In inpatient rehabilitation, large amounts of practice can occur safely without direct therapist supervision: an observational study

Group versus individual delivery of upper limb intervention for adults post-stroke: A systematic review and meta-analysis

ObjectiveTo systematically review the evidence and examine the effectiveness of group-based UL intervention versus individual therapy, in decreasing impairment and improving UL function post-stroke.Data SourcesA comprehensive search of four key databases (CINAHL, Embase, Emcare, and MEDLINE) identified relevant studies published from inception through to November 2024.Review methodsTwo reviewers independently performed screening for inclusion according to selection criteria. Eligible studies provided dose-matched group and individual UL rehabilitation programs. Outcomes that measured UL impairment (Fugl-Meyer Upper Extremity Test) or function (Action Research Arm Test) were extracted for meta-analysis. Methodological quality was assessed using the PEDro scale.ResultsOf 3291 publications, eight studies were included (n = 348) (seven randomised controlled trials and one controlled trial) of poor to good quality. A random effects meta-analysis model was conducted. Statistical significance was determined using analysis of covariance. No significant effects were shown in the meta-analyses on the effect of group versus individual therapy on UL impairment (mean difference 0.87, 95% CI: -0.87 to 2.62, p = .327) or function (mean difference 1.53, 95% CI: -0.23 to 3.29, p = .089). Results were limited by small sample sizes and substantial heterogeneity, with wide variation in intervention type, dosage and setting.ConclusionMeta-analyses suggest group-based UL intervention may be as effective as intervention delivered one-to-one, post-stroke. Additional studies of large sample size and rigorous methodology are necessary to substantiate these findings. Future research should investigate which types of UL intervention are most effective when provided in group-based settings across the different stages of stroke recovery.

Outcomes of the My Therapy self-management program in people admitted for rehabilitation: A stepped wedge cluster randomized clinical trial

BACKGROUND

Self-management programs can increase the time spent on prescribed therapeutic exercises and activities in rehabilitation inpatients, which has been associated with better functional outcomes and shorter hospital stays.

OBJECTIVES

To determine whether implementation of a self-management program ('My Therapy') improves functional independence relative to routine care in people admitted for physical rehabilitation.

METHODS

This stepped wedge, cluster randomized trial was conducted over 54 weeks (9 periods of 6-week duration, April 2021 - April 2022) across 9 clusters (general rehabilitation wards) within 4 hospitals (Victoria, Australia). We included all adults (≥18 years) admitted for rehabilitation to participating wards. The intervention included routine care plus 'My Therapy', comprising a sub-set of exercises and activities from supervised sessions which could be performed safely, without supervision or assistance. The primary outcomes were the proportion of participants achieving a minimal clinically important difference (MCID) in the Functional Independence Measure, (FIM™) and change in total FIM™ score from admission to discharge.

RESULTS

2550 participants (62 % women) were recruited (control: n = 1458, intervention: n = 1092), with mean (SD) age 77 (13) years and 37 % orthopedic diagnosis. Under intervention conditions, participants reported a mean (SD) of 29 (21) minutes/day of self-directed therapy, compared to 4 (SD 14) minutes/day, under control conditions. There was no evidence of a difference between control and intervention conditions in the odds of achieving an MCID in FIM™ (adjusted odds ratio 0.93, 95 % CI 0.65 to 1.31), or in the change in FIM™ score (adjusted mean difference: -0.27 units, 95 % CI -2.67 to 2.13).

CONCLUSIONS

My Therapy was delivered safely to a large, diverse sample of participants admitted for rehabilitation, with an increase in daily rehabilitation dosage. However, given the lack of difference in functional improvement with participation in My Therapy, self-management programs may need to be supplemented with other strategies to improve function in people admitted for rehabilitation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12621000313831), https://www.anzctr.org.au/.

