Pico questions for stroke patients

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Running head: STROKE REHABILITATION

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Running head: STROKE REHABILITATION

Stroke Rehabilitation

What is a stroke? A stroke, also known as a brain attack, is a condition that affects the brain and nervous system due to a lack of blood supply to the brain. It is the 5th leading cause of death and the main cause of disability in the United States. About 795,000 people in the United States suffer from a stroke each year (CDC, 2017). The three main kinds of strokes are ischemic strokes, which are the most common, hemorrhagic strokes, and transient ischemic attacks (TIA), also known as mini strokes. Strokes have a high risk of reoccurring, especially if remedial measures are not administered. Patients who have suffered from a stroke may have their function impaired in various ways, requiring acute initial care and possibly rehabilitation. A stroke may present itself in many ways such as slurred speech, change in sensation, decreased strength, paralysis, and even headache. Patients who suffer strokes will need the assistance of an entire team of health care professionals ranging from nurses, speech therapists, occupational therapists, physical therapists, neurologists, respiratory therapists, and social workers as well.

A constant concern for stroke patients is effective rehabilitation to improve their strength and regain their ability to perform daily activities of daily living (ADL). In Western medicine, treatment includes pharmacological treatments, surgical procedures, and multi-professional rehabilitation. In Eastern medicine, acupuncture and physiotherapy are used in conjunction with Western medicine to improve functional disability and reduce the risk of further complications. “Acupuncture use as a complementary or alternative therapy has increased worldwide and has become widely applied to stroke rehabilitation over the last decade, which confirms that the efficacy of acupuncture can have a great impact on stroke management” (Jun, Jian, Dhiaedin, Qinhui, Xiao, Yi, & Ma, 2017, p. 2).

This paper will discuss the application of the topic and how it impacts the MSN program specialty track, supportive evidence regarding acupuncture, supportive evidence on the identification of frequency of its occurrence, a discussion of the stakeholders impacted by the issue, a statement of the PICOT/PICO question based on the evidence, and lastly conclude with a summary and a self-reflection.

Application and Impact on MSN Program Track

Nurses play an integral role in the care of patients who have suffered a stroke. The numbers of advanced practice nurses who have a Master of Science Degree or Doctorate Degree in nursing has increased over the years and continue to grow in the nursing profession. This author has chosen to pursue the Advanced Registered Nurse Practitioners (ARNP) track. As an ARNP, the role is to not only diagnosis and treat patients, but also to educate patients on new and alternative evidence based treatment modalities focusing on prevention and wellness.

“Approximately 70% of stroke survivors experience functional disabilities, motor dysfunction being the most significant symptom” (Jun, Jian, Dhiaedin, Qinhui, Xiao, Yi, & Ma, 2017, p. 2). Muscle weakness, loss of mobility, and flaccidity or weaknesses of one side of the body are some of the physical disabilities commonly experienced following a stroke. There may be varying degrees of impairment in stroke patients. Some patients will be able to regain their functioning in the acute phase of recovery, while others will spend months of time in rehabilitation settings in pursuit of greater independence in activities of daily living. Patients suffering from strokes may be unable to perform simple skills such as bed mobility, transfers, and ambulation. Many stroke patients also have a change in their body’s neurological system that can include pain, numbness, tingling, or pins and needles sensations. Beyond physical impairments, patients may exhibit changes in their cognition, memory, speech, and emotional responses. Patients with stroke experience great changes in their life, which may lead to limitations that also affect one’s family and his or her community at large. As an ARNP, the need to help the community and improve a stroke patient’s quality of life is a large but not insurmountable goal. With this in mind, it is essential to collaborate and work together as a team with physicians, neurologists, physical therapists, acupuncturists, and researchers, to advocate acupuncture as part of the treatment plan for post stroke patients. There is always a need for further research to guide the evidence-based practice (EBP) of advanced practice nurses in the treatment of stroke victims.

