Riabilitazione Neurologica (2) PROGETTO FORMATIVO SPECIALE / C.L. FISIOTERPIA.

Riabilitazione Riabilitazione

Neurologica (Neurologica (22))

PROGETTO FORMATIVO SPECIALE / C.L. FISIOTERPIA

Barnes, J Neurol Neurosurg Psychiat, 2003

Cosa è la riabilitazione neurologica?

Due principi sono fondamentali:

1. La riabilitazione è un processo attivo, distinto dal miglioramento spontaneo (recupero o convalescenza) e dal trattamento terapeutico (a pazienti non partecipanti).

2. Gli obbiettivi perseguiti dalla riabilitazione sono centrati sulla persona

RIABILITAZIONE NEUROLOGICARIABILITAZIONE NEUROLOGICA

What is a model of illness?

Illness refers to all aspects of ill healthpersonal, family, society, etc

Need a framework to analyse illnessTo describe it

Need a modelTo plan rational interventions

WHO ICF model of illness

• The framework» can be seen as a systems analytic approach,» considering illness as a hierarchy of systems

• A MODEL

• In this model, illness comprises» interacting systems» which may have emergent properties

WHO ICFInternational Classification of Functioning,

Disability and Health

Rivisitata ICIDH ICF:– Aggiunta fattori di contesto :

• fisici (archittetonici, vestiti, etc)

• personali (experienze, attitudini, etc)

• sociali (familgia/amicizie, cultura, etc)

– Cambio parole (e concetti ?)• disabilità -> attività

• handicap -> participazione

• Concetto globale di ‘functioning’

Interactions between the components of Interactions between the components of ICF (WHO 2001)ICF (WHO 2001)

Organ (pathology)

WHO ICF Model of illnessFour Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Physical

Social

Well-being

Riabilitazione neurologica: eRiabilitazione neurologica: elementi lementi per la definizioneper la definizione

Scopi della riabilitazioneScopi della riabilitazione

Processo della riabilitazioneProcesso della riabilitazione

Caratteristiche di un servizio di Caratteristiche di un servizio di riabilitazioneriabilitazione

Rehabilitation of patients with cognitive deficits

Dr Derick T Wade* Professor in Community Rehabilitation

Faculteit der Geneeskunde, Universiteit Maastricht

* Professor in Neurological Disability

Oxford Centre for Enablement

Windmill Road, Oxford OX3 7LD

Effectiveness of Rehabilitation for Cognitive Deficits

Cardiff 17 – 19 September, 2002

Rehabilitation aims Rehabilitation aims (outcome)(outcome)

To maximise patient participation in societyTo maximise patient participation in society– maximise role function in communitymaximise role function in community– maximise status in communitymaximise status in community

To maximise patient well-beingTo maximise patient well-being– somatic somatic and and emotionalemotional– achieving satisfaction (adaptationachieving satisfaction (adaptation))

To minimise stress on & distress of relativesTo minimise stress on & distress of relatives– somatic somatic and and emotionalemotional

ICF e Obiettivi della RiabilitazioneICF e Obiettivi della Riabilitazione

Massimizzare il repertorio Massimizzare il repertorio comportamentalecomportamentale– Ottimizzando i contestiOttimizzando i contesti

personale, fisico, socialepersonale, fisico, sociale

– Minimizzando le menomazioniMinimizzando le menomazionitutte, ma specialmente quelli con impatto sulle tutte, ma specialmente quelli con impatto sulle attivitàattività

– Minimizzando il danno d’organo (pathology)Minimizzando il danno d’organo (pathology)– Ottimizzando le opportunità di interazione Ottimizzando le opportunità di interazione

socialesociale

ICF e InterventiICF e Interventi

Danno d’organoDanno d’organo– Diagnosi e trattamento della malattiaDiagnosi e trattamento della malattia– Diagnosi e trattamento delle complicanzeDiagnosi e trattamento delle complicanze– Diagnosi e trattamento di malattie incidentaliDiagnosi e trattamento di malattie incidentali

ImpairmentsImpairments– Cognitivi (neglect, word finding)Cognitivi (neglect, word finding)– Altro deficit (motorio Altro deficit (motorio scrittura) scrittura)– Impedire peggioramenti (eccesso di Impedire peggioramenti (eccesso di

farmaci!!)farmaci!!)


