Physiotherapeutic theory for neurological rehabili
Summary
Summary physiotherpautic theory: stroke
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Physiotherapeutic theory for neurological rehabili
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Katholieke Universiteit Leuven (KU Leuven)
Summary of the stroke lesson given by prof G.Verheyden of the course physiotherapeutic theory. It is a summary of the powerpoint slides and additional items noted during the lesson. The slides were in English and my own notes are always in Dutch as much as possible. It is therefore a mix of the 2 l...
Physiotherapeutic theory for neurological rehabili
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physiotherapeutic theory: stroke rehabilitation
INTRODUCTION
Elke 2 seconde heeft iemand een stroke
- Variabiliteit in de wereld
- Dit is niet in BE maar wereldwijd
SOME QUESTIONS
Stroke patients should be mobilized=verticalized (on the edge of/out of bed)
Which of the following is the internationally agreed outcome measure for the upper limb activity domain?
- Action research arm test
Which domains are evaluated in the Barthel Index?
- dressing, walking, bladder (in)continence
Recovery after stroke is…
- Nonlinear
Research suggests that at 5 years after stroke, patients are from a motor and functional perspective…
- Back at the level they were at 2 months after stroke
PICO stands for…
- Patient, Intervention, Control, Outcome
What is the best description of a 'phase II' trial?
- A RCT which shows safety and feasibility and whick is the basis for a ‘phase III’ trial
MAGIC(app) is…
- An app that provides various clinical guidelines
(BE)FAST PRINCIPE
TIA: stroke like symptoms die in 24 h terug verdwenen zijn
Time is brain
Indien 1 vn de 3 FAS= bellen ambulance
RISK FACTORS
Controleerbare
- Roken
- Binge drinking
- Middelen misbruik
- Inactiviteit
- obesitas
Niet controleerbare
- Erdere stroke & TIA
- leeftijd
- Physial inactivity
- Heart disease and atrial fibrilation
- Binge drinking & substance misuse
- Hormonal contraception & HRT
- Family history or ethnicity
- Hoge bloeddruk (hypertensie)
- Diabetes
- Hoge cholesterol
STRESS is NOT a risk factor
Nala Melis Pagina 1
, physiotherapeutic theory: stroke rehabilitation
VERY EARLY MOBILIZATION AFTER STROKE – AVERT
P in acute fase zo snel mogelijk mobiliseren/verticalisering -> betere resultaten
A very early moblization after stroke fast-tracks return to walking: further results from phase II AVERT
randomized controlled trail (Cumming et al., 2011)
- Very early= binnen eerste 24h na cva
Verticaliseren P
- Phase 2 study
Gelimiteerd aantal P
Testen hypothese in erste study
1. AVERT
A Very Early Rehabilitation Trial (AVERT)
“Mobilisation” within the first 24h post stroke
- Bringing patients in an upright position
- voor sommige P zal dit zitten zijn voor andere staan of zelfs rond bed stappen
“Is safe and feasible” = fase 2 trial
- Is het nadelig voor de P?
Feasible: mogelijk om dit in klinische omgeving/praktijk toe te passen, haalbaar, kunnen we dit laten werken?
AVERT group achieved significantly faster “to walk again” than control group
- = intention, verdere specificatie van de hypothese
Thus, large international study warranted (>2000 patients)
Controle groep= normale behandeling
- Vaak pas kine na 3-4 dagen
Phase 3
- Effectiviteit nagaan hypothese
- Obv # P in phase 2 berekenen hoeveel P nodig voor fase 3 study = power calculatiesample size calculation
2. FASE 2 TRIAL
= gelimiteerde groep van P -> is het echt effectief? -> fase 3 trial nodig!
Op basis van fase 2 bepaal je hoeveel P je nodig hebt om een definitief antwoord te krijgen op het feit dat de
hypothese waar is.
Is de behandeling echt effectief?
Main outcome
- Met standard care behaald 40% independent walking na 20 dagen
- Met AVERT behaald 60% independent walking na 20 dagen
→ verschil na 20 dagen is relevant, er moet nog een fase 3
uitgevoerd worden maar dit verschil zegt al wel iets
→ we zien ook dat dit verschil blijft na langere tijd
- AVERT = P sneller terug zelfstandig kunnen wandelen
3. FASE 3 TRIAL
Efficacy and safety of very early mobilisation within 24h of stroke onset (AVERT): a RCT (Bernhardt et al.,2015)
- N=2104 from 56 acute stroke units!
- Vervolg vorige study (fase 2)
- Niet echt ≠te zien tussen normal care & AVERT, = resultaten fase 2 niet
bevestigd
- Geen sinificant verschil meer te zien tussen de 2 groepen
Neutraal resultaat
Geven 1sst therapy ≠verschil geen verschil VEM of usual care
- In fact…
“Fewer patients in the very early mobilisation group had a favorable
outcome than those in the usual care group (n=480 [46%] vs n=525 [50%]; adjusted odds ratio [OR] 0·73,
95% CI 0·59-0·90; p=0·004).”
Favourable outcome 3 months after stroke = modified Rankin Scale score of 0-2 (mRS)
Main outcome fase 3 study
o Negative trail experminental slechter als controle voor MAIN OUTCOME
Nala Melis Pagina 2
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