Physiotherapists' attitudes toward circuit class therapy and 7 day per week therapy is influenced by normative beliefs, past experience, and perceived control: A qualitative study

Group-based circuit training to improve mobility after stroke: a cross-sectional survey of German and Austrian physical therapists in outpatient settings

BACKGROUND

A contextual transferability analysis identified group-based circuit training (GCT) as an optimal intervention in German and Austrian outpatient physical therapy to improve mobility post-stroke. GCT incorporates task-oriented, high-repetitive, balance, aerobic and strength training and allows for increased therapy time without increasing personnel.

OBJECTIVE

To determine the extent to which German and Austrian physical therapists (PTs) use GCT and its components in the outpatient treatment of stroke-related mobility deficits and to identify factors associated with using GCT components.

METHODS

A cross-sectional online survey was conducted. Data were analyzed descriptively and using ordinal regression.

RESULTS

Ninety-three PTs participated. None reported using GCT moderately to frequently (4- 10/10 patients). The percentage of PTs reporting frequent use (7- 10/10 patients) of task-oriented, balance, strength, aerobic, and high-repetitive training was 45.2%, 43.0%, 26.9%, 19.4%, and 8.6%, respectively. Teaching or supervising students, time for evidence-based practice activities at work, and working in Austria was associated with using GCT components frequently.

CONCLUSION

German and Austrian PTs do not yet use GCT in outpatient physical therapy for stroke. Almost half of PTs, however, employ task-oriented training as recommended across guidelines. A detailed, theory-driven and country-specific evaluation of barriers to GCT uptake is necessary to inform implementation.

Revisiting dose and intensity of training: Opportunities to enhance recovery following stroke

PURPOSE

Stroke is a global leading cause of adult disability with survivors often enduring persistent impairments and loss of function. Both intensity and dosage of training appear to be important factors to help restore behavior. However, current practice fails to achieve sufficient intensity and dose of training to promote meaningful recovery. The purpose of this review is to propose therapeutic solutions that can help achieve a higher dose and/or intensity of therapy. Raising awareness of these intensive, high-dose, treatment strategies might encourage clinicians to re-evaluate current practice and optimize delivery of stroke rehabilitation for maximal recovery.

METHODS

Literature that tested and evaluated solutions to increase dose or intensity of training was reviewed. For each therapeutic strategy, we outline evidence of clinical benefit, supporting neurophysiological data (where available) and discuss feasibility of clinical implementation.

RESULTS

Possible therapeutic solutions included constraint induced movement therapy, robotics, circuit therapy, bursts of training, gaming technologies, goal-oriented instructions, and cardiovascular exercise.

CONCLUSION

Our view is that clinicians should evaluate current practice to determine how intensive high-dose training can be implemented to promote greater recovery after stroke.

Functional standing frame programme early after severe sub-acute stroke (SPIRES): a randomised controlled feasibility trial

BACKGROUND

Early mobilisation (> 24 h post-stroke) is recommended for people with stroke. However, there is a paucity of evidence about how to implement early mobilisation for people who have had a severe stroke. Prolonged standing and task-specific training (sit-to-stand repetitions) have separately been evaluated in the literature; however, these functionally linked tasks have not been evaluated in combination for people with severe sub-acute stroke.

METHODS

The objective was to determine the feasibility of conducting a randomised controlled trial (RCT) of a functional standing frame programme compared with usual physiotherapy for people with severe sub-acute stroke. An assessor-blinded feasibility RCT with nested qualitative component (interviews and focus group) and process evaluation was adopted. Participants were aged ≥ 18 years with new diagnosis of severe sub-acute stroke (modified Rankin Scale (mRS) 4/5) from four Stroke Rehabilitation Units across South West England. Participants were randomised to receive either: (1) functional standing frame programme (30 min. standing plus sit-to-stand repetitions) plus 15 min of usual physiotherapy daily (intervention); (2) usual physiotherapy (45 min) daily (control). Both programmes were protocolised to be undertaken a minimum of five sessions per week for 3 weeks. Feasibility indicators included process, resource, management, and safety. Adherence, fidelity, and acceptability of the trial and intervention were evaluated using data recorded by therapists, observation of intervention and control sessions, interviews and one focus group. Patient measures of motor impairment, activities/participation, and quality of life were carried out by blinded assessors at baseline, 3, 15, 29, and 55 weeks post-randomisation.