Supportive Evidence

Acupuncture is a therapeutic holistic technique of Eastern medicine performed by trained practitioners in an effort to stimulate critical trigger points on the body by inserting thin needles though the skin. It is believed by acupuncture practitioners that the flow of energy throughout the body will become re-balanced. It is widely used in Taiwan and other eastern countries and has been a component of Traditional Chinese Medicine for 3,000 years (Huang, Wang, Yang, Liou, Chen, & Lin, 2014). The treatment of acupuncture has become more popular in the United States and is evolving into one of the most common forms of integrative interventions. “More than 10 million acupuncture treatments are administered annually in the United States alone” (Hao, & Mittelman, 2014, p. 1).

It is considered a viable alternative treatment for post-stroke rehabilitation. According to Bai, Li, Hu, Xie, Wang, & Zhu (2013), a recent study in Canada showed that 87% of stroke patients were willing to accept acupuncture as treatment and 98% of stroke patients were willing to learn about acupuncture and the impact it has on stroke rehabilitation. The stakeholders who are impacted are stroke patients’, the patient’s families and caretakers, healthcare providers, and third-party healthcare payers such as insurance companies, and the government. It has been observed that acupuncture, specifically scalp acupuncture treatment, can result in 80% to 90% of patients experiencing improvement in paralysis and ataxia, and some patients showing full recovery (Hao & Mittelman, 2014).

PICOT Question

In EBP, the PICOT format is used to frame and answer health related questions (Melnyk, Fineout-Overhold, Stillwell, and Williamson, 2010). PICOT is an acronym that refers to patient, population, or problem, intervention, comparison, outcome, and time. Patient, population, or problem refers to whom is receiving the care or what problem is being addressed. Intervention refers to what the treatment or procedure is. Comparison is what the alternative intervention is. Outcome is referred to as the goal and Time is the time frame being addressed, which is optional in some cases (Melnyk, Fineout-Overhold, Stillwell, and Williamson, 2010).

This author developed a PICOT related to the nursing issue of acupuncture impacting stroke rehabilitation based on the evidence, and it is as follows: In elderly patients between the ages of 40-70 years who have experienced an ischemic stroke, how effective is acupuncture in conjunction with standard stroke therapy in comparison to only standard stroke therapy in improving mobility over a 12-week period following the event? The population are patients who are between 40-70 years old who experience an ischemic stroke, the intervention is acupuncture treatment in conjunction with standard stroke therapy, the comparison would be only standard stroke therapy, the outcome would be to improve mobility and the time frame would be over a 12-week period following the event.

In order to develop this question, this author had to initially think about an area of interest. Working with stroke patients and wanting to improve patients’ mobility post stroke, acupuncture used for stroke rehabilitation was chosen as a topic. According to the American Heart Association (2017), antiplatelet, anticoagulant, and cholesterol lowering therapies are prescribed to prevent recurrent strokes. As more and more people look to holistic or non-pharmacological treatments, understanding the effects of acupuncture on stroke and the impact it has on mobility, gives additional tools to provide resources to the patients served as an ARNP. Searching the literature, there was a lot of information found relating to the topic of acupuncture and mobility. Keywords that were used were acupuncture, stroke, and mobility, which resulted with many evidence-based findings that ensure the most effective and current treatments. Research has shown that “acupuncture helps deactivate the areas within the brain that are associated with processing pain” (Hao & Mittelman, 2014, p. 7). Helping patients understand their options for the treatment of stroke related dysfunction through evidence-based research might prove helpful as alternative approaches for patients who do not respond to more conventional treatments or wish to use holistic medicine.

