Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study

Exploring Dynamics in Post-stroke Motor Rehabilitation: A Systematic Review of Implementation Barriers and Facilitators using the COM-B Model

PurposeThis systematic review aimed to identify barriers and facilitators in post-stroke motor rehabilitation across patient, caregiver, and healthcare professional levels, employing the capability, opportunity, motivation, behavior (COM-B) model and the theoretical domains framework (TDF).Materials and MethodsA systematic search of PubMed, EMBASE, Cochrane Library, Web of Science, and CINAHL, following PRISMA guidelines, covered literature until January 20, 2025. Studies reporting qualitative, quantitative, or mixed-methods data on post-stroke motor rehabilitation barriers and facilitators were included. Quality assessment utilized MMAT 2018.ResultsAnalyzing 48 studies, we found that barriers to post-stroke motor rehabilitation encompassed motor impairments, cognitive issues, resource scarcity, and environmental factors, while facilitators included good physical abilities, resource accessibility, and social support. The COM-B model elucidated the dynamic interplay between capability, opportunity, and motivation, suggesting educational interventions and telerehabilitation as avenues for improvement.ConclusionThis systematic review, guided by the COM-B model, identifies key barriers and facilitators in post-stroke motor rehabilitation. It emphasizes the importance of targeted education, improved telerehabilitation infrastructure, and robust social support systems to address multifaceted challenges.

High Intensity Interval Training POst-STroke (HIIT-POST): Perspectives of People Living With Stroke and Health Professionals

BackgroundHigh intensity interval training (HIIT) is a mode of aerobic exercise that can increase neurotrophin concentration, improve cardiovascular health, and enhance recovery post-stroke. However, HIIT is not commonly prescribed in stroke rehabilitation. Exploring the clinical utility of, and barriers and facilitators to, HIIT is necessary to optimize clinical use.ObjectiveTo identify perceptions of HIIT from people with stroke and health professionals working in stroke rehabilitation.MethodsPeople with stroke and health professionals in Australia were invited to participate in an online questionnaire. Participants were further invited to complete a one-on-one semi-structured interview. A Framework Analysis approach was applied to identify key themes.ResultsTwenty-six people with stroke (mean ± standard deviation = 49.2 ± 60.6 months post-stroke, 57.7% female) and 37 health professionals (2 medical and 35 allied health) completed questionnaires. Ten people with stroke (5 female) and 8 allied health professionals completed an interview. Aerobic exercise was not considered a priority after stroke, though participants were interested in HIIT. People with stroke reported a lack of understanding of the benefits of HIIT and use of the term "high intensity" as barriers to participation. Facilitators included education about safety of HIIT and referral to health professionals. Health professionals reported a lack of knowledge of HIIT prescription parameters and participant motivation as barriers to prescription. Facilitators included education of HIIT prescription and benefits and appropriate screening prior to commencement.ConclusionsPeople with stroke and health professionals are interested in HIIT after stroke. Increasing knowledge and confidence to participate in, and prescribe HIIT, may increase clinical use.

Facilitators and Barriers to Implementing High-Intensity Gait Training in Inpatient Stroke Rehabilitation: A Mixed-Methods Study

(1) Background: High-intensity gait training (HIT) is a recommended intervention that improves walking function (e.g., speed and distance) in individuals who are undergoing stroke rehabilitation. This study explored clinicians' perceived barriers and facilitators to implementing HIT utilizing a mixed-methods approach comprising a survey and exploratory qualitative research. (2) Methods: Clinicians (n = 13) who were implementing HIT at three facilities participated. We collected and analyzed data using the consolidated framework for implementation research. Three focus groups were recorded and transcribed, and data were coded and thematically categorized. (3) Results: Survey results identified that the facilitators with a strong impact on implementation were access to knowledge/resources and intervention knowledge/beliefs. The only agreed-upon barrier with a strong impact was lack of tension for change. The focus groups resulted in 87 quotes that were coded into 27 constructs. Frequently cited outer setting facilitators were cosmopolitanism and peer pressure, and the only barrier was related to the patient needs. Innovation characteristics that were facilitators included relative advantage and design quality and packaging, and complexity was a barrier. Inner setting facilitators included networks and communication, learning climate, leadership engagement, and readiness for implementation. However, communication, leadership engagement, and available resources were also barriers. Regarding characteristics of individuals, knowledge and beliefs were both barriers and facilitators. In the implementation process domain, common facilitators were formally appointed implementation leaders and innovation participants. Barriers in this domain were related to the patients. (4) Conclusions: Clinicians identified many barriers and facilitators to implementing HIT that often varied between facilities. Further research is warranted to deepen our understanding of clinicians' experiences with HIT implementation.

Improving effective depression care in an outpatient psychiatric clinic

BACKGROUND

With more than 20 million adults experiencing a major depressive episode in 2020, depression is one of the most widespread and costly illnesses in the United States.