AttivitàAttività– Esercizio delle funzioni colpite, secondo gli Esercizio delle funzioni colpite, secondo gli

obiettivi del paziente, in rapporto obiettivi del paziente, in rapporto all’ambiente quotidianoall’ambiente quotidiano

PartecipazionePartecipazione– Organizzare opportunità per inserimento Organizzare opportunità per inserimento

socialesociale


Contesto personaleContesto personale– Aumentare la fiducia in se stessoAumentare la fiducia in se stesso– Ridurre i timori di insuccessoRidurre i timori di insuccesso

Contesto fisicoContesto fisico– Uso di ausili cognitivi (diari, sistemi di allarme-Uso di ausili cognitivi (diari, sistemi di allarme-

ricordo, post-it)ricordo, post-it)

Contesto socialeContesto sociale– Lavoro stabileLavoro stabile– Inserimentonella comunitàInserimentonella comunità

Aims of the rehabilitation processAims of the rehabilitation process

Maximise patients’ participation in Maximise patients’ participation in

their social settingtheir social setting Minimise the risk of medical Minimise the risk of medical

complication (e.g. contractures)complication (e.g. contractures) Minimise the pain and distress Minimise the pain and distress

experienced by the patient (maximise experienced by the patient (maximise

quality of life)quality of life) Minimise the distress of and stress on Minimise the distress of and stress on

the patient's the patient's family and/or carersfamily and/or carersDT Wade e BA de Jong, DT Wade e BA de Jong, BMJBMJ 2000;320:1385-13882000;320:1385-1388

Approaches of the rehabilitation Approaches of the rehabilitation processprocess

Approaches that reduce disability Approaches designed to acquire new skills and strategies, which will maximise activity Approaches that help to alter the environment, both physical and social, so that a given disability carries with it minimal consequent handicap

Barnes, J Neurol Neurosurg Barnes, J Neurol Neurosurg Psychiat, 2003Psychiat, 2003

Rehabilitaton ProcessRehabilitaton Process

Rehabilitation is a reiterative, active, educational, problem Rehabilitation is a reiterative, active, educational, problem solving process focused on a patient's behaviour solving process focused on a patient's behaviour (disability/activity), with the following components(disability/activity), with the following components::

• AssessmentAssessment: the identification of the nature and extent of the : the identification of the nature and extent of the patient's problems and the factors relevant to their resolutionpatient's problems and the factors relevant to their resolution

• Goal settingGoal setting• InterventionIntervention, which may include either or both of , which may include either or both of

a.a. treatmentstreatments, which affect the process of change; , which affect the process of change; b.b. supportsupport, which maintains the patient's quality of life and his , which maintains the patient's quality of life and his

or her safetyor her safety• EvaluationEvaluation: to check on the effects of any : to check on the effects of any interventionintervention

DT Wade e BA de Jong, DT Wade e BA de Jong, BMJBMJ 2000;320:1385-13882000;320:1385-1388

Rehabilitaton ProcessRehabilitaton Process

Barnes, J Neurol Neurosurg Barnes, J Neurol Neurosurg Psychiat, 2003Psychiat, 2003

To work in partnership with the disabled person To work in partnership with the disabled person and their familyand their family To give accurate information and advice about the To give accurate information and advice about the nature of the disability, natural history, prognosis, etcnature of the disability, natural history, prognosis, etc To listen to the needs and perceptions of the To listen to the needs and perceptions of the disabled person and their familydisabled person and their family To work with other professional colleagues in an To work with other professional colleagues in an interdisciplinary fashioninterdisciplinary fashion To liaise as necessary with key carers and To liaise as necessary with key carers and advocates advocates To assist with the establishment of realistic To assist with the establishment of realistic rehabilitation rehabilitation goalsgoals, which are both appropriate to that , which are both appropriate to that person’s disability and their family, social, and person’s disability and their family, social, and employment employment needsneeds