Research Literature Support

Acupuncture has been associated with various long-term effects on stroke patients. Hegyi & Szigeti (2012) conducted a pilot study to research and examine the long-term effects of acupuncture, specifically Yamamoto New Scalp Acupuncture (YNSA) therapy, on daily activities and body balance in addition to standard therapy among patients with stroke compared to no acupuncture. The researchers employed a randomized control prospective design where 50 participants were recruited over a period of 3 years with half of them, n=25, receiving acupuncture and the other half being the control group. The inclusion criteria were patients with ischemic or hemorrhagic stroke, lack of movement coordination, admission within 6 weeks, and brain damage of less than 30%. All participants were given standard rehabilitation while only 25 patients were given YNSA, a type of traditional Eastern acupuncture, once every month in the course of the trial. The findings were although both groups showed improvement in their condition compared to prior to the treatment, patients receiving YNSA therapy showed significantly more improvement in all sensory, motor, and function during the initial 2 years of examination after the stroke. It was, therefore, concluded that YNSA therapies after stroke could significantly aid improvement in neurologic and functional recovery and improve quality of life. While a control group was involved, the limitation to this study is that there was no sham control.

Other than its long-term effects, acupuncture has positive effects on the body balance among stroke patients. In a research article by Huang, et al., (2014), the investigators studied the effect of acupuncture therapy on balance in stroke patients. The quantitative, retrospective, case control study involved a total of N=629 stroke patients with 284 being excluded for not meeting the inclusion criteria, n=242 were given standard therapy, and n=103 patients received a combination of standard therapy and acupuncture. Following some adjustment, only n=66 stroke patients were chosen for the study group and n=66 patients for the control group. While all patients were provided with physiotherapy for 1-hour/day, for 5 days/week, only the study group received acupuncture 2 times in a week for a period of 3-4 weeks. The results of the study showed that stroke patients among the low-Br stage (weak and flaccid), who received a combination of physiotherapy and acupuncture, had a higher static balance function compared to those who received physiotherapy only. While the study entailed a strict inclusion and exclusion criteria, its limitations were that bias was built in to the retrospective study design. There was no rating system for evaluating the acupuncturists and physiotherapists, and the placebo effect not being determined due to the difficulties with blinding in acupuncture.

Furthermore, acupuncture is a safe method that has extra effects on stroke patients. Chen, et al. (2016) conducted a research to find out whether acupuncture therapy has extra effects in rehabilitation for stroke. The quantitative study included N=250 patients who were randomly assigned standard rehabilitation therapy with or without acupuncture. A total of 18 acupuncture sessions were conducted over a period of 3 weeks. The National Institute of Health Stroke Scale (NIHSS) evaluation was used as the primary outcome measurement. Other assessments included the Fugl-Meyer Assessment (FMA) scale for motor functions; video fluoroscopic swallowing study (VFSS) and bedside swallowing assessment (BSA); while the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) were used for cognitive function; and the adverse reaction of acupuncture for safety assessment. The results of the study showed that acupuncture therapy is associated with several additional effects in improving neurologic deficits, cognitive impairment, swallowing disorder, and lower limb function, but has no noteworthy improvement for upper limb function during the short-term study duration. While its trial design was flexible and integrated, the limitation of the study is its short study period of 3 weeks.

Lastly, the impact of acupuncture on cerebral blood flow among post-stroke patients is enormous. In a research article by Ratmansky, et al. (2016), a randomized controlled trial was conducted to examine the impact of acupuncture on cerebral blood flow by true acupuncture and sham acupuncture. The quantitative study involved N=17 patients (n=8 for true acupuncture and n=9 for sham acupuncture) who had experienced a stroke 1-3 months before and with a National Institute of Health (NIH) score of 4-13. They received two 30-minute treatment periods of true or sham acupuncture followed with a 30-minute rest and then again, a 20 minutes period of needle puncture during which cerebral blood flow velocity was monitored. The results indicated that true acupoints had significantly increased cerebral blood flow velocity. Therefore the conclusion that true acupuncture increases cerebral blood flow in post-stroke patients was shown. The limitation to this study was that it involved a small sample size and acupuncture was given just once.

