Goal-Directed and person-centred Rehabilitation for spasticity post-stroke and brain injury.

Purpose

Stroke and brain injury-survivors have difficulty controlling muscles and in many cases, 'tightness' of muscles called spasticity. Spasticity is often painful, akin to muscle-cramp. It can limit mobility and independence and cause distressing complications of contractures, skin breakdown and pressure sores.

The aim of this work was to development a preliminary model 'goal-Directed and person-centred Rehabilitation (Direct-Rehab)', to link clinical decision making for patient centred treatment, with the goals and process of treatment. This requires a focus on linking physical rehabilitation treatments (often in combination with pharmacological treatments such as botulinum toxin) to person-centred goals.

Approach

Initially individualised goals for spasticity treatment incorporating botulinum toxin intervention for upper limb spasticity (n=696) were analysed from four studies published in 2008-2012), spanning a total of 18 centres (12 in the UK and 6 in Australia). Confirmatory analysis included a further 927 goals from a large international cohort study spanning 22 countries published in 2013.

Having performed this categorisation, a preliminary treatment planning model was produced using a consensus process with neurorehabilitation clinicians at two workshops. Participants were asked to comment and amend the draft model. Consultation was also undertaken with Patient Public Involvement participants (two expert patient advisors).

Outcomes

We identified 6 goal areas in two principal domains, which were mapped on to the WHO International Classification of disability Functioning and Health (WHO-ICF), from 1623 goals in five published studies.

 

Goal areas in the 'Symptoms and impairment' domain were:

1. Reduction of spasticity-related pain (11%)

2.Prevention of contractures and deformity (23%)

3. Control of unwanted involuntary movements, associated reactions or spasms whilst walking (11%).

 

Goal areas in the 'Activities' domain were:

1. Making it easier to care for the affected limb ('passive-function' (Sheean 2001)) e.g. maintaining palmar/axillary hygiene (35%)

2. Using the affected limb for some purpose ('active-function') defined either by the motor task for function (e.g. grasping/holding/releasing objects) (12%) - or by a functional task (e.g. eating/drinking) (5%), or both

3. Improved mobility - such as safer transfers or walking (2%).

 

Other goal areas that were used only occasionally were improving body image (cosmesis) (1%) and facilitating therapy (0.01%).

Consensus process participants (in two workshops) were asked to comment on the draft model, through an iterative development to amend and refine Direct-Rehab. Goal area selection was linked to assessment using the Arm Activity and Leg Activity measures. Goal categorisation (area) was then linked to broad treatment area under the headings of 1. Self-management and 2. Therapist directed treatment. A diagrammatic representation of the Direct-Rehab model was produced.  

We have produced the preliminary model for Direct-Rehab for further development and subsequent testing.

Cost and savings

Cost savings should be produced but are yet to be demonstrated following implementation and evaluation of the model in practice.

Implications

Formal development and testing of Direct-Rehab in now needed. In particular, development of treatment option selection is required and is planned in the project.

Top three learning points

  1. Person-centred goals are central to engaging individuals in their care.
  2. Person-centred goals can also be used to plan and revise subsequent treatment selection within rehabilitation.
  3. Pathways for care can deliver improved outcomes through co-ordinated and targeted treatment planning.

Fund acknowledgements

Stephen Ashford has been funded by the National Institute of Health Research (NIHR) in the form of a Clinical Lectureship award.

This paper presents independent research funded by the National Institute for Health Research (NIHR) UK and NIHR CLAHRC Northwest London.

The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the NIHR CLAHRC Northwest London or the Department for Health, UK.

Additional notes

This work was presented at Physiotherapy UK 2019

Please see the attached Innovations poster below.

For further information about this work please contact Stephen Ashford.

 

Reference(s):

1. Ashford S. Slade M. Turner-Stokes L. (2013) Conceptualisation and development of the Arm Activity Measure (ArmA) for assessment of activity in the hemiparetic arm. Disability and Rehabilitation. 35(18):1513-8. DOI:10.3109/09638288.2012.743602.

2. Ashford S. Jackson D. Mahaffey P. Vanderstay R. Turner-Stokes L. (2016) Conceptualisation and development of the Leg Activity Measure (LegA) for patient and carer reported assessment of activity (function) in the paretic leg in people with acquired brain injury, Physiotherapy Research International. 10.1002/pri.1660