ICF e misure di risultato

ICF e assessmentICF e assessment

•MISURE DI DISABILITA’/ATTIVITA’MISURE DI DISABILITA’/ATTIVITA’

•Indice di Barthel (BI)Indice di Barthel (BI)

•Misura di Indipenza Funzionale Misura di Indipenza Funzionale

(FIM) (FIM)

•MISURA DI INDIPENDENZA FUNZIOALEMISURA DI INDIPENDENZA FUNZIOALE

Le scale, come “misuratori di risultato” (outcome measure), devono soddisfare i seguenti criteri:

1. Validità: deve essere una scala che misura ciò che si vuole misurare;

2. Affidabilità: lo strumento deve essere accurato, stabile nel tempo, riproducibile;

3. Sensibilità: la scale deve essere in grado di cogliere variazioni clinicamente significative;

4. Semplicità: semplice da impiegarsi;

5. Comunicabilità: lo strumento deve essere facilmente compreso anche dai non specialisti;

6. Utilità clinica

Goal settingGoal setting

The process of rehabilitation is set around the establishment of goals. The first goal to be set is the long term strategic aim. Once a realistic and achievable long term goal has been established then the smaller steps needed to achieve that goal are determined.

The goals must be precise and should be:• Specific• Measurable• Achievable• Relevant• Time limited

SMART

Characteristics of a rehabilitation Characteristics of a rehabilitation serviceservice

It comprises a multi-disciplinary group (team) of It comprises a multi-disciplinary group (team) of people who focus their attention on a patient's people who focus their attention on a patient's disability, and:disability, and:Work together towards common goals with each Work together towards common goals with each patient;patient;Involve and educate the patient and family in the Involve and educate the patient and family in the process;process;Have relevant expertise and experience Have relevant expertise and experience (knowledge and skills); and(knowledge and skills); andCan, between them, resolve most of the Can, between them, resolve most of the common problems faced by their patientscommon problems faced by their patients

The multidisciplinary team centered The multidisciplinary team centered around patient and caregiveraround patient and caregiver

Recent advances in rehabilitationRecent advances in rehabilitationDT Wade, BA de JongDT Wade, BA de Jong

BMJBMJ 2000;320;1385-1388 2000;320;1385-1388

Outcome measures for clinical Outcome measures for clinical rehabilitation trials: Impairment, rehabilitation trials: Impairment, function, quality of life, or value? function, quality of life, or value?

Wade DT: Wade DT: Am J Phys Med Rehabil, Am J Phys Med Rehabil, 2003;82(Suppl):S26–S312003;82(Suppl):S26–S31..Outcome: What Is It?

Nel campo della ricerca riabilitativa il termine “outcome” indica è una “variazione attesa” in un parametro o in uno “stato”. Outcome è il nuovo stato in cui il paziente si viene a trovare come risultato di un intervento (programma riabilitativo).

Nella riabilitazione vi sono spesso molti inteverventi nel tempo e i relativi “outcomes” non sono sempre ovvi.

Outcome measures for clinical Outcome measures for clinical rehabilitation trials: Impairment, rehabilitation trials: Impairment, function, quality of life, or value?function, quality of life, or value?

In un paziente con ictus, tutti gli “outcomes” della In un paziente con ictus, tutti gli “outcomes” della tabella possono essere pertinenti in ragione di cosa tabella possono essere pertinenti in ragione di cosa si vuole valutare e perché.si vuole valutare e perché.

Outcome measures for clinical Outcome measures for clinical rehabilitation trials: Impairment, rehabilitation trials: Impairment, function, quality of life, or value? function, quality of life, or value?

Wade DT: Wade DT: Am J Phys Med Rehabil, Am J Phys Med Rehabil, 2003;82(Suppl):S26–S312003;82(Suppl):S26–S31..