Theoretical Framework and Change Model

Nurse researchers regularly use theoretical frameworks to design and carry out research. A theoretical framework gives a logical, unified, and systematic way of visualizing related events or processes pertinent to a discipline. In research, a framework demonstrates the general conceptual design of the study, incorporating at least a portion of a specific theory as the foundation of the study. A theoretical framework often entails propositional statements illustrating the relationships among variables. A theoretical framework that will be used for this project will involve The Self-Care Nursing Theory, also referred to as Orem Model of Nursing developed by Dorothea Orem. The theory is a grand nursing theory and has been used in various instances of nursing, especially in patients undergoing rehabilitation. It gives attention to each individual’s ability to carry out self-care, which includes the performance of activities that individuals commence and complete on their own behalf in upholding life, health, and well-being (Saleem Punjani, 2013). Orem’s major assumptions included that individuals should be self-reliant and in charge of their own care as well as others in their family.

Stroke is known to cause slurred speech, change in sensation, decreased strength, paralysis, and even headache, taking away an affected persons’ ability to perform ADL’s. Despite the long-term nature of their condition, stroke patients require the support and encouragement of healthcare professionals. This is particularly through the rehabilitation settings where patients are empowered to become more independent after undergoing various types of treatment. While other forms of therapy such as physical therapy (PT) and occupational therapy (OT) have been shown to improve the condition of stroke patients, acupuncture therapy has been demonstrated to have better results in improving all sensory and motor functions resulting in a higher static balance among weak patients, and increasing cerebral blood flow in post-stroke patients.

This project will utilize Deming’s Plan-Do-Study-Act (PDSA) change management model. It is a method of testing change after its implementation to provide quality improvement in healthcare practice. It consists of a cycle of four steps that guides the thinking process into splitting the task into steps, assessing the results, improving them, and testing them again (Gazza, 2015). In the first step of this study (Plan), the researcher will plan, setting objectives based on the service and patients’ needs. In the second step (Do), the plan will be implemented and outcomes will be observed. The third step (Study), this researcher will study and analyze the data collected and analyze the results obtained. Lastly, (Act), conclusions will be drawn based on the findings of the study, and actions will take place to ensure the improvements are implemented (Donnelly & Kirk, 2015).

Using this theoretical framework and change model will promote success and sustainability for this project discussed. Assisting in stroke rehabilitation, like acupuncture, and providing education to stroke patients can help regain independence and improve quality of life.

Research Approach/Design

The research approach that will be used will be a quantitative research approach using an experimental design. Quantitative research focuses on data that can be collected, measured, and analyzed in a structured way. The goal of quantitative research is to build accurate and reliable measurements that allow for statistical analysis. An experimental design is the process of planning a study, dividing the participants into two groups, the experimental group and the control group, introducing a change; in this case, acupuncture to the experimental group. This design approach was selected to meet specified objectives and answer the PICOT question of this study.

In this quantitative research, the PICOT question is as follows: In elderly patients between the ages of 40-70 years of age who have experienced an ischemic stroke, how effective is acupuncture in conjunction with standard stroke therapy in comparison to standard stroke therapy in improving mobility over a 12-week period following the event? The population are patients between the age of 40-70 who experience an ischemic stroke, the intervention is acupuncture treatment in conjunction with standard stroke therapy, the comparison would be only standard stroke therapy, the outcome would be to improve mobility, and the time frame would be over a 12-week period following the event.

One advantage of a quantitative design approach is that it is objective. This type of research is numerical and develops statistically significant conclusions on a certain population after studying a representative sample of the population. The data sets are large, and the researcher has control of the variables used in the study. One disadvantage of a quantitative design approach is the need for a larger population sample. Not having accurate data due to certain criteria’s or participants not following through the study is a disadvantage for the study. In quantitative research, the larger the sample, the more statistically accurate the results will be (Goertzen, 2017).

Sampling

The population of a study is a group of people who share a common condition or set of desirable characteristics pertinent to the research question. It is difficult to involve the entire population in clinical research; therefore, a representation of the population is selected. There are two types of sampling methods, probability sampling and nonprobability sampling. Probability sampling is when all subjects have an equal chance of being selected for the study, and nonprobability sampling does not provide equal chances for each subject (Elfil & Negida, 2017). This study will use non-probability sampling. Two advantages of non-probability sampling are that it is cost effective and time effective compared to probability sampling. A disadvantage of non-probability is that it is not an ideal study. For example, not all patients seen at one hospital have the same characteristics as other hospitals (wealthier neighborhoods versus poorer). However, it would be hard to randomly sample all patients who have had an ischemic stroke. The target population will include a sample size of N=100 patients between 40-70 years of age who have experienced an ischemic stroke. Informed consent will be sought from each participant, and collected information will be stored in password protected electronic devices.

