joanna fletcher smith

Professor Marion Walker1, Jane Horne1, Dr Alan Sunderland1, Dr Avril Drummond1, Dr Judi Edmans1, Katherine Garvey1

, Anna Wan2, Hannah Turner2

1The University of Nottingham; 2Nottingham University Hospitals NHS Trust.

Joanna Fletcher-Smith Division of Rehabilitation & Ageing

The University of Nottingham

Dressing Rehabilitation Post Stroke

Presentation Overview

• Dressing evidence that informed the DRESS study• The Inter-rater reliability study of the NSDA• Aims of the DRESS study• Development of treatment manuals• Assessments• Examples of dressing treatment• Methods• Results• Conclusion

Dressing Evidence

Development of the Nottingham Stroke Dressing Assessment (Walker 1991)

• Motor ability significantly correlated with lower body dressing

• Cognitive ability significantly correlated with upper body dressing

Dressing Evidence

Crossover Design Study (Walker et al 1996)

Group 1 (treatment) Group 2 (control)

3 months

Assessment Assessment

Group 2 (treatment) Group 1 (control)

3 months

Assessment Assessment

Dressing Evidence

Survey of Occupational Therapy Dressing Practice (Walker C et al 2003)

• Time-limited, pragmatic, problem solving approach used by most UK therapists

• 30% of working day spent in delivering dressing interventions

• Neuropsychological literature not used to inform practice

Dressing Evidence

Patterns of Dressing Recovery (Walker C et al 2004)

• Patients who had movement in both arms could dress without error despite significant cognitive problems

• Patients with arm paresis and cognitive impairment had difficulty in learning compensatory dressing strategies

Dressing Evidence

Action Errors and Dressing Disability (Sunderland et al 2006)

8 single case design (video evidence)

• Right hemisphere damage & visuospatial problems:

Difficulty finding correct garment opening for the arm

Showed body neglect, not pulling t-shirt up over left shoulder

Improved dressing ability following therapy

• Left hemisphere damage & ideomotor apraxia:

Unable to learn correct sequence of activity & dressed unaffected UL first

No evidence of treatment effect

Study Aim:• to investigate the inter-rater reliability of the NSDA and

accompanying Dressing Error Analysis form

Inter-Rater Reliability Study of the Nottingham Stroke Dressing Assessment

(Fletcher-Smith et al 2010)

THE NOTTINGHAM STROKE DRESSING ASSESSMENT (NSDA)

• Two gender specific versions (56 stages for females, 36 stages for males)

• Each dressing stage is scored depending on observed ability...

0 = dependent on physical assistance1 = dependent on verbal assistance only2 = independent

• An overall % score can then be obtained


Jumper Score Comments and aids used

Selecting correct hole with affected arm

Selecting correct hole with non-affected arm

Pulling over head

Pulling down

Example: The stages involved in putting on a jumper...

NSDA ERROR ANALYSIS FORM

11 possible dressing errors:

A. Does not InitiateB. Fails to attend to taskC. Confuses or cannot find garment openingsD. Does things in the wrong orderE. Body neglectF. Does not push material high enough up paretic armG. Disorganised, no apparent strategyH. Visual NeglectI. Selection errorJ. PerseverationK. Clumsiness

METHODS

• 20 patients (14 females, 6 males) with persistent dressing difficulties

• 2 weeks post stroke

• 2 stroke research occupational therapists & 1 clinical occupational therapist acted as raters

• All 20 patients were observed during dressing

• The 3 raters independently completed the NSDA and error analysis form

• Data was analyzed using STATA software (StataCorp 2007)

• A kappa (k) test was performed to assess the level of agreement between the three raters

RESULTS

• 44 NSDA items could be tested

• NSDA level of agreement: Excellent agreement (k >0.75) on 29 items Good agreement (k >0.6) on 8 items Fair agreement (k >0.4) on 5 items Poor agreement (k <0.4) on 2 items

• The intra-class correlation coefficient (ICC) between the 3 raters’ final percentage score was 0.99 (Excellent agreement)