Is the Combination of Robot-Assisted Therapy and Transcranial Direct Current Stimulation Useful for Upper Limb Motor Recovery? A Systematic Review with Meta-Analysis

Stroke is the third leading cause of disability in the world, and effective rehabilitation is needed to improve lost functionality post-stroke. In this regard, robot-assisted therapy (RAT) and transcranial direct current stimulation (tDCS) are promising rehabilitative approaches that have been shown to be effective in motor recovery. In the past decade, they have been combined to study whether their combination produces adjuvant and greater effects on stroke recovery. The aim of this study was to estimate the effectiveness of the combined use of RATs and tDCS in the motor recovery of the upper extremities after stroke. After reviewing 227 studies, we included nine randomised clinical trials (RCTs) in this study. We analysed the methodological quality of all nine RCTs in the meta-analysis. The analysed outcomes were deficit severity, hand dexterity, spasticity, and activity. The addition of tDCS to RAT produced a negligible additional benefit on the effects of upper limb function (SMD -0.09, 95% CI -0.31 to 0.12), hand dexterity (SMD 0.12, 95% CI -0.22 to 0.46), spasticity (SMD 0.04, 95% CI -0.24 to 0.32), and activity (SMD 0.66, 95% CI -1.82 to 3.14). There is no evidence of an additional effect when adding tDCS to RAT for upper limb recovery after stroke. Combining tDCS with RAT does not improve upper limb motor function, spasticity, and/or hand dexterity. Future research should focus on the use of RAT protocols in which the patient is given an active role, focusing on the intensity and dosage, and determining how certain variables influence the success of RAT.

Early and intensive motor training to enhance neurological recovery in people with spinal cord injury: trial protocol

STUDY DESIGN

Protocol for a multi-centre randomised controlled trial (the SCI-MT trial).

OBJECTIVES

To determine whether 10 weeks of intensive motor training enhances neurological recovery in people with recent spinal cord injury (SCI).

SETTING

Fifteen spinal injury units in Australia, Scotland, England, Italy, Netherlands, Norway, and Belgium.

METHODS

A pragmatic randomised controlled trial will be undertaken. Two hundred and twenty people with recent SCI (onset in the preceding 10 weeks, American Spinal Injuries Association Impairment Scale (AIS) A lesion with motor function more than three levels below the motor level on one or both sides, or an AIS C or D lesion) will be randomised to receive either usual care plus intensive motor training (12 h of motor training per week for 10 weeks) or usual care alone. The primary outcome is neurological recovery at 10 weeks, measured with the Total Motor Score from the International Standards for Neurological Classification of SCI. Secondary outcomes include global measures of motor function, ability to walk, quality of life, participants' perceptions about ability to perform self-selected goals, length of hospital stay and participants' impressions of therapeutic benefit at 10 weeks and 6 months. A cost-effectiveness study and process evaluation will be run alongside the trial. The first participant was randomised in June 2021 and the trial is due for completion in 2025.

CONCLUSIONS

The findings of the SCI-MT Trial will guide recommendations about the type and dose of inpatient therapy that optimises neurological recovery in people with SCI.

TRIAL REGISTRATION

ACTRN12621000091808 (1.2.2021).

Depression and a lack of socialization are associated with high levels of boredom during stroke rehabilitation: An exploratory study using a new conceptual framework

This exploratory sub-study aimed to develop a framework to conceptualize boredom in stroke survivors during inpatient rehabilitation, establish the effect of an activity promotion intervention on boredom, and to investigate factors that are associated with boredom. A framework was developed and explored within a cluster non-randomised controlled trial. Self-reported boredom was measured in 160 stroke survivors 13 (±5) days after rehabilitation admission; 91 participants received usual-care (control) and 69 had access to a patient-driven model of activity promotion (intervention). Individuals with pre-existing dementia or unable to participate in standard rehabilitation were excluded. Hierarchical logistic regression analysis was used to identify demographic, health and activity measures associated with boredom. Results indicated 39% of participants were highly bored. There was no statistically significant difference in boredom levels between treatment groups (difference -11%, 95% CI -26% to 4%). The presence of depression (OR 6.17, 95% CI 2.57-14.79) and lower levels of socialization (OR 0.96, 95% CI 0.92-0.99) predicted high boredom levels. This comprehensive framework provides a foundation for understanding the many interacting factors associated with boredom. Results suggest managing depression and improving opportunities for socialization may support meaningful engagement in rehabilitation to optimize recovery following stroke.

Impairments, and physical design and culture of a rehabilitation unit influence stroke survivor activity: qualitative analysis of rehabilitation staff perceptions

PURPOSE

This study aimed to investigate rehabilitation staff perceptions of factors influencing stroke survivor activity outside of dedicated therapy time for the purpose of supporting successful translation of activity promoting interventions in a rehabilitation unit.

