Download response-to-27 - College of Occupational Therapists

Intercollegiate Stroke Working Party 2016
National Clinical Guideline on the Management of people with stroke (fifth edition)
Feedback form for comments on draft chapters
This form is for you to make any comments you wish on the draft guideline. It is designed to help us
collate all comments.
Comments on the overall structure of the guideline, or on a particular chapter should be titled ‘general’
but specific marked examples would be helpful.
The guideline is in 7 chapters and has numbered parts (e.g. 6.2, 5.3.2). Please specify the part you are
referring to accurately, by number. If necessary add other detail. (e.g. 5.3.1 rec B, 4.2 para 2).
Always please:
 Make your comments or suggestions as specific but as short as possible
 Give any references (and justify anything outrageous!)
Please give your name and email contact.
Name Louise Clark (Chair of the Stroke Forum)
Organisation Responding on behalf of College of Occupational Therapy- Specialist Section for
Neurological Practice
Email [email protected]
Date/version Peer Review 1 April – 22 April 2016
Part
General
2 2.11
2.2.12 A/B
Comment
Thank you for the huge amount of work that has clearly gone into the development of this
guideline. In short, on review, we feel that the guideline represents the available
evidence well. However, it seems in some areas that the valuable consensus statements
that gave clinicians pragmatic guidance previously have reduced.
Some sections appear more detailed than others, with some of the cognitive sections
having a lot of technical detail and others being very brief and more of an overview of
general approach to take- reads as sections written by different people. Detail re
executive function, apraxia and perception would be beneficial. Vision section especially
brief, with no mention of orthoptists.
In some instances where the recommendations are repeated across sections, they read
slightly differently.
In increased reflection of the role/interventions offered by Orthoptists, orthotists and
rehab nursing would also be valued.
Response times are stipulated for OT but not SLT or PT in the recommendations.
From an Occupational Therapy perspective we would love to see an increased mention of
impact of deficits on function, education re deficits of both patient and family members
represented across all the areas, and considerations for safety around discharge
highlighted.
We hope our feedback is useful and look forward to seeing the final version.
Thank you
?A comment about services should be able to make arrangements to offer in excess of 45
minutes for people who are able to tolerate and are clearly benefitting from higher levels
of intensity
Reflect the need that brief psychological interventions delivered by non psychology staff
2 2.12 F
3 3.2 A
3 3.10 D
3 3.10 E
3 3.10 G
3 3.11
3 3.12 A
4 4.1.1 A
4 4.1.1 B
4 4.1.1 C
4 4.1.2 A
4 4.13 B
4 4.14 A
4.4.14 B
4 4.2 A
4 4.2 B
4 4.3 A
4 4.3 B
4 4.3 C
4 4.3.2 B
4. 4.3.3 A
4. 4.3.3 A
4. 4.3.3 A
4. 4.3.3 B
must be able to access supervision with a psychologist
?refer to Level 3 of stepped care model- or define how you determine severe
Could this be an appropriately trained professional (with relevant competencies) ie nurse?
Can you expand ‘multiple methods’- to include bloods, completion of fluid balance charts
etc
Could we say competent instead of trained as implies a maintenance of competencies
??what about agreed ‘at risk’ feeding following local protocols
Specialist implies therapy- ?what about overnight. Or remove specialist and replace with
someone with appropriate stroke handling skills
May be confusing in combination with the 45 minute target
‘In all relevant’ rather than ‘all’
Assessment tool such as….
Why so long to wait to see OT? If impacting on function and management- should be
sooner so we can begin education and assist MDT in appropriate approach and
management. Also currently are measured against fewer than 96 hours in SSNAP
Confusingly written and is a bit reductionist? Could we consider inclusion of other
essential ADLs- such as toileting, feeding and self medication??
Could EADL examples be given here, to show the range that should be considered
Could you specifically say including advice regarding exclusion period
(3rd statement) "notify DVLA if disability lasting more than 3 months". Can this be
checked - The DVLA website states 1 month for this.
Could you add Including voluntary work and family roles
Vocational rehabilitation input should include facilitation of increased level and
complexity of activity required for preparation in return to work
Role of DEA’s in Job Centres changing with many DEA’s becoming generic job advisors,
therefore not able to offer the required level of input to support RTW. Role of Work
Psychologists within DWP also changing limiting assessment, advice and employer contact
to support RTW. Lack of access to/availability of specialist vocational rehabilitation
teams. Therefore lack of specialist knowledge of specific conditions, such as Stroke, may
therefore adversely impact success rates and experience for stroke survivors of statutory
provision offered.
Do you describe somewhere ‘those with potential’?- how is this being determined? A
statement re conservative management of those without potential could be useful, but
carefully written so as not to ‘write people off’
Using locally agreed protocols based on available evidence base. Could we mention falls
where you say safely. Treatment should be evaluated using standardised
measure/achievement of goals
Shame to have lost the recommended screening tools
Or with indicators of deficits being present?? Rehab might not challenging enough to
show it and then may be discharged without issues being identified
And appropriate measures used, valid for use with those with aphasia where possible
Standardised approach such as
Interventions such as….?Include strategy training such as those referred to in Donkervoort
trial
Any suggestions of assessment method/tool?
Assess across relevant activities to the individual to establish impact on function.
