Vol. 26 • Issue 7
• Page 16
Research is the cornerstone of evidence-based practice and is in much greater demand than ever before. But how can clinicians use research? When can we apply it?
All skilled therapists should incorporate evidence-based interventions into treatment plans. We can then evaluate the success of our treatments by the subsequent functional outcomes. This is the same approach, with the same goals, followed by clinical researchers in the lab. Ideally, clinicians and researchers would work side by side to trial interventions and determine which lead to the "best" gains or functional improvements.
At our facility, Kessler Institute for Rehabilitation in New Jersey, we have the unique privilege of establishing such a relationship with the Kessler Foundation Research Center (KFRC) Stroke Lab. Through the guidance and direction of the stroke lab's director, Anna Barrett, MD, we are able to offer our patients in acute rehabilitation the unique opportunity to participate in a clinical research-clinical care (CRCC) partnership program to trial a prism-based intervention for post-stroke spatial neglect.
Barrett and Burkholder (2006) define "spatial neglect" as a failure to report, respond or orient to the environment on the side opposite the individual's brain injury. Spatial neglect appears to be the strongest predictor of functional independence compared with any other stroke-related deficit, including hemiparesis and aphasia (Fullerton and colleagues, 1986). Debilitating loss of ADL is much more common in people with this disorder (Jehkonen and colleagues, 2006).
Given the strong relationship between spatial neglect and post-stroke disability, it is unfortunate that specific spatial-neglect assessment is not part of the conventional stroke-care toolbox. The NIH Stroke Scale includes only one item sensitive to spatial neglect, and the Functional Independence Measure (FIM) includes no specific neglect assessment. Unsurprisingly, both of these measures are insensitive to disability after right-brain stroke.
Further, traditional OT interventions for spatial neglect are based on sensorimotor rehabilitation and didactic/learning theory, which are methods to teach healthy or developing brains to acquire skills. These approaches, then, may not optimize learning in a person with an impaired brain.
When we sought best practices for a "brain-based" approach to treating spatial neglect, we were able to find a number of resources (Cicerone et al., 2005; Menon et al.). These emphasize reinstituting healthy function by encouraging healing and reconstruction of the damaged spatial brain system. Usually these approaches do not require the subject to be aware of the disorder or participate consciously, which is fortunate since many people with spatial neglect also lack awareness of their symptoms.
We identified three examples of this kind of remediation demonstrated to be effective in controlled studies:
• intensive training in adaptive movements, accompanied by visual cues (visual scanning training);
• intensive training of adaptive movements while activating the left side of the body (limb activation therapy); and
• using medications that stimulate recovery of "aiming" movement systems (usually critical dopamine movement pathways).
The therapy interventions, however, had drawbacks. Visual scanning training was found to be effective in four-week, one-hour daily programs; this is longer than most therapy settings permit. Limb activation therapy, developed in Ireland, is not manualized and known to most U.S. practitioners; it also requires a trained therapist.
Since none of the identified interventions were ideal for our setting, we began discussing with the stroke lab researchers whether other treatments for spatial neglect could be both effective and practical, even in home and skilled care environments where therapists may be unavailable.
Through our discussions with the research team, we became interested in using optical prisms to optimize intensive adaptive movement therapy. Our review of existing research showed some promising evidence that the use of prisms may benefit stroke survivors with spatial neglect. In fact, some survivors even resumed self-dressing and independent wheelchair navigation after treatment. The stroke lab had previously reported that prisms might selectively improve "aiming" system problems, such as difficulty preparing movements leftward and moving the left side of the body.
Prisms represent not only a neuroscience-based, affordable and feasible treatment option, but a treatment that might pave the way for future precision rehabilitation approaches more effective at the individual level.
In the current partnership, we enroll stroke patients in a four-year spatial neglect study funded by the National Institutes of Health and the National Institute of Neurological Disorders and Stroke. All admitted stroke patients are screened for unilateral spatial neglect by a therapist-researcher team. When the patient meets our criteria for inclusion in the study, he or she is offered the opportunity to consent to participate.
