Implementation of an evidence-based combined therapy for post-stroke unilateral spatial neglect: a feasibility study
Geneviève LaGarde, Johanne Higgins and Lucie Tremblay
Nowadays, more people are surviving stroke and may live with and permanent disability. One such cause of permanent disability is unilateral spatial neglect (USN), a common consequence of stroke (43% of right brain-lesioned patients and 20% of left brain-lesioned patients according to Ringman, Saver and Woolson, 2004) that makes individuals unaware of objects, persons and even body parts located to the side of space opposite to the brain damage. This important condition transposes directly into everyday activities: eating from only one side of a plate, writing on one side of a page, and more importantly, bumping into walls, persons or moving objects while navigating in the environment. USN predicts poorer motor recovery, longer hospitalisation time and greater functional impairment (Ringman et al., 2004; Barer, 1990).
If the best available evidence to date supports the use of different intervention techniques in the rehabilitation of post-stroke USN (for a review see Kerkhoff and Shenck, 2012), no single strategy seems to be better than all the others (Maxton, Dineen, Padamsey and Munshi, 2013) and their overall efficacy remains uncertain (Ting et al., 2011). Nevertheless, it was found that visual scanning therapy and prism adaptation warrant consideration (Ting et al., 2011; Cicerone, 2000). As well, limb activation has been proposed for the treatment of left neglect rehabilitation (Riestra and Barrett, 2013).
Haynes, Devereaux and Guyatt (2002) propose a conceptual model that determines how interventions should be implemented at a time when research-informed health care should prevail. Patients’ benefits should depend primarily on decisions that not only incorporate the best current research evidence, but that also considers the current clinical state and circumstances as well as the patient's preferences.
Considering the above, the focus of our work arises from the need to 1- develop an integrative treatment strategy for the treatment of USN and 2- study its applicability in the prevailing clinical context of care of an intensive in-patient rehabilitation facility. Thus, we selected three of the most promising existing techniques: visual scanning, prism adaptation and limb activation, which would together offer a variety of rehabilitation contexts and maximize the frequency and intensity of interventions specifically targeting USN.
Participants and screening/baseline measures
Participants were recruited from a consecutive series of patients admitted to the neurology program in an intensive, in-patient rehabilitation facility in Montreal, Canada. If presence of USN was suspected at admission (based either on medical chart or early observations from clinicians), patients were invited to complete a formal screening assessment using the GEREN battery (Azouvi et al. 2002), which includes both neuropsychological and functional measures. Inclusion criteria were 1) stroke confirmed by CT or MRI (medical chart) 2) signs of USN (quantitative or qualitative) on psychometrics tests of the GEREN battery 3) score of ten minimally equivalent to mild form of USN on the Catherine Bergego Scale (CBS; Bergego et al., 1997) 4) ability to give informed consent (sufficient cognitive functions as assessed by a neuropsychologist). The institutional Research Ethics Board approved this study and all participants gave informed consent.
Program: USN-specific interventions were administered for four consecutive weeks for 20-30 minutes (as a part of regular treatment) per day, four times per week by therapists of four disciplines (physical therapy, occupational therapy, speech therapy, neuropsychology). A target of 64 USN-specific intervention sessions was therefore established for each participant. First, limb activation consisted of encouraging participants to use their left paretic limb as part of their occupational therapy treatments. In physical therapy, participants were submitted to the prism adaptation procedure (Rode, Klos, Courtois-Jacquin, Rossetti and Pisella, 2006). In speech therapy and neuropsychology, participants performed tasks following a structured visual scanning and cueing program (based on best practices described in Paquette, 2009 and Haskins, 2012).
Main outcome measure
At the end of the intensive intervention program, the CBS was administered to measure functional change.
A total of 27 patients admitted for post-stroke intensive functional rehabilitation in the neurology program at IRGLM were identified as presenting with possible USN symptoms. Nineteen of them (70,3%) were formally screened. From that number, 11 (57,9%) met the inclusion criteria and accepted to participate in the study. Those 11 participants received an average of 37.6 intervention sessions, across all disciplines, representing 58.7% of the target number of neglect-specific interventions.
