Structure and feasibility of extra practice during stroke rehabilitation: A systematic scoping review

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/.

Digital Apps to Improve Mobility in Adults with Neurological Conditions: A Health App-Focused Systematic Review

The provision of mobility exercises through a smartphone application (app) for people undertaking neurological rehabilitation may improve mobility outcomes. However, it is difficult for clinicians and consumers to select high-quality, appropriate apps. This review aimed to identify (1) which mobile health (mHealth) apps are suitable for prescribing mobility exercises for adults with neurological health conditions, (2) how well these apps incorporate telehealth strategies, and (3) how well these apps rate in terms of quality and capacity for behaviour change. The Australian Apple iTunes Store was systematically searched, by using a search code and manually, for apps suitable for training mobility in neurological rehabilitation. Additional searches were conducted in known app repositories and for web-based apps. Trained reviewers extracted data from the included apps, including population-specific characteristics; quality, by using the Mobile App Rating Scale (MARS); and behaviour change potential, by using the App Behaviour Change Scale (ABACUS). The included apps (n = 18) provided <50 to >10,000 exercises, many incurred a subscription fee (n = 13), and half included telehealth features. App quality was moderate (mean MARS score of 3.2/5 and SD of 0.5), and potential for behaviour change was poor (mean ABACUS score of 5.7/21 and SD of 2.1). A limited number of high-quality apps are available for the prescription of mobility exercises in people with neurological conditions.

Evaluating the Dissemination and Implementation Impact of a Rehabilitation Intervention: The Graded Repetitive Arm Supplementary Program (GRASP)

Purpose

To evaluate the dissemination and implementation impacts of a rehabilitation intervention.

Methods

Systematic evaluation of data sources including academic publishing metrics, publications, and surveys was used to describe the dissemination and implementation impact of the graded repetitive arm supplementary program (GRASP). Three categories in the Payback Framework were evaluated: knowledge production and dissemination, benefits to future research and research use, and real-world uptake and implementation.

Results

In the Knowledge production and dissemination category, seven publications, authored by the GRASP research team, were associated with the GRASP, and there were approximately 17,000 download counts of GRASP manuals from the website from 120 countries. In the Benefits to future research and research use category, 15 studies and 8 registered clinical trials, authored by researchers outside of the GRASP team, have used GRASP as an intervention. In the real-world uptake and implementation category, GRASP has informed recommendations in 2 clinical guidelines and 20 review papers, and had high implementation uptake (e.g., 35% [53/154] of UK therapists surveyed had used GRASP; 95% [649/681] who downloaded GRASP had used it). More than 75% of those who had used GRASP identified that GRASP provides more intensity in upper extremity rehabilitation, is evidence-based and easy to implement, and the equipment and manual are easy to obtain.

Conclusion

The Payback Framework is useful to evaluate the dissemination and implementation impacts of a rehabilitation intervention. GRASP has been implemented extensively in clinical practice and community in a relatively short time since it has been developed.

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.

The sustainability of upper limb robotic therapy for stroke survivors in an inpatient rehabilitation setting

PURPOSE

To investigate the sustainability of Robot-assisted upper limb therapy (RT-UL) as part of routine occupational therapy and physiotherapy clinical practice.

METHODS

Two separate audits, 12 months apart, of RT-UL computer data records were undertaken to determine sustainability in a subacute rehabilitation unit. Records of the two audits were compared in terms of the number of early subacute stroke survivors using RT-UL, the number of RT-UL sessions, duration of RT-UL sessions, and disciplines prescribing RT-UL.

RESULTS

During Audit 1 58% (n = 18) of stroke survivors received RT-UL compared to 50% (n = 7) in Audit 2. The total number of RT-UL sessions reduced between audits (148 vs. 36 sessions) reflecting the overall reduction in admission rates for stroke survivors. There was no significant difference between audits in the average number of RT-UL sessions per patient (p = 0.203) nor the length of sessions (p = 0.762). Patients engaged in active therapy more than three-quarters of the time when on the robotic device. Physiotherapists were the primary prescribers of RT-UL when compared to occupational therapists.