RESULTS

• 7 Error items could be tested

• Error analysis form level of agreement:Excellent agreement (k >0.75) on 2 items Good agreement (k >0.6) on 4 items Fair agreement (k >0.4) on 1 items

DISCUSSION

• Study involved a representative sample of UK stroke population

• The NSDA can be considered reliable regardless of severity of dressing problems

• The use of 3 raters significantly adds to the robustness of the methodology employed

• Sample size

• Not all dressing stages could be assessed

• The items with fair or poor agreement were also for the least

commonly worn garments

CONCLUSION

• The NSDA and error analysis form have psychometrically proven inter-rater reliability

• The NSDA provides occupational therapists with a reliable standardized outcome measure for use in the assessment of post stroke dressing ability

Development and Evaluation of Complex Interventions

Theory Modelling Exploratory trial Definitive RCT Long term implementation

Pre-

Phase I

Phase II

Phase III

Phase IV

MRC Framework

Continuum of increasing evidence

The DRESS studyWalker MF, Sunderland A, Fletcher-Smith J, Drummond A,

Logan P, Edmans J, Horn J.

A Pilot Randomised Controlled Trial

Dressing Rehabilitation Evaluation Stroke Study

• Dressing problems are common

54% dependent at 6 months

36% at 2 years post stroke

• Dependence more common in those with cognitive

difficulties (e.g. spatial confusion, memory, unilateral

neglect, apraxia etc)

• Treatment for dressing difficulties not evidence based

(Walker C et al, 2004)

Background

• Right hemisphere damage & visuospatial problems:

Improved dressing ability following therapy

• Left hemisphere damage & ideomotor apraxia:

No evidence of treatment effect

(Sunderland et al 2006)

Background

A randomised controlled trial of a neuropsychologically

informed dressing therapy

• Phase II feasibility study

• 30 month duration

• Funded by The Stroke Association

DRESS

Aims of the Study

• Can a definitive treatment manual be compiled to address cognitive impairments which commonly affect dressing performance after stroke?

• Is it feasible to deliver a neuropsychologically informed dressing therapy?

• Is there any indication that this approach may be beneficial?

• Can we gather enough information to predict the power of a definitive phase III RCT?

DRESS – Part 1

• 6 month duration

• Development of 2 treatment manuals:

Cognitive treatment manual

Functional approach treatment manual

DRESS – Part 2

• 70 patients randomised to cognitive (n=35) or functional (n=35) Rx group

• Research Assistant:

Baseline Assessments and randomisation

• 2 Research OTs as treating therapists provide:

Initial baseline functional dressing assessment (NSDA)

3 dressing sessions a week for 6 weeks

• Blinded Assessor (OT):

Outcome assessments

• Independent therapist:

Fidelity of treatment

Patient Selection

• Patients from Nottingham Stroke Unit

• 2 weeks post stroke

• Persistent dressing problems

• Included if impaired on at least one baseline cognitive screening test

Line cancellation test10 hole peg testObject decision test (VOSP)Gesture imitation

Patient Selection

• Exclusion

Inability to sit in chair <15 mins

Pre-morbid Rankin>3

Known diagnosis of depression or dementia (prior to stroke)

Living outside of catchment area

Demographic Data

• Age• Gender• Side of stroke• Barthel Index• Sheffield Screening Test for Acquired Language Disorders• Motricity Index for motor impairment

Web randomisation:Neuropsychological group Vs Conventional groupStratified: side of lesion, score on NSDA

Conventional Group (n = 35)

• Functional treatment manual based on current UK practice (Walker C 2004)

• No attempt made to formally assess cognitive impairments evident during dressing or relate these to the neuropsychological literature

• Repeated practice using a problem solving approach

• Not evidence based

Neuropsychological Group (n = 35)

• Further detailed cognitive testing and observation of dressing errors on the T-shirt test

• Formulation of a treatment approach based on outcome of both functional assessments and neuropsychological testing

