Physical and occupational therapy in inpatient stroke rehabilitation: the contribution of therapy extenders

Safety and Feasibility Study of the Medical Care Pit Walking Support System for Rehabilitation of Acute Stroke Patients

Stroke rehabilitation with mechanical assistance improves outcomes by facilitating repetition and relieving the care burden of therapy staff. Here, we tested the Medical Care Pit (MCP) walking assistance training device in the rehabilitation of eight acute stroke patients (median age 60.7 ± 16.3 years) who had recently suffered ischemic (three) or hemorrhagic (five) stroke (14.1 ± 6.5 days). Patients received standard rehabilitation approximately 5 days per week (weekdays only), plus MCP therapy twice a week, totaling four MCP sessions over 2 weeks. Fugl-Meyer Assessment-Lower Extremities (FMA-LE), Functional Ambulation Category (FAC), and other gait-associated parameters were measured. Over the 10.5 ± 1.6 days of therapy, MCP qualitatively assisted in gait analysis and real-time patient feedback while independent walking scores significantly improved (FAC 2.2 ± 0.8 to 3.1 ± 1.3, p = 0.020). FMA-LE scores also slightly improved but not to significance (p = 0.106). Objective burden on patients, as measured by modified Borg scale, was significantly improved (2.7 ± 1.6 to 2.0 ± 1.6, p = 0.014). In terms of questionnaires, anxiety scores for the physical therapist regarding gait training and falling with MCP significantly decreased (3.8 ± 2.3 to 1.0 ± 1.6; p = 0.027 and 3.1 ± 2.2 to 0.8 ± 1.3; p = 0.045) from the first to fourth sessions. Taken together, MCP, in addition to the usual rehabilitation program, was effective in gait rehabilitation for independent walking and relieved burdens on the patients. Such walking support systems may be an important part of acute stroke rehabilitation.

Exploring stroke survivors' experiences and understandings of occupational therapy

BACKGROUND

Occupational therapists view people with stroke as occupational beings who may experience occupational issues. Concurrently, occupational therapy practice is guided by research evidence that supports predominantly impairment-based practices. There has been limited exploration of how people with stroke experience and understand occupational therapy in the context of the potential tension between the professional philosophy and the research-based evidence.

AIMS/OBJECTIVE

To explore the experience and understanding of occupational therapy with stroke survivors.

MATERIAL AND METHODS

Interpretative phenomenology guided semi-structured interviews with nine participants from five states across Australia.

RESULTS

Three themes emerged: Understanding of occupational therapy grows by 'doing' outlines how participants understood occupational therapy based on their individual experiences over time; Personal factors influence the experience highlights how participants had diverse expectations for recovery that influenced their occupational therapy experience. Context shapes occupational therapy experience identified that the therapeutic relationship and context of occupational therapy were important factors in shaping experiences.

CONCLUSION

Both impairment-based and occupation-based therapy were considered valuable aspects of occupational therapy, representing the proposed tension between the professional philosophy and research-based evidence. Occupation-based and client-centred practice was more often experienced in the outpatient setting, with challenges described for both within the inpatient setting.

Human resources for health (and rehabilitation): Six Rehab-Workforce Challenges for the century

BACKGROUND

People with disabilities face challenges accessing basic rehabilitation health care. In 2006, the United Nations Convention on the Rights of Persons with Disabilities (CRPD) outlined the global necessity to meet the rehabilitation needs of people with disabilities, but this goal is often challenged by the undersupply and inequitable distribution of rehabilitation workers. While the aggregate study and monitoring of the physical rehabilitation workforce has been mostly ignored by researchers or policy-makers, this paper aims to present the 'challenges and opportunities' for guiding further long-term research and policies on developing the relatively neglected, highly heterogeneous physical rehabilitation workforce.

METHODS

The challenges were identified through a two-phased investigation. Phase 1: critical review of the rehabilitation workforce literature, organized by the availability, accessibility, acceptability and quality (AAAQ) framework. Phase 2: integrate reviewed data into a SWOT framework to identify the strengths and opportunities to be maximized and the weaknesses and threats to be overcome.

RESULTS

The critical review and SWOT analysis have identified the following global situation: (i) needs-based shortages and lack of access to rehabilitation workers, particularly in lower income countries and in rural/remote areas; (ii) deficiencies in the data sources and monitoring structures; and (iii) few exemplary innovations, of both national and international scope, that may help reduce supply-side shortages in underserved areas.

DISCUSSION

Based on the results, we have prioritized the following 'Six Rehab-Workforce Challenges': (1) monitoring supply requirements: accounting for rehabilitation needs and demand; (2) supply data sources: the need for structural improvements; (3) ensuring the study of a whole rehabilitation workforce (i.e. not focused on single professions), including across service levels; (4) staffing underserved locations: the rising of education, attractiveness and tele-service; (5) adapt policy options to different contexts (e.g. rural vs urban), even within a country; and (6) develop international solutions, within an interdependent world.

CONCLUSIONS

Concrete examples of feasible local, global and research action toward meeting the Six Rehab-Workforce Challenges are provided. Altogether, these may help advance a policy and research agenda for ensuring that an adequate rehabilitation workforce can meet the current and future rehabilitation health needs.

Building a framework for implementing new interventions

Implementation into real-world practice of interventions previously studied in randomized controlled trials is an ongoing challenge. In this article, we describe the methodology we used for the first phase of a project for the implementation and outcomes assessment of an occupational therapy pressure ulcer prevention intervention for people with spinal cord injury in the Veterans Health Administration. This first phase of the project was guided by practice-based evidence research methodology and resulted in an intervention manual tailored to meet the needs of Veterans and the establishment of a system for documenting and monitoring care processes, patient characteristics, and intervention outcomes. This system, in turn, will provide the data-gathering template for the next phase in which the beneficial effects of the intervention will be assessed. We conclude by recommending that clinicians explore the utility of this approach for the implementation of other novel interventions.

Occupational Therapists and Observation: What are You Looking At?

Visual observation is a fundamental skill underlying all occupational performance assessments in occupational therapy. The purpose of this study was to determine whether eye movement patterns differ between occupational therapists and non-healthcare professionals during observation of static images portraying a client post-stroke (domain-specific content) or naturalistic scenes (domain-irrelevant content). Ten licensed occupational therapists (OT group) and 10 participants matched for age, gender, and education level (NonOT group) completed the study. Participants viewed two counterbalanced blocks of 10 images (scene and stroke) under the pretext of preparing for a memory test. The OT group differed in the viewing strategies during observation and in how they directed their eyes (higher frequency of fixations, shorter fixation durations, and increased saccade count) for domain-specific and domain-irrelevant images alike. Observation patterns used by occupational therapists are presumably related to top-down influences that are not necessarily related to domain-specific knowledge but perhaps to general experience with performing assessments using observational methods.