CONCLUSIONS

RT-UL was in continued and regular use with stroke survivors 2 years after initial implementation within an inpatient rehabilitation setting. RT-UL practice was intensive and used routinely with patients.IMPLICATIONS FOR REHABILITATIONRT-UL is a sustainable and intensive intervention for stroke survivors within an inpatient rehabilitative setting.The cost-benefits of RT-UL should be evaluated from the perspective of the whole rehabilitation service not just at an individual patient level.RT-UL may be considered a "bridging" form of UL practice for those with more limited active UL movement until there is sufficient UL movement and power for more complex real-world task-specific practice.

Repetitions, duration and intensity of upper limb practice following the implementation of robot assisted therapy with sub-acute stroke survivors: an observational study

BACKGROUND

Robot assisted upper limb (UL) therapy has been identified as an intervention with the potential to help improve the amount of practice performed by stroke survivors.

OBJECTIVES

This study aimed to measure the amount of UL practice (i.e., repetitions, duration, intensity) performed by subacute stroke survivors, in particular those with severe UL impairment, pre and post implementation of robot assisted upper limb therapy (RT-UL) into an inpatient rehabilitation setting.

METHODS

Two observational study phases (pre-RT-UL and post-RT-UL) were undertaken of occupational therapy and physiotherapy sessions performed by subacute stroke survivors. Upper limb tasks observed and recorded in therapy were classified as either impairment-related therapy or activity-related.

RESULTS

In the pre-RT-UL observational phase, 7 subacute stroke survivors were observed across 11 days involving 25 therapy sessions. Post-RT-UL, 12 subacute stroke survivors were observed across 12 days involving 29 therapy sessions. There were no significant differences in characteristics of patients observed in each phase (p > .05). The mean difference (95% CI) between pre and post RT-UL for repetitions (reps) (569 (1 to 1136) and intensity (7 (4-11)) reps/min of practice increased for all patients, including those with severe UL impairment (337 (37-638)) reps and 8 (2-14) reps/minute, with the duration of therapy unchanged.

CONCLUSIONS

This is the first study to have observed an increase in UL practice with the inclusion of RT-UL as part of routine clinical practice. This increase in practice is considered to be due to RT-UL providing highly supportive and expeditious semi-supervised practice. Notably, RT-UL was able to be implemented within the existing organisational structures with only basic training of therapy staff.IMPLICATIONS FOR REHABILITATIONRobotics presents as a viable intervention to increase the amount and intensity of upper limb practice performed by stroke survivors in routine clinical practiceRobotics were able to be implemented within the existing organisational structures with only basic training of therapy staff.

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.

Introducing robotic upper limb training into routine clinical practice for stroke survivors: Perceptions of occupational therapists and physiotherapists

INTRODUCTION

Robot-assisted therapy for the upper limb (RT-UL) is an emerging form of intervention for stroke survivors with upper limb deficits. However, there is limited knowledge regarding therapists' perceptions of RT-UL and the factors influencing the implementation of RT-UL into the clinical setting. This is important when considering that therapists in Australia are primarily responsible for the prescription of RT-UL in daily practice. This study aimed to explore occupational therapists' and physiotherapists' perceptions of RT-UL and the perceived barriers and enablers influencing implementation.

METHODS

Two discipline-specific focus groups were conducted involving occupational therapists (n = 6) and physiotherapists (n = 6). Participants were members of the same multidisciplinary team working in an Australian public health rehabilitation facility where RT-UL (i.e. InMotion2) was being introduced for the first time. Focus groups explored therapist perceptions of the new RT-UL as well as perceived barriers and enablers to implementation. Focus groups were recorded, transcribed and deductively analysed using the Theoretical Domains Framework (TDF).

RESULTS

Out of the 14 domains of the TDF, 7 were raised by participants during the focus groups: environmental context and resources, beliefs about consequences, optimism, knowledge, skills, social influences, and social and professional role and identity. Therapists' expressed their optimism towards the introduction of RT-UL but believed successful implementation would be primarily dependent on the availability of clinical leadership, training and a suitable client mix.

CONCLUSION

Therapists perceived that RT-UL would provide opportunity for increased upper limb practice particularly for patients with severe upper limb impairment. To facilitate implementation, support of RT-UL should come from both management and clinical leaders and training include RT-UL efficacy, device functionality and patient suitability. The availability of a single RT-UL device in a workplace may create unique interdisciplinary and logistical challenges.

