Is intensity of therapy important?

Dr Derick T Wade,Professor in Neurological

Rehabilitation,Oxford Centre for Enablement,

Windmill Road, OXFORD OX3 7HE, UKTel: +44-(0)1865-737310Fax: +44-(0)1865-737309

email: derick.wade@ntlworld.com

Why is intensity of therapy important?

• The questionsdoes 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. 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.

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 papersWhen 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

Abnormal organ structure or function;

disease/damage

Impairment

Symptoms & signs experienced

Impairments of function implied

Personal contextexperience, expectation, attitude, choice, belief,

disease label

Social contextExpectations, attitudes,

beliefs etc of others

Participation

Patient roles; Others’ roles

Physical context

Activities

Behaviour; goal-directed actions

Temporal contextstage in life; stage in illness

Objects and structures:Peri-personal, general

Illness is:• A dysfunction within the whole

systemTraditionally 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 pathologyDiagnosis, cure/control, implications

• Uses bio-medical model of illnessLow attention to anything other than

• Pathology• Somatic distress (pain)

Not recognise other causes of illnessNot 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 situationUsing holistic biopsychosocial illness

model• Focuses on

Patient problems, wishes etcPatient activities in first instance

• Goals are toOptimise social function, adaptabilityMinimise 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-beingAlter situation / achieve goals

• Monitor change and progressTransfer 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 physiotherapyGiving wheelchair, adapting house and

teaching how to use it• Order also may be important• Difficult to describe, classify or

quantifyBest 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

drugsAltering neural structures

• Nerve growth factors etc

• Also noteMaking 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:SpontaneouslySecondary to other treatments

• E.g. increased activity

Treatment - activities

• To be discussed

Treatment - participation

• Most interventions to alter social participation are at other levelsAn 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 environmentPeri-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 attitudesLaws, rights, responsibilitiesCulture of organisations & systems

Treatment – personal context

• May try to alter or influence:Expectations, beliefs, attitudesSelf-efficacy, confidence etc

• Involves actions such as:Providing informationCognitive behavioural therapyContacting others in similar situation

System analysis

• Rehabilitation is a systemInvolves many peopleIncludes many activitiesAll spread over time

• SystemsAre, 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 criticalThe 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 equipmentWhat is possibleHow 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 goalsConfidence/self efficacy

• Belief it can be achievedFeedback 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

• AlsoFeedback on achievement/failureVarying situations

Roles of rehabilitation team

• To optimise environmentStructuresPeople (staff, family)

• To ensure practice isSafeAppropriate to abilities

• To teach techniques, strategies etc• To encourage practice in different

settings

In a session a therapist may:

Facilitate practice of an activity directlyProvide support (emotional, social)Provide information, new knowledgePractice other activities, indirectly

• E.g. communicationTeach how to use equipmentTeach others how to facilitate safe

practiceOrganise actions by othersCollect data, set goals etc

Rehabilitation

• Helps patientSelect the most appropriate destinationTravel along best pathwayMake best selection at any junctions

• Makes pathwaysafe & easy to followHave emergency support network

Therapists

• Participate in team toSelect and adjust pathwayProvide safety net

• Help patientOvercome particular obstacles safelyNavigate parts of the pathwayLearn new skills to manage travel

Conclusions• Intensity of practice determines

extent of change in specific, targeted activitiesTherapist has a role in facilitating safe

practice• Therapists have many other tasks

beyond practice• Relationship between rehabilitation

input and outcome unclearExtent (quantity) probably low

relationshipExpertise (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, UKTel: +44-(0)1865-737310Fax: +44-(0)1865-737309

email: derick.wade@ntlworld.com

*** NOT VERY IMPORTANT ***