Complete data on the CBS was obtained for seven out of the 11 enrolled participants. That subgroup of participants received an average of 68.8% of the target number of intervention sessions. At baseline the average score on the CBS was 14.3 out of thirty and at the follow up evaluation, the average score was 9.3, a lower score representing lower levels of USN. Thus, an average gain of 5 points out of 30 on the CBS was obtained for this subgroup of seven participants.
The aim of this study was to determine the feasibility of implementing a novel and interdisciplinary approach for the treatment of post-stroke USN in the prevailing context of care in an intensive, in-patient rehabilitation facility.
An important finding is the loss of many potential participants as well as a high rate of losses to follow-up. Also, none of the participants that completed the study received the intended number of intervention sessions. Interestingly, it was perceived by clinicians involved in the study that obstacles and challenges leading to this situation could be classified into 3 categories: 1) those pertaining to patients, 2) those pertaining to clinical circumstances and 3) those pertaining to clinicians.
Challenges relating to patients were the variable interest toward the proposed intensive and repetitive interventions from one patient to another and the diversity of post-stroke general profiles (presence of co-morbid cognitive dysfunctions such as attentional deficits or disinhibition, that could reduce the patient's availability towards USN-specific interventions). Obstacles pertaining to clinical circumstances were first the absence of an implementation agent that could have heightened the adherence to the study protocol and communication between the clinicians at the beginning of the study as well throughout the whole process. Second, the clinical circumstances prevailing in our intensive functional rehabilitation setting is characterized by certain conditions such as short length of stay and safe return home as a primary goal of intervention. These conditions, in the general context of limited health care resources, are less favourable to a systematic application of intensive evidence-based interventions specific to incapacity restoration.
In addition to the three factors on which clinical decisions should be made according to Haynes' theoretical model, current practices in the treatment of USN at IRGLM were also influenced by a fourth factor: clinicians' characteristics. Examples of obstacles linked to clinicians were the observed variability in the use of new outcome measures and interventions (different underlying preferences and individual beliefs) and the different ways to manage clinical priorities from one professional to another.
In spite of these challenges, an average improvement of 16,6% on the CBS was measured in the subgroup of patients who received the highest percentage of interventions. On average these persons improved from a moderate to a mild form of USN a change that could have a favourable impact on the patient's quality of life. Also, the implementation trial led to significant clinical benefits that were highlighted by the participating clinicians. First, it allowed many professionals to discover and learn about new assessment tools and interventions techniques. Second, the participating clinicians now benefit from same level of knowledge concerning post-stroke USN and the available and most promising assessment and intervention methods. Third, the study shed light on the actual USN-specific practice at the neurology program and its possible improvements. Finally, it was reported that clinicians were more prone to raise the intensity and variety of USN interventions when this incapacity represented the patient's main problem and when other limitations were not predominant.
In conclusion, based on this study, it seems that even the combination of existing and promising methods for the treatment of USN has its limitations and the implementation of such an extensive program comes with significant challenges. Nevertheless, our study could stand as an incentive for clinicians to reorient the choice of their actions and decisions towards a more reflexive approach, in an attempt to reach, in their practice, a more balanced implication of the three essentials factors proposed in Haynes' model (patient preferences, clinical circumstances and evidence-based recommendations), and to minimize the clinician-oriented decisions. Finally, instead of aiming for the implementation of extensive evidence-based approaches for all potential patients presenting with a specific post-stroke limitation, our study encourages the development of more flexible and better-targeted interventions based on the best available scientific data.
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Geneviève LaGarde: Ph.D., neuropsychologist at Institut de Réadaptation Gingras Lindsay de Montréal (IRGLM) and member of Center for Interdisciplinary Research in Rehabilitation of Greater Montreal
Institut de Réadaptation Gingras-Lindsay de Montréal du CIUSSS centre-est de l'Île-de-Montréal
Johanne Higgins: Ph.D., École de Réadaptation, Faculté de Médecine, Université de Montréal; Center for Interdisciplinary Research in Rehabilitation of Greater Montreal (IRGLM)
Lucie Tremblay: Clinical coordinator, Institut de Réadaptation Gingras-Lindsay de Montréal (IRGLM)
This clinical study was supported by the Lindsay Rehabilitation Hospital Foundation
Corresponding Author: email@example.com
International Journal of Disability, Community &
Volume 15, No. 1