RESULTS

Forty-five participants (51-96 years; 42% male, mRS 4 = 80% 5 = 20%) were randomised (n = 22 to intervention). Twenty-seven (60%) participants were followed-up at all time points. Twelve participants (27%) died during the trial; no deaths were related to the trial. Adherence to the minimum number of sessions was low: none of the participants completed all 21 sessions, and only 8 participants (18%) across both groups completed ≥ 15 sessions, over the 3 weeks; 39% intervention; 51% control sessions were completed; mean session duration 39 min (SD 19) control, 37 min intervention (SD 11). Intervention group: mean standing time 13 min (SD 9); mean sit-to-stand repetitions/session 5 (SD 4). Interviews were conducted with 10 participants, four relatives and six physiotherapists. Five physiotherapists attended a focus group.

CONCLUSIONS

The majority of progression criteria for this feasibility trial were met. However, adherence to the interventions was unacceptably low. This aspect of the trial design needs to be addressed prior to moving to a definitive RCT of this standing frame intervention in people with severe sub-acute stroke. Solutions have been identified to address these concerns.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN15412695 . Registration 19 December 2016.

Implementing the PREP2 Algorithm to Predict Upper Limb Recovery Potential After Stroke in Clinical Practice: A Qualitative Study

OBJECTIVE

Predicting motor recovery after stroke is a key factor when planning and providing rehabilitation for individual patients. The Predict REcovery Potential (PREP2) prediction tool was developed to help clinicians predict upper limb functional outcome. In parallel to further model validation, the purpose of this study was to explore how PREP2 was implemented in clinical practice within the Auckland District Health Board (ADHB) in New Zealand.

METHODS

In this case study design using semi-structured interviews, 19 interviews were conducted with clinicians involved in stroke care at ADHB. To explore factors influencing implementation, interview content was coded and analyzed using the consolidated framework for implementation research. Strategies identified by the Expert Recommendations for Implementing Change Project were used to describe how implementation was undertaken.

RESULTS

Implementation of PREP2 was initiated and driven by therapists. Key factors driving implementation were as follows: the support given to staff from the implementation team; the knowledge, beliefs, and self-efficacy of staff; and the perceived benefits of having PREP2 prediction information. Twenty-six Expert Recommendations for Implementing Change strategies were identified relating to 3 areas: implementation team, clinical/academic partnerships, and training.

CONCLUSIONS

The PREP2 prediction tool was successfully implemented in clinical practice at ADHB. Barriers and facilitators to implementation success were identified, and implementation strategies were described. Lessons learned can aid future development and implementation of prediction models in clinical practice.

IMPACT

Translating evidence-based interventions into clinical practice can be challenging and slow; however, shortly after its local validation, PREP2 was successfully implemented into clinical practice at the same site in New Zealand. In parallel to further model validation, organizations and practices can glean useful lessons to aid future implementation.

Patients' and Health Professionals' Experiences of Group Training to Increase Intensity of Training after Acquired Brain Injury: A Focus Group Study

BACKGROUND

Increased intensity of training in the subacute phase after acquired brain injury facilitates plasticity and enhances better function. Group training can be a motivating factor and an effective means of increasing intensity. Reports on patients' and health care professionals' experiences on increasing the amount of active practice through group training during in-patient rehabilitation after acquired brain injury have been limited.

METHODS

Two focus groups, patients and health care professionals, participated each in two interviews, before and after implementation of the Activity block, i.e., 2-hour daily intensive group training. The data from the interviews were analyzed from a phenomenological perspective.