Development of a participatory, tailored behaviour change intervention to increase active practice during inpatient stroke rehabilitation

Purpose: An evidence-practice gap exists between the amount of active practice recommended and the amount completed by stroke inpatients. The aim of this paper is to describe steps in the design of a participatory, theoretically tailored staff behaviour change intervention to help staff use strategies to increase active practice by stroke inpatients.Methods: A staff behaviour change intervention was developed in one rehabilitation unit in Queensland, Australia using a six-step process guided by the Behaviour Change Wheel framework. Mixed methods were used including direct observation (behavioural mapping), and focus groups to identify barriers and facilitators to implementation. Barriers and facilitators were mapped to the behaviour change techniques, and a behaviour change intervention developed in participation with rehabilitation staff.Results: Staff chose to implement ward-based practice books. Barriers included patient factors (including low motivation and severity of stroke), environmental segregation and limited skills for motivating patients. Staff belief in increasing active practice was a facilitator to implementation. The staff intervention included a training programme about motivation, environmental restructuring, audit, and feedback.Conclusions: This example of collaborative implementation research can be used and adapted by clinicians and researchers in other rehabilitation services.IMPLICATIONS FOR REHABILITATIONRehabilitation staff can be actively involved in designing behaviour change interventions.Behaviour change interventions should target local barriers to increase activity levels and practice completed by stroke inpatients.The process of co-designing behaviour change interventions has the potential to improve the uptake of a strategy such as ward-based practice books, by more precisely identifying local barriers and possible solutions.

Goal-oriented instructions increase the intensity of practice in stroke rehabilitation compared with non-specific instructions: a within-participant, repeated measures experimental study

QUESTIONS

In stroke rehabilitation, do goal-oriented instructions increase the intensity of practice during therapy compared to a non-specific instruction? Is one type of goal-oriented instruction more effective at increasing the intensity of practice achieved by stroke survivors during therapy?

DESIGN

A within-participant, repeated measures experimental study.

PARTICIPANTS

Twenty-four adults undertaking stroke rehabilitation at a metropolitan hospital as an inpatient or outpatient.

INTERVENTION

Participants were observed performing exercises across 3 days. On each day, they performed an exercise with a non-specific instruction ('do some [exercise]') as a baseline measure and the same exercise with one of three goal-oriented instructions, delivered in a randomised order. The three goal-oriented instructions were: 'do [exercise] 25 times' (instruction A), 'do [exercise] 25 times as fast as you can' (instruction B), and 'do [exercise] 25 times, as fast as you can, aiming for a personal best' (instruction C). The last instruction included verbal encouragement during the exercise.

OUTCOME MEASURES

The time taken to complete 25 repetitions under the baseline condition and each instruction was recorded and converted into repetitions per minute.

RESULTS

All of the goal-oriented instructions resulted in a significant increase in the rate of repetitions of the exercise being performed compared to the baseline measure: percentage increase from baseline (95% CI) was 62% (31 to 93) with instruction A, 116% (67 to 165) with instruction B, and 128% (84 to 171) with instruction C. Instruction C had a significantly greater effect than instruction A: mean difference in percentage increase 65% (95% CI 13 to 118).

CONCLUSION

Goal-oriented instructions can result in significant increases in the rate of repetitions of exercise in stroke rehabilitation. The use of goal-oriented instructions is a simple, no-cost strategy that can be used to increase the intensity of practice in stroke rehabilitation.

TRIAL REGISTRATION

ACTRN12619000146190.

Steps, duration and intensity of usual walking practice during subacute rehabilitation after stroke: an observational study

BACKGROUND

Duration of therapy time is an inadequate indicator of stroke rehabilitation. Steps, duration, and intensity of active therapy time may provide a better indicator of practice.

OBJECTIVE

This study quantified usual walking practice in terms of steps, duration and intensity of active therapy time, and distance walked during physical therapy sessions in people with sub-acute stroke undertaking inpatient rehabilitation and to examine whether usual walking practice differed depending on walking ability.