MATERIALS AND METHODS

Purposive sampling of multi-disciplinary teams from four rehabilitation units was performed, and semi-structured interviews were conducted by telephone, digitally audio-recorded and then transcribed verbatim. A stepped iterative process of thematic analysis was employed until data saturation was reached.

RESULTS

All but one of the 22 participants were female, the majority were either physiotherapists or occupational therapists, with a median of 4 years (interquartile range, 2-10) working at their respective rehabilitation units. Analysis of the data revealed three themes: (i) stroke survivor characteristics influence their activity outside therapy, (ii) the rehabilitation environment influences physical, cognitive, and social activity, and (iii) institutional priorities, staff culture, and attitude can be barriers to activity. Rehabilitation units were perceived to be unstimulating, and visitors considered enablers of activity when resources were perceived to be scarce.

CONCLUSIONS

Our results suggest careful consideration of the involvement of visitors, an individual's needs and preferences, and the institution's priorities and staff attitude may result in greater stroke survivor activity during rehabilitation.Implications for rehabilitationStaff should consider stroke survivor impairments and a rehabilitation unit's institutional priorities and staff attitudes when aiming to enhance stroke survivor engagement in activity.The physical and social environment of a rehabilitation unit can be optimised by rehabilitation staff to promote activity.Utilisation of visitors of stroke survivors on a rehabilitation unit may be one way to enhance engagement in activity.Discussion within the rehabilitation team concerning "ownership" of the role of supporting stroke survivor activity outside of structured therapy time may support better engagement in same.

Nurse-Led Motor Function Rehabilitation Program for Acute Ischemic Stroke: A Randomized Pilot Study

BACKGROUND

Rehabilitation care for patients with stroke in the acute stage must be strengthened. However, the evidence on how to strengthen this care is insufficient.

PURPOSE

This article was designed to evaluate the feasibility and effectiveness of implementing a nurse-led motor function rehabilitation program on patients with acute ischemic stroke.

METHODS

From January to October 2018, patients with initial acute ischemic stroke were assigned to one of two groups using a pilot randomized controlled trial design, with one group receiving a nurse-led motor function intervention program developed based on Orem's theory (7 consecutive days, twice daily for 30 minutes, experimental group) and the other receiving usual care (control group). The effectiveness measures included changes in the Motor Assessment Scale, the modified Barthel Index, and the National Institutes of Health Stroke Scale. The feasibility measures included patient retention rate, incidence of adverse events, and acceptance of nurses and patients.

RESULTS

We assigned 104 patients (male: 55.7%; age: 62.8 ± 13.2 years) to receive either a nurse-led motor function rehabilitation program or usual care. Eighty-eight patients were evaluated after 7 days (87% retention rate), including 43 (83% retention rate) in the experimental group. Patients accepted the intervention well, and no severe adverse events were reported. Nurses had good fidelity and showed high acceptance. The experimental group showed significantly higher postintervention Motor Assessment Scale and modified Barthel Index scores than the control group (p < .001), whereas postintervention National Institutes of Health Stroke Scale scores did not differ significantly between the two groups.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The nurse-led rehabilitation program used in this study was shown to be feasible and effective in improving motor function in patients with acute ischemic stroke. Further study is recommended to determine related clinical recommendations.

The cost to see the Wizard: buy-ins and trade-offs in neurological rehabilitation

This scientific commentary refers to ‘A decision-neuroscientific intervention to improve cognitive recovery after stroke’ by Studer et al. (doi:10.1093/brain/awab128).

A quality improvement project targeting physical, cognitive and social activity levels in inpatient rehabilitation

Background/aims

People undergoing inpatient rehabilitation largely spend their day by the bedside, inactive and alone. Increasing patients' physical, cognitive and social activity levels may improve rehabilitation outcomes for both the individual and the service. The aim of this study was to trial an activity programME that aimed to increase inpatient physical, cognitive and social activity levels, provided within existing resources whilE maintaining or increasing patient satisfaction.

Methods

A mixed-methods approach was used to develop and evaluate a multi-component activity programme for patients undergoing inpatient rehabilitation.

Results

Patient activity across the unit did not change but the amount of time spent alone during a weekday was significantly reduced. Patient satisfaction levels remained high. Each new therapy group was well received by patients and the volunteers who supported implementation. Novel programmes included table tennis coaching and independent gym access for selected inpatients, which were well used and not resource intensive. Therapist prescription of independent practice programmes remained low. Broader initiatives such as patient education folders require revision and further investment to succeed.