In rehabilitation, outcome is more difficult to In rehabilitation, outcome is more difficult to measure because measure because

1)1) usually several outcomes are relevant,usually several outcomes are relevant,

2)2) relevant outcomes are affected by relevant outcomes are affected by

multiple factors in addition to treatment, and multiple factors in addition to treatment, and

3)3) even good measures rarely reflect the even good measures rarely reflect the

specific interest of any individual patient or specific interest of any individual patient or

member of the rehabilitation team, leading member of the rehabilitation team, leading

to some dissent. to some dissent.

Comparison of physician outcome measures and Comparison of physician outcome measures and patients' perception of benefits of inpatient patients' perception of benefits of inpatient

neurorehabilitationneurorehabilitation BMJBMJ 2002; 324:1493 2002; 324:1493

Rating scales of impairment, disability, and handicap are often used but only partially reflect the rehabilitation process, tending to be "physician oriented."

Physician outcome measures relate poorly with patients' perceived benefit from inpatient neurorehabilitation as measured on a visual analogue scale.

The low correlation of visual analogue scale with the functional outcome measures indicates that these measures reflect only a small part of patients' perceived benefit.

Measurement in the Measurement in the Neurorehabilitation based Neurorehabilitation based

on the ICFon the ICF

Determine if the measures you find

- are self completed by the patient

(patient reported outcomes)

or

- performance-based, rated by a

therapist

Are costs associated with the use of the measure?

How long does it take to complete/ administer the measure?

How much equipment is required? Is the measure available in the language

of the patient?

General Standards for Use of General Standards for Use of MeasuresMeasures

Validity Reliability Responsiveness Practicability

ValidityValidity

If the test does indeed measure what it is intended to measure, then we can say that the test is valid Psychology Glossary

Most important consideration, when selecting a measure

Is regarded as the extent to which a test measures what it is intended to measure?

ReliabilityReliability

It refers to the extent to which a test or other instrument is consistent in its measures Psychology Glossary

Maybe defined as "the degree to which a measure is free from random error"

Guidelines for how much is "good enough" are suggested to range from ccorrelations of 0.70 and more S. Schädler 2007

ReliabilityReliability

Intrarater reliabilityis the degree to which scores on a measure obtained by one trained observer agree with the scores obtained when the same observer reapplies the measure at another time

Interrater reliability

is the degree to which scores on a measure obtained by one trained observer agree with the scores obtained by another observer

Threads of ReliabilityThreads of Reliability

Fatigue Boredom Distraction Untrained raters

Sh. Wood-Dauphinee 2005

ResponsivenessResponsiveness

Sensitivity to change The ability of the measure to assess

and quantify clinically important change

Two things are very important:

- the minimal detectable change (MDC)

- the minimal clinical important

difference (MCID)

PracticabilityPracticability

For which population? Easy to complete Manual (test instruction) Costs (material, license) Education (time, costs)

What kind of outcome measures What kind of outcome measures should be chosen?should be chosen?

For assessment/ problem analysis For treatment planning For outcome measure For prognosis

Recent advances in rehabilitationRecent advances in rehabilitationDT Wade, BA de JongDT Wade, BA de Jong

BMJBMJ 2000;320;1385-1388 2000;320;1385-1388

Medicina basata sulle evidenzeMedicina basata sulle evidenzeee

RiabilitazioneRiabilitazione

La medicina basata sulle prove (evidenze scientifiche) è:

Integrazione di: •Esperienza clinica individuale •Miglior evidenza clinica esterna

derivata da una ricerca sistematica della letteratura esistente

•Risorse disponibili•Valori ed attese del paziente

(Sackett (Sackett 1997)1997)

Archie Cochrane (1909-1988)

“It is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized controlled trials.”

Archie Cochrane (1909-1988)

Monografia “Effectiveness and Efficiency” (1971)

Randomized clinical trials (RCT)

Evidence-based Medicine (EBM)

The conventional evidence-based practice approach to evaluate interventions has been divided into three components: efficacy efficacy : : has it been shown to work in ideal circumstances?; effectiveness effectiveness :: has it been shown to have an important effect across a range of settings and circumstances?; and efficiencyfficiency : has it been shown to provide value for money?