METHODS

A prospective observational study was conducted across two metropolitan rehabilitation units in Australia. Twenty-four stroke survivors were observed over three physical therapy sessions. Walking ability was categorized as unassisted or assisted based on Item 5 of the Motor Assessment Scale. Walking practice was categorized as basic or advanced. Steps, duration, intensity and distance walked were measured during physical therapy sessions.

RESULTS

Overall, participants took 560 steps (SD 309) over 13min (SD 6) at an intensity of steps 44 steps/min (SD 17) and walked 222m (SD 143) in physical therapy. Unassisted walkers (n=6, 25%) undertook more (or trended towards more) practice of advanced walking than assisted walkers in terms of steps (MD 254 steps, 95% CI 48-462), duration (MD 5min, 95% CI 0-10), intensity (MD 18steps/min, 95% CI -8 to 44) and distance (MD 112m, 95% CI -12 to 236).

CONCLUSION

Stroke survivors undergoing inpatient rehabilitation spent approximately 20% of physical therapy actively engaged in walking practice. Those able to walk without assistance took more steps for longer, at a higher intensity.

TRIAL REGISTRATION

ACTRN12613000764730 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364545).

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

QUESTIONS

When a hospital gymnasium used for inpatient rehabilitation is set up to allow semi-supervised practice: what percentage of practice is performed as semi-supervised practice, what percentage of patients in the gym are actively engaged in practice at one time, and is the semi-supervised practice that occurs safe?

DESIGN

An observational study using periodic behaviour mapping.

PARTICIPANTS

Patients in general and stroke rehabilitation units of a metropolitan hospital.

OUTCOME MEASURES

Observations in the rehabilitation gym quantified the number of patients in the gym and the numbers of patients practising and resting. In observations of patients practising, the condition of practice was recorded as being with a therapist, with a family member, or with no direct supervision. The number of adverse events during the data collection period was collected from the hospital Incident Information Management System.

RESULTS

The rehabilitation gym was observed on 113 occasions, resulting in 1319 individual patient observations. An average of 12 patients were in the gym during the observations. Practice was being performed with family supervision in 15% of observations and with no direct supervision in 26% of observations, resulting in semi-supervised practice accounting for 41% of all observations of practice. The percentage of observations that were of patients taking part in active practice was 78%. There were no adverse events in the gym.

CONCLUSION

In an inpatient setting, a large percentage of practice can be performed as semi-supervised practice. This does not appear to compromise the time spent in active practice or patient safety.

A low cost kinect-based virtual rehabilitation system for inpatient rehabilitation of the upper limb in patients with subacute stroke: A randomized, double-blind, sham-controlled pilot trial

BACKGROUND

We designed this study to prove the efficacy of the low-cost Kinect-based virtual rehabilitation (VR) system for upper limb recovery among patients with subacute stroke.

METHODS

A double-blind, randomized, sham-controlled trial was performed. A total of 23 subjects with subacute stroke (<3 months) were allocated to sham (n = 11) and real VR group (n = 12). Both groups participated in a daily 30-minute occupational therapy for upper limb recovery for 10 consecutive weekdays. Subjects received an additional daily 30-minute Kinect-based or sham VR. Assessment was performed before the VR, immediately and 1 month after the last session of VR. Fugl-Meyer Assessment (FMA) (primary outcome) and other secondary functional outcomes were measured. Accelerometers were used to measure hemiparetic upper limb movements during the therapy.

RESULTS

FMA immediately after last VR session was not different between the sham (46.8 ± 16.0) and the real VR group (49.4 ± 14.2) (P = .937 in intention to treat analysis). Significant differences of total activity counts (TAC) were found in hemiparetic upper limb during the therapy between groups (F2,26 = 4.43; P = .22). Real VR group (107,926 ± 68,874) showed significantly more TACs compared with the sham VR group (46,686 ± 25,814) but there was no statistical significance between real VR and control (64,575 ± 27,533).

CONCLUSION

Low-cost Kinect-based upper limb rehabilitation system was not more efficacious compared with sham VR. However, the compliance in VR was good and VR system induced more arm motion than control and similar activity compared with the conventional therapy, which suggests its utility as an adjuvant additional therapy during inpatient stroke rehabilitation.