Conclusions

It is possible to change and evaluate multiple therapy services concurrently. The absence of change in overall activity levels demonstrates a need to establish the most successful components, harness support from the organisation to address some of the physical/environmental barriers and expand smaller programmes, and invest more time to consolidate the whole-of-service changes required to push the rehabilitation service in the direction of greater patient activity and ownership. Clinicians should pursue, implement, evaluate and revise novel programmes to engage their patient population.

Evaluation of a staff behaviour change intervention to increase the use of ward-based practice books and active practice during inpatient stroke rehabilitation: a phase-1 pre-post observational study

OBJECTIVE

The aim of this study was to evaluate a staff behaviour change intervention to increase the use of ward-based practice books and active practice by stroke inpatients.

DESIGN

This is a pre-post observational study.

SETTING

This study was conducted in a inpatient rehabilitation unit in Australia.

SUBJECTS

Stroke inpatients participated in the study.

INTERVENTION

A staff behaviour change intervention was designed to support staff to implement practice books. The intervention included staff training on motivation and coaching, and weekly audit and feedback for six months. The environment was restructured to bring staff together weekly at the bedside to review audit data and share skills.

MAIN MEASURES

Medical record audit and behavioural mapping were used to compare the number of stroke participants with/using a practice book pre- and post-intervention. Pre- and post-intervention, the percentage of observations where a stroke participant was actively practising, repetitions of practice recorded and type of supervision were compared.

RESULTS

A total of 24 participants were observed (n = 12 pre, n = 12 post). Post-intervention, the number of participants with practice books increased from one to six (OR = 11, 95% CI = (0.9, 550.7)), but this change was not statistically significant (P = 0.069). Five participants recorded repetitions in their practice books post-intervention, three were observed using practice books. There was no change in median repetitions recorded (r_pbs = 0.00, 95% CI = (-0.4, 0.4), P = 1.000) or observed active practice (r_pbs = -0.02, 95% CI = (-0.4, 0.4), P = 0.933). Active practice was often fully supervised by a therapist.

CONCLUSION

A staff behaviour change intervention has the potential to increase the number of stroke survivors receiving ward-based practice books but did not increase active practice.

Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study

Background

Therapy is key to effective stroke care, but many patients receive little.

Objectives

To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.

Design

Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.

Setting

Stroke services in England, Wales and Northern Ireland.

Participants

A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.

Results

Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.

Limitations

Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.

Conclusions

Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.

Dosage and predictors of arm practice during inpatient stroke rehabilitation: an inception cohort study

PURPOSE

To describe the amount/type of arm practice completed by stroke survivors during inpatient rehabilitation; and establish predictors of arm practice dose achieved.

MATERIALS AND METHODS

Inception cohort study including 99 consecutively admitted stroke survivors. Amount (repetitions) and type of arm practice completed during inpatient rehabilitation and possible predictors of dose were recorded.

RESULTS

Average length-of-stay was 36.9 days (standard deviation (SD) = 30.0, median = 28.0, interquartile range = 39.5) and days of therapy provided was 11.1 days (SD = 13.3, median = 6.0, IQR = 12.0). Mean number of arm practice sessions completed overall was 12.8 (SD = 15.3, median = 7.0, interquartile range = 15.0), or 2.0 sessions per week (SD = 1.5, median = 1.5, interquartile range = 1.7). Mean repetitions of practice completed per therapy day was 86.1 (SD = 76.5, median = 68.5, interquartile range = 88.2). Variation in practice dose was best explained by age (-1.3 repetitions per year of age, p = 0.04) and cognitive impairment (-34.9 repetitions, p = 0.03). In participants without cognitive impairment (n = 73) variation in dose was best explained by stroke severity (modified Rankin Sale = 5, -48.4 repetitions, p = 0.01), and the inability to grasp/release (Box and Block Test = 0, +48.3 repetitions, p = 0.03).

CONCLUSIONS

The amount of arm practice completed was low. Daily sessions were often not provided as recommended in clinical guidelines. Clinicians should focus on strategies to increase intensity and opportunities for arm practice.Implications for RehabilitationDose (repetitions) of arm practice varied greatly during inpatient rehabilitation.Number of arm rehabilitation sessions provided was lower than levels recommended in clinical guidelines.Therapists and researchers should focus on strategies to increase amount of therapy and opportunities for arm practice.