Evidence-based practice for stroke

The lancet neurology Vol 8 April 2009The lancet neurology Vol 8 April 2009

Efficacia versus Efficacia versus EfficienzaEfficienza

Basic elements of clinical decision makingBasic elements of clinical decision making

Quali sono le caratteristiche Quali sono le caratteristiche degli RCTs inclusi nella degli RCTs inclusi nella

revisionerevisione??

Metodi: Randomizzazione, Cecità

Partecipanti: tipo di pazienti, Storia di malattia

Interventi: Dose, durata del trattamento,

Co-trattamentiOutcomes

AAN evidence classification AAN evidence classification scheme for a therapeutic articlescheme for a therapeutic article

Class I

Class II

Class III

Class IV

The Validity of The Validity of Cognitive RehabilitationCognitive Rehabilitation

Strategies for Evaluating Effectiveness and Strategies for Evaluating Effectiveness and Translating Research to Clinical PracticeTranslating Research to Clinical Practice

Keith D. Cicerone, Ph.D.Keith D. Cicerone, Ph.D.

REVIEW ARTICLEREVIEW ARTICLE

Evidence-Based Cognitive Evidence-Based Cognitive Rehabilitation: Rehabilitation: RecommendationsRecommendationsfor Clinical Practicefor Clinical PracticeKeith D. Cicerone et al., Arch Phys Med Rehabil 2000; Keith D. Cicerone et al., Arch Phys Med Rehabil 2000; 81:1596-615.81:1596-615.

Levels of EvidenceLevels of Evidence

Class IClass I

Well designed, prospective, randomized Well designed, prospective, randomized controlled trialscontrolled trials

Well designed, prospective studies with Well designed, prospective studies with ‘quasi-random’ assignment to treatment ‘quasi-random’ assignment to treatment conditions (Ia)conditions (Ia)


Class IIClass II Prospective, non-randomized cohort Prospective, non-randomized cohort

studiesstudiesRetrospective, non-randomized case Retrospective, non-randomized case

control studiescontrol studiesClinical series with well-designed Clinical series with well-designed

controls allowing between-subject controls allowing between-subject comparisonscomparisons


Class IIIClass III

Clinical series without concurrent Clinical series without concurrent controlscontrols

Case studies with appropriate single-Case studies with appropriate single-subject methodology and subject methodology and measurementsmeasurements

Practice ParametersPractice Parameters

Practice StandardPractice Standard

Based on at least one, well-designed Based on at least one, well-designed Class I study with adequate sample,Class I study with adequate sample,

oror

Overwhelming Class II evidence, that Overwhelming Class II evidence, that provides good evidence to support the provides good evidence to support the effectiveness of the interventioneffectiveness of the intervention

Practice ParametersPractice Parameters

Practice GuidelinePractice Guideline

Based on well-designed Class II studies Based on well-designed Class II studies that provide fair evidence to support the that provide fair evidence to support the effectiveness of the intervention effectiveness of the intervention

AAN system for translation of AAN system for translation of evidence to recommendationsevidence to recommendations

Rating of recommendationsTranslation of evidence to

recommendationsA = Established as useful/predictive or not useful/predictive for the given condition in the specified population

Level A rating requires at least one convincing class I study or at least two consistent, convincing class II studies

B = Probably useful/predictive or not useful/predictive for the given condition in the specified population

Level B rating requires at least one convincing class II study or overwhelming class III evidence

C = Possibly useful/predictive or not useful/predictive for the given condition in the specified population

Level C rating requires at least two convincing class III studies

U = Data inadequate or conflicting. Given current knowledge, test, predictor is unproven.

Practice ParametersPractice ParametersPractice OptionPractice Option

Based on Class II or Class III studies, with Based on Class II or Class III studies, with additional grounds to support the additional grounds to support the effectiveness of the intervention, but with effectiveness of the intervention, but with unclear clinical certaintyunclear clinical certainty

BIF/AIFA, 2006

META-ANALISI: combinare cosa con cosa ?

