”.

Some facts

  • Avr age for heart faulire in USA: 59 years
  • Avr age for stroke in USA: 67 years
  • Avr age for stroke in NZ: 65 (for non Maori), 55 for Maori

Highlights (often stressed by various participants)

  • Any health-related research, field trials, long-term rehabilitation monitoring, anything, require Information Systems tools and support
  • Activity and Exercise is the New Ultimate Medicine
  • Prevention is paramount. Highest impact. The most cost-effective.
  • Individual responses to treatment is hugely variable. Everyone is different. For many diseases, such as MS, stroke, PD, etc, everycase is different. Individual symptomps, levels, quality of life vary widely.
  • Most research goes into “CURE RESEARCH” – finding funding sources for rehab and prevention is much harder.
  • What’s important: healthy lifestyle choices, empowering people to be aware of the choices, and be informed, individual care, personal responsibility (you are the person to do the most work, exercise can be done alone, no big support required, individual faith in individual hands)
  • Lobby government and stimulate research that demonstrates that activity and exercising is the best, most cost effective medication there is. Exercises do not have side effects as compared to many medication-based treatments.
  • Narratives as a mean to communicate with wilder audience, media, political decision makers. The use of individual narratives.

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