Data Collection Methodology

A total number of N=100 patients who have experienced an ischemic stroke will be recruited between two hospitals and randomly divided into a control group and study group depending on specific criteria. The study will be conducted over a 2-year period. The control group, n=50, will receive the standard stroke therapy (PT and OT for about an hour), 5 times per week for 12 weeks, while the study group, n=50, will receive standard stroke therapy in addition to acupuncture 5 times per week for 12 weeks. The inclusion criteria consist of: stroke patients between the ages of 40-70, ischemic stroke confirmed by a brain computed tomography (CT) or magnetic resonance imaging (MRI), and recent stroke diagnosed less than 1-month. The exclusion criteria include: stroke with severe cognitive impairment and a history of another chronic disorder including cancer, epilepsy, cardiac disease, bleeding disorders, and impaired renal or hepatic function. Screening and a baseline assessment will be completed with all participants on the initial visit. Two physicians who are specialized in Traditional Eastern Medicine with more than 6 years of clinical experience will perform acupuncture. The study process will be explained to ensure adherence to the instructions and informed consent will be obtained.

Evaluation will take place during the 4th, 8th, and 12th week of treatment. About 2 weeks after the 12 weeks of treatment study, the participants will then have a follow up. During the follow up, measurement of function will be assessed.

The Stroke Rehabilitation Assessment of Movement (STREAM) will be used to determine specific movement impairments as a result of stroke in both groups before and after the treatment period. The STREAM is applied in evaluating recovery of basic mobility and voluntary movement in stroke patients (Ward, 2011). It was devised for use by physical therapists to give a quantitative assessment of motor functioning among stroke patients. The STREAM was particularly designed to be simple enough to administer in a clinical setting. The quality of movements in the leg and arm as well as the quality of patient mobility during crucial functional activities, such as walking 10 feet will be tested. For each of the three assessments (leg, arm, and mobility) 10 items will be evaluated, resulting in a total of 30 items. Each item will be rated on a scale of 0=patient unable to perform, to 3=normal movement. Examples of items on the STREAM include flexion of the knee and the hip in a supine position, protraction of the scapula in a supine position, and rolling onto one side from a supine position (Ward, 2011). The assessment takes about 15 minutes and is suitable for patients between 40-70 years of age. The assessment sessions will be videotaped and stored in electronic devices.

Data quality is important in clinical research as it minimizes the chances of occurrence of errors. Planning for data quality will not only help in detecting errors when they occur but also ensures the research findings are accurate and reliable (Howlett, 2013). Each step in the collection, storage, and processing of data impacts its quality. For this study, a system will be designed and executed by the coordinating center researchers with the approval of the study leadership and endorsement of the study site and resource center persons. Proper training of research assistants will enhance the quality of data, and site visits will allow data collection and storage to be directly observed. Qualified experts will perform the treatments and the participants will be given clear directions as to what is expected of them.

Analysis

The mobility data collected during the initial admission to the rehabilitation centers and 12 weeks after the treatment sessions will be analyzed using chi-square tests for the categorical variables and t-test for the continuous variables. Statistical comparisons will be carried out based on the two time points. Categorical variables will be analyzed using chi-square tests for the two groups (Drummond, 2017). The purpose of chi-square test will be to evaluate if the difference between observed data and expected data is due to chance, or if it is due to a relationship between the various variables under study (mobility and acupuncture) (Drummond, 2017). Therefore, the test is an outstanding choice to aid in better understanding and interpreting the relationship between the two categorical variables under study. The measurement data will be analyzed using t-test to assess whether the means of the study group and the control group are statistically different from each other. The t-test analysis has been shown to be suitable whenever one wants to evaluate the means of two groups and particularly appropriate as the analysis for two-group randomized experimental design (Drummond, 2017). For all analyses, p<0.05 will be considered statistically significant.