RESULTS

Three categories emerged from the data analyzes (i) training intensity, (ii) motivation and meaningfulness, and (iii) expectations and concerns. Both groups experienced that the training after implementation of the Activity block had become more intense and that motivation was increased induced by the group setting. Also, both groups found self-management enhanced. Some challenges were also reported. Patients expressed concerns to finding a balance between rest and activity, while the health professionals mentioned practical challenges, i.e., planning the content of the day and finding their role in the Activity block.

CONCLUSION

Activity block benefitted a heterogeneous group of patients with acquired brain injury and was perceived as an overall positive experience by patients and health personnel. Matching the training to the individuals' need for support, finding a balance between rest and activity and using tasks that support patients' motivation, appeared important.

The role of normative beliefs in the mediation of a school-based drug prevention program: A secondary analysis of the #Tamojunto cluster-randomized trial

AIMS

To investigate the mediating effects of normative beliefs of drug use on the effects of the #Tamojunto school-based prevention program (Unplugged).

DESIGN

Secondary analysis of a cluster randomized controlled trial.

SETTING

Brazil. Participants: A total of 6,391 adolescents (12.68 y.o) from 72 public schools in 6 Brazilian cities. Intervention: Schools were assigned to an experimental condition (#Tamojunto curriculum) or a control condition (no prevention program). Measurements: Baseline data were collected prior to program implementation, and follow-up data were collected 9 and 21 months later. The substances examined were alcohol (including binge drinking), tobacco, marijuana and inhalants. Five in-parallel mediation models evaluated whether the positive and negative beliefs were mediators of the likely effects of the intervention on drug use.

FINDINGS

Lack of evidences regarding differences in normative beliefs or drug use were found between the intervention and control groups. However, there was a clear association between negative drug beliefs and lower consumption (i.e. OR = 0.78; 95% CI 0.70; 0.87, for cannabis use) as well as between positive drug beliefs and higher consumption (i.e. OR = 1.77; 95% CI 1.56; 2.02, for cannabis use) independent of the assigned group.

CONCLUSIONS

These results suggest that there is a lack of evidence that the program impact the normative beliefs, as proposed by the theoretical model of the program, suggesting that modifications are needed to produce the intended effect of the program. Negative normative beliefs seem to be a potential protective factor for drug use, but the program's effect itself on drug use via normative beliefs was not found to be statistically significant. Program activities intended to affect normative beliefs should be improved.

Delivering Intensive Rehabilitation in Stroke: Factors Influencing Implementation

BACKGROUND

The evidence base for stroke rehabilitation recommends intensive and repetitive task-specific practice, as well as aerobic exercise. However, translating these -evidence-based interventions from research into clinical practice remains a major -challenge.

OBJECTIVE

The objective of this study was to investigate factors influencing implementation of higher-intensity activity in stroke rehabilitation settings.

DESIGN

This qualitative study used a cross-sectional design.

METHODS

Semi-structured interviews were conducted with rehabilitation therapists from 4 sites across 2 Canadian provinces who had experience in delivering a higher-intensity intervention as part of a clinical trial (Determining Optimal post-Stroke Exercise [DOSE]). An interview guide was developed, and data were analyzed using implementation frameworks.

RESULTS

Fifteen therapists were interviewed before data saturation was reached. Therapists and patients generally had positive experiences regarding high-intensity interventions. However, therapists felt they would adapt the protocol to accommodate their beliefs about ensuring movement quality. The requirement for all patients to have a graded exercise test and the use of sensors (eg, heart rate monitors) gave therapists confidence to push patients harder than they normally would. Paradoxically, a system that enables routine graded exercise testing and the availability of staff and equipment contribute challenges for implementation in everyday practice.

CONCLUSIONS

Even therapists involved in delivering a high-intensity intervention as part of a trial wanted to adapt it for clinical practice; therefore, it is imperative that researchers are explicit regarding key intervention components and what can be adapted to help ensure implementation fidelity. Changes in therapists' beliefs and system-level changes (staffing and resources) are likely necessary to facilitate higher-intensity rehabilitation in practice.