A lab research assistant gathers each participant's initial baseline data, and what follows is a week of intensive, 30-minute, individual treatment sessions where high-diopter (20) prisms are worn during repetitive and closely monitored movement training. The structured training sessions are performed daily, and we perform re-assessments on day 10 or at the end of two weeks of prism adaptation training.
One of the goals of our research was to identify specific neurological and physical factors of patients who will benefit from prisms and those who will not. Previous studies of intensive prism-adaptation training in other labs have shown that while some participants with spatial neglect improved, at least one out of four participants did not improve at all. In fact, some studies did not show any improvement in groups of more than 20 subjects. We will only know our results after much more information is collected, but the process has been very informative to our therapy teams, who have seen significant improvement in some study participants and have become interested in why the treatment seems to help.
The research required our participants to be assessed for spatial neglect using a standard method that would yield a numerical score. This was a different approach than the process-oriented assessment we had done in the past, since instruments such as the FIM do not include specific assessment of spatial neglect.
We used the Behavioral Inattention Test (Wilson and colleagues, 1987) and the Catherine Bergego Scale (CBS; Azouvi and colleagues. 2003). In the occupational therapists' part of the partnership, we completed training to administer the CBS predictably and accurately.
Although our clinicians frequently felt confident about identifying spatial neglect, we found that the way we detected and classified relevant spatial neglect symptoms improved when we borrowed from research methods. During the training, it was interesting to learn that an individual clinician's level of skill, experience with the disorder and/or ideas about the disorder definitely influence how spatial neglect is assessed.
For example, when we separately scored a patient's ability to respond to verbal stimuli on the impaired side, dress the impaired foot, and ambulate without collisions to the impaired side, we realized these skills may be completely separable. That is, a patient may have left-sided collisions, but have no difficulty with dressing on the left or eating symmetrically. This might be due to a relatively pure problem with "where" spatial attention in far space, or an isolated "aiming" tendency to veer when walking. By scoring items separately, we became more sensitive to these partial or mild impairments which can occur even in clients who are being treated for other disorders (e.g., spasticity), during the chronic phase of stroke recovery.
From Research to Bedside
The challenge of developing a way to rapidly identify candidates for the research prompted the therapy staff to rethink the formal vision assessment we perform on all our stroke patients at Kessler within 72 hours of admission. Four standardized measures have now been selected as part of the screening process for all of our patients in order to identify spatial neglect: the line bisection test and star cancellation subtests from the Behavioral Inattention Test, the draw-a-clock test, and the CBS.
We also have made prism training available to patients outside the research study during conventional OT sessions, at the discretion of the occupational therapist. The patient wears yoked prisms to potentially augment tabletop activities, fine-motor tasks, home management, or reaching tasks when the patient may be sitting on the edge of a mat. The therapist must determine each individual's tolerance to wearing the prisms, which is often task specific. However, patients have worn them for 30-minute intervals.
The therapist's observations of the patient's output (e.g, body symmetry or improved field of visual attention) needs to guide clinical decision making. The benefit of prisms during free performance of typical OT activities has not been fully researched, although this treatment is in clinical use and individual therapists have observed its potential benefit.
The collaborative efforts of Kessler Institute for Rehabilitation and Kessler Foundation Research Center advanced our practice by expanding our clinicians' horizons and by offering our patients cutting edge technologies/treatments. The team recently presented its CRCC spatial neglect program to the North East Cerebrovascular Consortium, where we reported that the first nine patients to undergo prism treatment experienced significant improvement as measured by the CBS.
We demonstrated that occupational therapists have a unique opportunity to develop research partnerships that can promote gold-standard care based on clinical research. We also reported that many patients and families deeply appreciate the opportunity to take part in clinical research that has direct application early on in their recovery.
References available at www.advanceweb.com/OT or upon request.
Kimberly Hreha, OTR, has worked at Kessler Institute for Rehabilitation in West Orange, NJ, for four years and has been involved in research studies with the Kessler Foundation for the last two years. Monika Eller, OTR, is the Severe Disorders of Consciousness (SDOC) Program manager at Kessler's West Orange campus. Anna M. Barrett, MD, is a neurologist and clinician-researcher at the Kessler Foundation and is president-elect of the American Society of Neurorehabilitation.