• Prescribed treatments followed from neuropsychological manual

• Evidence based

T-Shirt Test

A. Does not initiate

B. Fails to attend to task

C. Confuses or cannot find hem/arm openings

D. Dresses non-paretic arm first

E. Does not cover the paretic shoulder

F. Does not push material high enough up paretic arm

G. Disorganised, no apparent strategy

3 minutes

Formulation of Treatment Plan

Observed Error Further Assessment Cognitive Impairment

A. Does not initiate Trail making, verbal fluency Executive function

B. Fails to attend Tone counting Sustained attention

C. Confuses garment openings Number location test Spatial confusion

D. Does things in wrong order Gesture Imitation Apraxia

E. Body neglect Fluff test Personal neglect

F. Does not push material high enough

Story recall, face recognition Memory or diffuse problem

G. No apparent strategy Gesture imitation Apraxia or diffuse problem

H. Visual neglect Star cancellation Visual neglect

I & J. Selection error/Perseveration

Action Imitation, Tone Counting, Trail Making, Verbal Fluency

Diffuse problem

K. Clumsiness Gesture imitation Apraxia

Treatment Example – Attention

• Alerting tones (Robertson et al 1998)

• Minimise Distraction (treat in gym or quiet area)

Treatment Example – Spatial Confusion

• Systematic laying out (markers)

• Step by Step Instruction

(with graded errorless learning)

Verbal

Written

Visual (photos)

“Left arm, right arm, over your

head”

Treatment Examples – Unilateral Visual Neglect

• The lighthouse strategy uses a visual imagery technique to encourage visual scanning to the contra-lesional side

Beep

Reality Testing – Visual Neglect

• Letter search

(26 alphabet letter tiles)

How much treatment?

• Dressing treatment ~ 18 sessions over 6 weeks

• 2 research occupational therapists provided both interventions

• Ward assistants/support staff provided routine care

• Treatment continued at home if necessary

6 Week Outcome Assessment

• Independent Assessor

Nottingham Stroke Dressing Assessment

Line cancellation test

10 hole peg test

Visual Object and Space Perception

Gesture Imitation

Acceptability questionnaire

Consented

N=110

Excluded: N=40

(Passed screening tests)

Randomized

N=70

Neuropsychological Approach

N= 36

Conventional Therapy

N= 34

Lost to therapy or

follow-up.

N=3

Lost to therapy or

follow-up.

N=3

6 week

assessment

N=33

6 week

assessment

N=31

Trial Recruitment

Neuropsychological

Group (N=33)

Conventional

Group (N=31)

Age Median

IQR

77

73-83

81

74-84

Days since stroke 26

19-40

22

18-33

Female : Male 21:12 17:14

Left : Right lesion 11:20 14:19

No significant differences between the groups

Trial Participants

Neuropsychological

Group (N=33)

Conventional

Group (N=31)

NSDA Median

IQR

29%

11-59

46%

12-71

Barthel 5.5

4-8

6

4-8

Motricity Index 52

26-70

42

8-68

Cognitive Screening

Lines cancelled 34

11-36

33

17-36

Object decision 11

8-14.5

11

8-14

Pegs per second .49

.30-.61

.85

.29-.57

Gesture Imitation 17

14-20

19

15-20

No significant differences between the groups (Mann-Whitney U tests, all p>.4)

Scores on Baseline Assessment

NSDA % Independence

0

10

20

30

40

50

60

70

80

90

100

Baseline Outcome


Neuropsychological Approach

NS

Average Outcome

NSDA Mean Change Scores

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Left Lesion Right Lesion


Neuropsychological Approachp=.08

ANOVA change scores with baseline motricity removed as covariate F(1,35)= 3.40, p=0.073

Sub-Group Analysis

• We can deliver a systematic approach to assessment and deliver a neuropsychologically informed intervention

• Both groups improved over time

• Trend for greater improvement in neuropsychological group

• Trend for greater improvement in patients with right hemisphere lesionsConfirms previous findings

• Need for a large phase III study in patients with right hemisphere lesions

Conclusion

• Repeated OT dressing practice works!

• Assessment should include both functional & standardised psychometric tests

• Clinical reasoning should always be used in differential diagnosis and treatment

• Use the neuropsychological literature to inform practice

In Summary...

Thank you for listening

[email protected]

joanna fletcher smith

Health & Medicine