Is intensity of therapy important?

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: derick.wade@ntlworld.com

2. 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?

3. National Clinical Guideline for Stroke. 3rd edition. 2008Recommendation 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.

4. 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?

5. 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

6. 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

7. 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 Physical context Expectations, attitudes, beliefs etc of others Objects and structures: Peri-personal, general Participation Activities Patient roles; Others’ roles Behaviour;goal-directed actions

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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?

16. Treatment - pathology • Pathology • Changing neural plasticity/ability to learn • Increase – e.g. ?use amphetamines • Decrease – e.g. avoidsedative and similar drugs • Altering neural structures • Nerve growth factors etc • Also note • Making the correct diagnosis (or new one) • Giving or monitoring disease therapy

17. 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

18. Treatment - activities • To be discussed

19. 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)

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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

26. Changing activities • Depends primarily on learning: • How to manage despite impairment • Techniques • Strategies etc • Use of equipment • What is possible • How to overcome difficulties

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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: derick.wade@ntlworld.com *** NOT VERY IMPORTANT ***