Recording the Gait of Stroke Patients to Improve Motivation, Satisfaction and Outcome P Jayabalan MD, PhD 1, T Breisinger PT 2, R Kaplan PT 2, K Vitti PT 2, E Greene PT 2, R Donlan DO 1 JA Lanphere DO 1, J Shen MD 1 1 Department of Physical Medicine & Rehabilitation, University of Pittsburgh Medical Center 2 Department of Physical Therapy, University of Pittsburgh Medical Center

THE STROKE PATIENT Significant negative impact on their lives (Thomas et al, 2006) Rehab progress can plateau (Hallams & Baker, 2009) ‘Lack of understanding’ (Rudd, 2009) ‘Lose motivation & give up’ (Hallams & Baker, 2009) MOTIVATION is a critical factor in outcome (Griffiths 1993, Mclean et al 2000)

STANDARD OF CARE OBSERVATIONAL GAIT ANALYSIS  Visual inspection of walking  Once/week in most rehab units  Assess neuromuscular and behavioral factors affecting gait  Monitor spasticity, pain and contracture  Subjective assessment of motivation  Evaluate interventions  Educational benefit to clinicians Findings are NOT conveyed to the patients visually

THE CONCEPT

THERAPY RECOVERY THE AMOTIVATED INDIVIDUAL -COMMUNICATE -EDUCATE -MOTIVATE Lack of encouragement from therapy staff can demotivate patients in rehabilitation - British Medical Journal, 2010

IMPROVE: MOTIVATIONSATISFACTION ADHERENCE TO THERAPY OUTCOME GOAL

OBJECTIVE Improve patient motivation, satisfaction and outcome by showing them: 1)Video tapes of their gait progression 2)Graphical representations of their change in gait ability

1) IMPROVE PATIENT:  Motivation  Satisfaction  Outcome 2) INTERVENTION:  Time efficient  Educational  Easy to perform  Inexpensive CHECKLIST FOR SUCCESS

Include Acute stroke Complete gait training as part of rehab VIDEO GROUP  Video taping of gait rounds + graphical representation of progress  n = 15 Standard of care  Regular gait rounds  No provision of videos or graphical representations of progress  All UPMC rehab facilities except Mercy  N=11 PROJECT OUTLINE

Cartilage Layer OUTCOME MEASURES MOTIVATION PITTSBURGH REHABILITATION PARTICIPATION SCALE (Lenze et al, 2004) SATISFACTION PATIENT OUTCOME PRESS GANEY SATISFACTION STRUCTURED QUESTIONNAIRE (Leichert scale) TUG and 10m WALK TESTS LENGTH OF STAY

Timed up and go (TUG) test 1. 10m walk test 2. The iPad® INTERVENTION + Patient Counseling Session Video and graphical progress reviewed with the patient 1x/week Patient walking ability recorded 2x/week Two standard PT tests are performed 1x/week Identified patients consent to video Timed up and go test 1x/week 10m walk test 1x/week Video recorded during gait rounds 2x/week Assess motivation, satisfaction and patient outcome METHODS

ON ADMISSION 3 WEEKS LATER

RESULTS - PARTICIPATION *

RESULTS - SATISFACTION -93% felt that the interventions directly improved their satisfaction with their rehab stay -92% felt the videos in particular helped them during their rehab admission % would strongly recommend these interventions to other patients iPAD Group

RESULTS – TUG TEST

RESULTS – LENGTH OF STAY N=6 Standard of Care N=10 iPad Group

RESULTS N=6 Standard of Care N=10 iPad Group PATIENT COMMENTS -‘It gave me confidence to know that when I go home I can cross the street safely’ -‘Seeing the areas in which I can improve my walking and then correcting them with rehab was greatly beneficial’ -‘I never believed I would get better – if I was shown this at the beginning I would believe’ -‘Was great to see where I was struggling with walking – wish I had 2 more weeks to participate!’ - ‘Great for my motivation and to see how far I’ve come’

DID THIS WORK? 1) IMPROVE PATIENT: Motivation Satisfaction Outcome/LOS 2) INTERVENTION: Time efficient Easy to perform Educational Inexpensive Electronic record Strong support from team

Limitations Small sample size Not specific findings Variability between patients Bottom Line – The intervention improved the patient experience THE WAY FORWARD

CONCLUSION Why did it work? As an INTERVENTION it is: Time efficient Easy to perform Educational Inexpensive Strongly supported by rehab team Could be part of electronic record What did it improve?  Motivation of our patients  Satisfaction and Outcome  Record improvements visually  Reduce variations in treatment  Improve patient care delivery  Improved communication and efficiency  Educated patients and treatment team FIRST OF ITS KIND!

THE STROKE REHAB TEAM THE PATIENT Physicians PT OT ST Nursing Case Manager Aides Social worker

AAPM&R Presentation 2014 University of Pittsburgh Medical Center (UPMC) T Breisinger DPT R Kaplan PT K Vitti PT R Donlan DO JA Lanphere D J Shen MD Stroke Unit, Mercy Hospital Department of PM&R