Consider further assessment for those with higher demands- such as return to
driving/work
Assess for impact on function- activities important for the individual
?Preserve cognitive capacity for completion of activities that are important to individualmay be spending time with family at visiting time- not washing and dressing
4. 4.3.3 C
4. 4.3.4 A
4 4.3.5 A
4. 4.3.6 A
4. 4.3.6 B
4 4.3.7 A
4 4.3.7 B
4.4.3.7 C
4 4.4.1 A
4 4.4.1
4 4.6 A
4 4.6 B
Practice relevant ADL’s
Just identifying those who fail to organise task will miss many with exec dysfunctionconsider adding in other descriptors- Executive dysfunction may also present as socially
inappropriate, impulsive behaviour, poor initiation, poor self-monitoring, failing to see the
‘bigger picture’.
?? Consider higher level screening- including exec function for those returning to
demanding work roles
From the Cochrane Review, the work undertaken on relating specific assessments to
specific executive function components could be used to add to the existing
recommendations, something like “Assessments for dysexecutive syndrome should
provide a profile of people’s executive function components to inform the selection of
targeted interventions, e.g. self-awareness training (Cheng 2006; Goverover 2007) when
the component of concept formation is affected.”
If recommendation B is based on working party consensus, self-awareness training, goal
management training, autobiographical memory cueing, and problem solving training
have RCT trials which suggested a statistically significant effect in favour of these
interventions. Although meta-analysis did not produce an overall statistically significant
result, the individual RCT evidence could inform the working party consensus to include
these specific interventions.
Recommended assessment measures? If the executive function, memory and attention
sections are to be consistent, assessments should determine which components are
affected, i.e. which attention type, which component of executive function. In this
section, assessments should include assessments of different memory types including
episodic memory, semantic memory, prospective memory and working memory.
Using a functional approach and a standardised measure?
Written in less detail than other sections. Interventions such as….
Assess for impact on function
Should this just be when suspected, or routinely screened for all patients?
Concerns that this misses those with potential R inattention (less common)
Assessments should test for egocentric and allocentric neglect such as the hearts test in
the OCS. Possible interventions should include video-feedback (Tham and Tegner 1997) as
the neglected side is played back to the non-involved side increasing the person with
stroke’s awareness of the impact of the neglect.
Consistent with the other cognitive sections, information should be provided to patients
and family/carers
That includes personal space, reaching space and locomotor space
Considered for assessment if returning to driving, use of electric wheelchair
Safety on discharge needs to be assessed and risk mitigated
Explanation needs to be given to family as well as pt
No mention of standardised assessments or use of outcome measures for SLT
Consider recommending agreed assessment protocols for use with people with aphasia
(for instance those used for cognition, mood, etc)
Considerations for safety on discharge- being able to call for help, read medications etc
Joint working with OT, Psych, SLT where cognitive and language deficits co exist
Recommended assessment method? Assessment via self-report, standardised measures
validated for use with stroke population or observation. May include assessment for
factors associated with triggers e.g. cognitive abilities, mood disorder, sleep difficulties,
not just using a fatigue scale alone
Strategies…. Such as…..
Management strategies should include:
Developing a shared understanding between therapist, stroke survivor and significant
others of the person’s experience
4 4.7
4 4.8 A
4 4.9 B
4 4.9.1 D
4 4.9.3 A
4 4.10.1 C
4 4.10
4 4.10.2 A
4 4.12.3 B
4 4.12.3 D
4 4.13 A
4 4.14 B
4 4.15 D
4 4.15 G
4 4.15 H
4 4.17
4 4.17 B
5 5.9.1 A
Identify personal indicators of fatigue to support self-monitoring and management
Identifying personal triggers (which include physical activities, mental activities and
emotional situations)
Modifying the environment
Leading a healthy lifestyle (including sleep hygiene techniques, adequate nutrition and
hydration, exercise)
Scheduling and pacing activities
Identifying activities that ‘re-energise’ the stroke survivor (not just rest)
Cognitive strategies to reduce mental effort and increase likelihood of success
Psychological support to address any mood disturbance, stress management and
adjustment to changes following stroke)
Medical management of associated disorders e.g. side effects of medication, endocrine
disturbance, anaemia, other medical conditions
No mention of people who it wouldn’t be appropriate to feed/contraindicated- those
clearly EOL- take into account pts wishes, advanced directives etc, explain decisions not to
feed to relatives
Particular effort/skilled resource should be given to facilitate those with aphasia to
demonstrate capacity
?remove word significant
Do you need to be clear this is re people with potential to improve/improving. How will
this be determined? At what point to stop?
Falls risk assessment (including assessment of the home environment) -as per COT and
NICE guidelines
Taking account of possible cognitive and language deficits
Delivered by professional with the appropriate competence, training and supervision
? Need to include recommendation re suicide risk and safety implications of severe and
persistent mood disorder on discharge planning and safety
Education re condition for pt and family
Assessed using??
Regularly- indescript
Electrical stimulation (not functional in this case)
No mention re current stance on supports/orthotics/taping?
Screened not assessed- assessed in more detail using RASP/Nottingham if issues identified
Consider safety implications- education
Be given advice re physical aspect of sexual relations- ie positions possible to be achieved
with levels of physical disability present
Considered not given- just to emphasise caution required due to number of
contraindications
Ideally under EMG guidance- re evidence of improved effectiveness
By someone with demonstrated competence and anatomical knowledge
Regularly (how regularly?)
Using goniometry/ photographs
Other than post botulinum toxin
Vision section seems limited/brief
Include assessment of functional implication with focus on safety
Refer to Orthoptists when screening has identified….
Safety implications for discharge
Drivers- computerised field tests etc
Treatments such as (add examples to give parity to other sections)
Should this be more than only physical state?
Has the completion of the Joint Health and Social care plan been deemed no longer
appropriate?