Using Patient Goals in Treatment More Effective in Results

Brasilia, Brazil — It was found in a recent study that stroke patients found greater satisfaction if their progress was assessed on the basis of patient-specified goals.

According to Lisa Shaw, MD, senior research associate, Institute for Ageing and Health in Newcastle University in Newcastle upon Tyne, United Kingdom, one third of patient-driven goals was bimanual, i.e. assessing the function of both hands, which may have been the reason for  better outcomes than standard measures which may have missed that.

Using botulinum toxin-A (BT) in conjunction with a standard upper-limb therapy program, it was found that on objective measures of arm function following a stroke, neither therapy showed improved function after 1 month. However, patients stated they were equally satisfied with either therapy if satisfaction was based on attainment of goals that they had chosen themselves.

The original BT for Upper Limb after stroke  trial compared upper-limb therapy alone with therapy plus BT, It was found that using BT improved muscle tone after 1 month and a longer-term, arm strength, basic arm function tasks  and pain. But it didn’t improve arm function overall. BT has increasingly been used to reduce spasticity.

The investigators then asked the patients which therapy goals they would choose and how attainment of those goals compared with outcomes on a standard arm function test. They designed a  controlled, randomized clinical trial with (blinded) observers to look at arm function according to the Action Research Arm Test (ARAT), which consists of grip, grasp, pinch, and gross movement assessments vs patient-specified goal attainment, as assessed by COPM, the Canadian Occupational Performance Measure  which involves performance and satisfaction.

Participants were adults with upper-limb spasticity and reduced function at least 1 month after stroke. The average age was 68 years. 65% to 71% of patients were men and about 82% of participants had had a thrombotic stroke.

The interventions consisted of a 1-month upper-limb therapy program for 1 hour twice weekly with  or without  BT, when  outcomes were assessed. BT was injected into muscles of the hand, wrist, elbow, or shoulder depending the individual patterns of spasticity.

Treatments were focused on four set goals and one optional goal within the COPM. The focus was on passive, stretching; active assisted upper-limb movement; positioning; hygiene  and intensive task-oriented practice for ARAT.

The most commonly selected goals — about 90% of each group — were washing, dressing, eating and drinking. Participants chose goals of self-care (65%); productivity i.e. working in the kitchen, managing the household, going to school, playing or writing (19%); and leisure activities (16%). One third of the goals were bimanual tasks.

After 1 month, there were no  differences in the degree of improvement between the BT and the control groups. No change from baseline  on the ARAT occurred in either group.

Dr. Shaw said that despite the finding that BT did not enhance goal attainment or arm function compared with standard upper-limb therapy alone, both the BT and control groups had  relevant improvements of greater than 2 points on the COPM. ARAT measures are mostly unimanual, however many COPM measures involve both  the hands and arms. Dr. Shaw said the study shows the importance of including patient-specified goals when studying  rehabilitation.

Werner Hacke, MD, PhD, MPsych, professor and chairman of the Department of Neurology at the University of Heidelberg, Germany, agreed, saying “It is about caring about the patient, and I believe it doesn’t matter what you do, if you care and you have a positive psychological impact on the patients, they will benefit, and they feel better. This is what is probably the most important thing about early rehabilitation — spending time with the patient, independent of what you do.”

He added that there is no proof that one or another physical therapy approach is better than another.

In stroke recovery finding the right physical therapy solution is vital. The TUTOR system of products provide an innovative method of providing an intensive exercise regimen to stroke survivors in rehabilitation of their affected limbs. The HANDTUTOR, ARMTUTOR, LEGTUTOR and 3DTUTOR are ergonomically designed gloves and braces that consist of sensors connected to dedicated software. Physical and occupational therapists monitor the patient’s movement ability and then design a customized exercise program for that patient.

Currently in use in leading U.S. and European hospitals and clinics the TUTORs are fully certified by the FDA and CE. They are available for adults as well as children from the age of 5 and up and can be used in the patient’s home through telerehabilitation.

See WWW.MEDITOUCH.CO.IL for further information.

 

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