LOCAL PROBLEM

An audit of medical records at an outpatient psychiatric clinic revealed that none of the patients (0/56) were receiving standardized depression screening at follow-up appointments.

METHODS

An 8-week rapid cycle Plan-Do-Study-Act model for change was used to spearhead a quality improvement (QI) project for effective depression care. The QI project comprised ongoing data collection through chart audit every 3 days, which drove tests of change (TOC). Team engagement surveys were also assessed for change in team engagement scores.

INTERVENTIONS

The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression, and an effective care log (ECL) measured effective depression care. Every 2 weeks, a TOC was implemented, which guided further iterative changes throughout the project.

RESULTS

Effective depression care increased to 74% over the course of the project, surpassing the initial aim of 50%. Completion rates of the PHQ-9 (76%) and ECL (91%) increased. Team engagement (27.1) also increased over the course of the project.

CONCLUSIONS

This project improved effective depression care. The success was largely due to the iterative TOCs, ECL, and team engagement.

Healthcare professionals' perceived barriers and facilitators of implementing clinical practice guidelines for stroke rehabilitation: A systematic review

OBJECTIVE

To identify healthcare professionals' perceived barriers and facilitators to clinical practice guideline implementation within stroke rehabilitation.

DATA SOURCES

CINAHL, MEDLINE, EMBASE, AMED, Cochrane library, Academic Search Complete and Scopus. Additional papers were identified through hand searching.

REVIEW METHODS

The review followed the Preferred Reporting Item for Systematic Reviews and Meta-Analysis Protocols systematic review approach. Any empirical research that provided qualitative data on healthcare professionals' perceived factors influencing clinical guideline implementation in stroke rehabilitation was included. One reviewer screened all titles and abstract reviews (n = 669). Another two reviewers independently screened 30% of title and abstract reviews, followed by full-text reviews (n = 61). Study quality was assessed using the mixed-method appraisal tool.

RESULTS

Data from 10 qualitative, six quantitative and six mixed-method studies published between 2000 and 2022, involving 1576 participants in total, were analysed and synthesised using modified thematic synthesis approach. The majority of participants were therapists n = 1297 (occupational therapists, physiotherapists, speech and language therapists). Organisational factors (time constraints, resources) alongside healthcare professionals' lack of knowledge and skills were the most cited barriers to guideline implementation. Contradictory attitudes and beliefs towards stroke guidelines applicability to real-life clinical practice and their evidence base were reported. Organisational support in the form of training, local protocols, performance monitoring and leadership were reported as perceived facilitators.

CONCLUSION

Barriers and facilitators are multifactorial and were identified at guideline, individual, team and organisational levels. There is a need to translate perceived barriers and facilitators into implementation interventions especially addressing organisational-level barriers.

Prenatal oral health guidelines: a theory- and practice-informed approach to survey development using a modified-Delphi technique and cognitive interviews

BACKGROUND

Pregnancy presents an opportune time for oral health promotion and intervention; however, implementation of the prenatal oral health guidelines remains a challenge among prenatal and oral health providers. The purpose of this study was twofold: To employ a theory-based approach to identify high-priority Consolidated Framework for Implementation Research (CFIR) constructs with the greatest potential to impact prenatal oral health guideline implementation, and to operationalize and pre-test survey items based on the prioritized CFIR constructs. Identifying barriers and facilitators to guideline implementation will inform the development of targeted interventions that address gaps in adherence which can positively impact oral-systemic health.

METHODS

The online survey development process employed three rounds of a modified-Delphi technique with prenatal (i.e., MD/DO, CNM) and oral health (i.e., DMD) Practice Advisory Board Members, cognitive interviews with prenatal and oral health providers, and deliberations among the research team and a Scientific Advisory Board (OBGYN, pediatric dentist, and researchers). High-impact CFIR constructs were identified and translated into survey items that were subsequently piloted and finalized.

RESULTS

During three modified-Delphi rounds, a total of 39 CFIR constructs were evaluated with final input and deliberations with the Practice Advisory Board, Scientific Advisory Board, and the research team achieving consensus on 19 constructs. The instrument was pre-tested with four prenatal and two oral health providers. Overall, participants reported that the survey items were feasible to respond to, took an appropriate length of time to complete, and were well-organized. Participants identified specific areas of improvement to clarify CFIR items. The final survey instrument included 21 CFIR items across four domains, with five constructs included from the intervention characteristics domain, two from the process domain, two from the outer setting domain, and 12 from the inner setting domain.

CONCLUSIONS

Lessons learned from the survey development process include the importance of soliciting diverse scientific and practice-based input, distinguishing between importance/impact and direction of impact (barrier/facilitator), and the need for additional qualitative methods during interdisciplinary collaborations. Overall, this study illustrated an iterative approach to identifying high-priority CFIR constructs that may influence the implementation of the prenatal oral health guidelines into practice settings.