DIVERSITA’ CLINICA

Gli studi affrontano lo stesso problema?

Gli studi sono diversi? Es. per:

- luogo di ricovero e tipo di assistenza prestata

- tipo di pazienti (età, sesso, gravità,…)

- trattamenti (farmaco, dose, durata, frequenza,…)

- definizione e misure degli esiti

- durata del follow-up

DIVERSITA’ METODOLOGICA

RCT a gruppi paralleli o crossover

Qualità degli studi (per es. randomizzazione e modalità di assegnazione ai gruppi di trattamento, oppure cecità della misurazione degli outcomes

Analisi (per es. ‘intenzione al trattamento’ vs. ‘trattati’ )


ETEROGENEITA’ STATISTICA

Vi è una diversità dei risultati degli studi maggiore di quella che ci si potrebbe aspettare per effetto del caso


Copyright © Mediss 2001 All rights reserved

Questi titoli indicano quale confronto è stato fatto e qual’è l’outcome di interesse

Questa linea orizzontale è la scala che misura l’effetto del trattamento. A destra la scala è <1 e significa che il trattamento ha reso meno probabile la morte.

Questa lineaverticale nelcentro è doveil trattamentoe il controllohanno lo stesso effetto- non vi èdifferenza tra idue


Per ognistudio vi èun id

I dati di ognistudio sono qui, divisi nelgruppo deitrattati e deicontrolli

Questo è il peso % assegnato aquestostudionell’analisi aggregata

Statistica utilizzata

Dati numericidel grafico

Ad ogni studio è assegnato un quadrato posto dove i dati misurano l’effetto. L’area del quadrato è proporzionale al peso % dello studio. La % di peso assegnata dipende dalla varianza dello studio (dimensioni e numero di eventi osservati). La linea orizzontale rappresenta l’intervallo di confidenza, una misura che ci indica di quanto il risultato può variare per effetto del caso. Quanto più l’intervallo di confidenza è ampio, tanto meno siamo confidenti nell’effetto osservato.


L’analisi aggregata dei risultati di tutti gli studi è rappresentata con un diamante (media pesata). Se l’intervallo di confidenza include l’unità significa che non abbiamo trovato una differenza statisticamente significativa tra i due trattamenti.

Evidence-Based PM&R?

Arch Phys Med Rehabil Vol78, November 1997

PM&R journalsPM&R journals

9 major impact factor–rated Physical Medicine and Rehabilitation (PM&R) journals:

•Archives of Physical Medicine and Rehabilitation, •American Journal of Physical Medicine and Rehabilitation, Physical Therapy, •Scandinavian Journal of Rehabilitation Medicine, •Journal of Rehabilitation Research and Development, •Supportive Care in Cancer, •Prosthetics and Orthotics International, •Journal of Orthopaedic and Sports Physical Therapy, •Journal of Manipulative and Physiological Therapeutics

Evidence-Based Practice and the Limits of Evidence-Based Practice and the Limits of Rational RehabilitationRational Rehabilitation

Keith D. Cicerone, Ph.DKeith D. Cicerone, Ph.DArch Phys Med Rehabil 2005; 86:1073-1074Arch Phys Med Rehabil 2005; 86:1073-1074

E’ difficile applicare i principi della “evidence-practice-medicine” alla ricerca in riabilitazione (contemporaneità di interventi e di diversi “outcome”, problemi etici nella randomizzazione) ma è una via “obbligataobbligata”.Vanno rispettati 3 “pilastri”: attenta considerazione delle migliori “prove” scientifiche disponibili esperienza clinica e valutazione personale considerazione dei valori e delle convinzioni del paziente.

Il “rispetto” del paziente pone comunque dei problemi da risolvere

GRAZIE PER L’ATTENZIONEGRAZIE PER L’ATTENZIONE

Riabilitazione Neurologica (2) PROGETTO FORMATIVO SPECIALE / C.L. FISIOTERPIA.

Documents

Transcript of Riabilitazione Neurologica (2) PROGETTO FORMATIVO SPECIALE / C.L. FISIOTERPIA.