Evaluation Plan

An evaluation plan is needed to provide information to improve a project and evaluate the level of success within the project. According to Serrador & Turner (2015), project efficiency, team satisfaction, impact on the customer, business success, and preparing for the future are five methods of project success. Project efficiency involves meeting schedule and budget goals. Team satisfaction measures skill development and team growth and retention. It is important to maintain customer satisfaction and fulfilling customer needs. It is also important to create a large market share. And finally preparing for the future by developing new technology and a new market (Serrador & Turner, 2015).

Information about change processes can be relayed to stakeholders in various ways. This is where the communication channels of an organization come into play. With modern technology evolving, face-to-face communication is becoming obsolete. The most important element in stakeholder communication is identifying the target audience. In this case, the stakeholders who are impacted are stroke patients, the patient’s families and caretakers, healthcare providers, and third-party healthcare payers such as insurance companies, and the government. Some formal methods of communication to address the education about the new process are through medical journals, medical society newsletters, national and international conferences, local meetings, emails, flyers, and community posters. It is important to understand that every project varies in its rate of change and choose the most advantageous communication channel that would best fit the stakeholders desire.

It is vital that the project be kept alive by providing ongoing evaluation that will sustain the intervention. Interpersonal skills of management can also aid in this message. The project message should be kept consistent and be constantly reinforced. Frequent and ongoing collaboration and communication with stakeholders will provide a strong support for the project. Even following the conclusion of this project, ongoing research and evaluation will continue to be needed in the study of acupuncture and its impact on posts-stroke mobility. For example, specific acupuncture techniques will need to be evaluated to determine if one provides more benefit than another. Additionally, timing and frequency on the acupuncture therapy will need to be further evaluated to determine the optimal treatment regimen. As such, the evaluation of this project will be ongoing for the foreseeable future.

Translation of Results; Dissemination within the FNP Track

Stroke recovery can be challenging and may require extensive rehabilitation. Using acupuncture as an alternative method of treatment is shown to be an effective and safe way of treating an acute ischemic stroke. If this proposal were completed, a change in practice would be one expectation. It would benefit the community to become aware of the benefits of alternative medicine and treatment for strokes. Acupuncture uses special techniques to regulate the functional activities of the brain and the body. Skilled and experienced acupuncturists are essential for treatment of patients with stroke. The treatment is suitable where there is need for recovery at an early stage.

FNPs are advanced practiced nurses who undergo advanced training and become qualified to manage common medical issues within a scope of practice. FNPs have an opportunity to advance practices in alternative medicine. It would be appropriate to incorporate the results found within this project to educate stroke patients on the benefits of acupuncture therapy. Also, the results concluded in this research can assist to apply pertinent information into practice. As a FNP, time would be spent with each patient to explain the benefits of acupuncture as part of stroke rehabilitation. Explanations of research studies will show the effectiveness of the therapy and personal experiences will be discussed. FNPs can also take part in various community education programs that would create awareness to the community about stroke education and rehabilitation. The results in this project can also help researchers in conducting further research related to the reduction of morbidity following strokes.

Conclusion

A constant concern for stroke patients is effective rehabilitation to improve their strength and regain their ability to perform daily activities of daily living (ADLs). The treatment options for stroke include pharmacological treatments, surgical procedures, and multi-professional rehabilitation. However, when used in conjunction with physiotherapy and Western medicine, acupuncture is considered a viable complementary or adjuvant treatment for post-stroke rehabilitation. It has been shown that YNSA therapies after stroke can significantly aid improvement in neurologic and functional recovery and improve quality of life. Also, weak and flaccid stroke patients who received a combination of physiotherapy and acupuncture, have a higher static balance function compared to those who received physiotherapy only. Acupuncture has also been demonstrated to increase cerebral blood flow in post-stroke patients, and can improve neurologic deficits, cognitive impairment, swallowing disorder, and lower limb function.