1. Audit of Current Practices and Outcomes for Upper Limb Management after Stroke
Bailey C1, Low Choy NL1,2
1 Physiotherapy Department, The Prince Charles Hospital,
2 School of Physiotherapy, Australian Catholic University
Background
National Stroke Foundation Clinical Guidelines for Stroke Management (2012) are available to guide translational studies in practice .

2. Aim Methods To investigate:
Adherance to stroke guidelines for the upper limb (UL) in stroke survivors receiving rehabilitation in the Rehabilitation and Acute Stroke (RAS) Unit at the Prince Charles Hospital
Methods
Medical charts and outcomes for sixty (60) stroke survivors (32 male, mean age: 76+/-14.12, range 32-97years) were audited over a 14 month period using multidisciplinary team reports.
The audit sought documented evidence for:
Guideline categories for UL dysfunction, severe weakness & subluxation
Functional Independence Measure (FIM motor scores), shoulder flexion/abduction strength, subluxation, shoulder pain & LOS.

3. Results Guideline compliance was relatively low, ranging between:
% for severe weakness
0-42.9% for UL dysfunction,
50% for subluxation.
Patients with subluxation at admission to RAS were significantly more likely to have a longer LOS (p=0.000) and patients with severe weakness on admission (shoulder strength ≤ 3/5) showed a trending increase LOS (p=0.050).
Patients with severe weakness (p=0.000) or UL dysfunction on admission (p=0.003) were significantly more likely to have lower FIM scores on discharge.
Patients with severe weakness (p=0.016) or subluxation (p=0.002) on admission were significantly more likely to have shoulder pain on discharge.
*** ** **
***
P=0.050 **

4. Implications for Changing Clinical Practice in RAS based on outcomes showing relatively low adherence to Clinical Guidelines
Educate staff, family & patients on subluxation and pain prevention
Identify & prevent subluxation on acute ward
Commence UL support & FES immediately on admission to acute ward environment - prior to transfer to Rehabilitation & Acute Stroke (RAS) Unit
Implement FES protocol for active motor return & task orientated practice
Implement collaborative UL goal setting sessions to optimise recovery
Use weekly planning meetings with OT / PT (shared goal setting / collaborative program content)
Explore opportunities for increasing intensity of practice (individualised programs / workstation model of care)

5. Clinical Guidelines requiring attention:
1. For people with severe weakness at risk of developing a subluxed shoulder, management should include 1 or more of the following interventions:
Electrical stimulation
Firm support devices
Education and training for the patient, family/carer & clinical staff on how to correctly handle / position the UL
2. For people who have developed a subluxed shoulder, management may include firm support devices to prevent further subluxation

6. Conclusions
Low adherence to UL stroke guidelines was evident in RAS unit.
Severe weakness on admission significantly increased LOS, presence of shoulder pain on discharge & decreased functional independence (FIM motor) at discharge.
Subluxation at admission increased LOS & presence of shoulder pain on discharge.
Attention to severe shoulder weakness & subluxation at admission may improve outcomes for stroke survivors.

7. References
National Health and Medical Research Council. Additional levels of evidence and grades for recommendations for developers of guidelines
Graham, K., & Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., et al. (2006). Lost in knowledge translation: Time for a map? The journal of Continuing Education in the Health Professions, 26,
Ada L, Foongchomcheay A, Canning C. Supportive devices for preventing and treating subluxation of the shoulder after stroke. Cochrane Database Syst Rev. 2005, Issue 1, CD
Ada, L, Foongchomcheay A. Efficacy of electrical stimulation in preventing or reducing subluxation of the shoulder after stroke: a meta-analysis. Australian Journal of Physiotherapy. 2002; 48(4):
Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: A systematic review. Lancet Neurol. 2009;8(8):
French B, Thomas LH, Leathley MJ, Sutton CJ, McAdam J, Forster A, et al. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev. 2007, Issue 4. CD
Mehrholz J, Platz T, Kugler J, Pohl M. Electromechanical and robot-assisted arm training fro improving arm function and activities of daily living after stroke. Cochrane Database Syst Rev. 2008, Issue 4. CD
Meilink A, Hemmen B, Seelen HAM, Kwakkel G. Impact of EMG-triggered neuromuscular stimulation of the wrist and finger extensors of the paretic hand after stroke: a systematic review of the literature. Clin Rehabil. 2008;22(4):
Yavuzer G, Selles R, Sezer N, Sutbeyaz S, Bussmann JB, Koseoglu F, et al. Mirror therapy improves hand function in subacute stroke: A randomised controlled trial. Arch Phys Med Rehabil. 2008;89(3):393-8.
Dohle C, Pullen J, Nakaten A, Kust J, Rietz C, Karbe H. Mirror therapy promotes recovery from severe hemiparesis: a randomised controlled trial. Neurorehabil Neural Repair. 2009:23(3):
Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DM, et al. Rehabilitation of hemiparesis after stroke with a mirror. Lancet. 1999;353(9169):
Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of Acute Musculoskeletal Pain. Australian Academic Press, Brisbane 2003.
Stewart KC, Cauraugh JH, Summers JJ. Bilateral movement training and stroke rehabilitation: A systematic review and meta-analysis. J Neurol Sci. 2006;244:89-85.