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Anåker A, Kevdzija M, Elf M. Enriched Environments in Stroke Units: Defining Characteristics and Limitations. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2024; 17:344-359. [PMID: 38494920 PMCID: PMC11080395 DOI: 10.1177/19375867231224972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Individuals with stroke rehabilitated in an enriched environment (EE) compared to a non-EE are more likely to participate in cognitive and social activities, promoting their rehabilitation and well-being. There is a need for a more comprehensive understanding of methods to implement EEs within complex health systems, particularly in stroke units. OBJECTIVE The aim of this systematic review was to compile the concept of an EE in stroke units. METHODS The literature was sourced from CINAHL, Embase, and Medline databases. A detailed screening and sifting process was used to identify relevant literature. Multiple reviewers independently appraised the identified literature using a Mixed-methods Appraisal Tool. After screening 336 studies, 11 were included. RESULTS This review reveals an EE is challenging to define and almost exclusively about activities based on access to individual and communal equipment. Generally, there are no common descriptions or conceptual agreements. CONCLUSIONS To the best of our knowledge, this is the first study to systematically review the concept of an EE in stroke units and shows that more studies on EEs are needed. The weak definitions and unclear theoretical backgrounds of an EE in the included studies could challenge operationalization. Future research should be based on more precise definitions of an EE and broader interventions that include changes to built and natural environments.
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Affiliation(s)
- Anna Anåker
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Maja Kevdzija
- TU Wien, Department of Building Theory by Design, Faculty of Architecture and Planning, Institute of Architecture and Design, Vienna, Austria
| | - Marie Elf
- School of Health and Welfare, Dalarna University, Falun, Sweden
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Stewart C, Power E, McCluskey A, Kuys S, Lovarini M. Implementing ward-based practice books to increase the amount of practice completed during inpatient stroke rehabilitation: a mixed-methods process evaluation. Disabil Rehabil 2024:1-11. [PMID: 38386409 DOI: 10.1080/09638288.2024.2315502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024]
Abstract
PURPOSE Stroke survivors must complete large amounts of practice to achieve functional improvements but spend many hours inactive during their rehabilitation. We conducted a mixed methods process evaluation exploring factors affecting the success of a 6-month behaviour change intervention to increase use of ward-based practice books. METHODS Audits of the presence, quality and use of ward based-practice books were conducted, alongside focus groups with staff (n = 19), and interviews with stroke survivors (n = 3) and family members (n = 4). Quantitative data were analysed descriptively. Focus group and interview transcripts were analysed using qualitative analysis. RESULTS Personal (patient-related) factors (including severe weakness, cognitive and communication deficits of stroke survivors), staff coaching skills, understanding and beliefs about their role, affected practice book use. Staff turnover, nursing shift work and a lack of action planning reduced success of the behaviour change intervention. CONCLUSIONS Staff with the necessary skills and understanding of their role in implementing ward practice overcame personal (patient-related) factors and assisted stroke survivors to successfully practice on the ward. To improve success of the intervention, repeated training of new staff is required. In addition to audit and feedback, team action planning is needed around the presence, quality, and use of ward practice books.
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Affiliation(s)
- Claire Stewart
- Australasian Rehabilitation Outcomes Centre, University of Wollongong, Wollongong, Australia
| | - Emma Power
- The University of Technology Sydney, Graduate School of Health, Sydney, Australia
- Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Annie McCluskey
- Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
- The StrokeEd Collaboration, Sydney, Australia
| | - Suzanne Kuys
- School of Allied Health, Australian Catholic University, Banyo, Australia
| | - Meryl Lovarini
- Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
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Broderick M, Burridge J, Demain S, Johnson L, Brereton J, O'Shea R, Bentley P. Multicentre pilot randomised control trial of a self-directed exergaming intervention for poststroke upper limb rehabilitation: research protocol. BMJ Open 2024; 14:e077121. [PMID: 38245014 PMCID: PMC10806628 DOI: 10.1136/bmjopen-2023-077121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 12/21/2023] [Indexed: 01/22/2024] Open
Abstract
INTRODUCTION Technology-facilitated, self-directed upper limb (UL) rehabilitation, as an adjunct to conventional care, could enhance poststroke UL recovery compared with conventional care alone, without imposing additional resource burden. The proposed pilot randomised controlled trial (RCT) aims to assess whether stroke survivors will engage in self-directed UL training, explore factors associated with intervention adherence and evaluate the study design for an RCT testing the efficacy of a self-directed exer-gaming intervention for UL recovery after stroke. METHODS AND ANALYSIS This is a multicentre, internal pilot RCT; parallel design, with nested qualitative methods. The sample will consist of stroke survivors with UL paresis, presenting within the previous 30 days. Participants randomised to the intervention group will be trained to use an exergaming device and will be supported to adopt this as part of their self-directed rehabilitation (ie, without formal support/supervision) for a 3-month period. The primary outcome will be the Fugl Meyer Upper Extremity Assessment (FM-UE) at 6 months poststroke. Secondary outcomes are the Action Research Arm Test (ARAT), the Barthel Index and the Modified Rankin Scale. Assessment time points will be prior to randomisation (0-1 month poststroke), 3 months and 6 months poststroke. A power calculation to inform sample size required for a definitive RCT will be conducted using FM-UE data from the sample across 0-6 months time points. Semistructured qualitative interviews will examine factors associated with intervention adoption. Reflexive thematic analysis will be used to code qualitative interview data and generate key themes associated with intervention adoption. ETHICS AND DISSEMINATION The study protocol (V.1.9) was granted ethical approval by the Health Research Authority, Health and Care Research Wales, and the London- Harrow Research Ethics Committee (ref. 21/LO/0054) on 19 May 2021. Trial results will be submitted for publication in peer-reviewed journals, presented at national and international stroke meetings and conferences and disseminated among stakeholder communities. TRIAL REGISTRATION NUMBER NCT04475692.
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Affiliation(s)
| | - Jane Burridge
- Life Sciences, University of Southampton, Southampton, UK
| | - Sara Demain
- Life Sciences, University of Southampton, Southampton, UK
| | - Louise Johnson
- Life Sciences, University of Southampton, Southampton, UK
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Joe Brereton
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | | | - Paul Bentley
- Brain Sciences, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
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Ghaziani E, Christensen SS, Arens CH, Wæhrens EE. Addressing ADL ability in people with poststroke cognitive impairments: A Danish survey of clinical practice. Scand J Occup Ther 2024; 31:2318204. [PMID: 38382558 DOI: 10.1080/11038128.2024.2318204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/09/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND In Denmark, stroke represents a leading disability cause. While people with difficulties in performing activities of daily living (ADL) due to poststroke cognitive impairments are often referred to occupational therapy, limited knowledge is available on the nature of these services. AIM/OBJECTIVE To explore how Danish occupational therapists describe their practice when addressing decreased ADL ability in people with poststroke cognitive impairments in hospital and municipality settings. MATERIAL AND METHODS National, cross-sectorial, web-based public survey. RESULTS 244 occupational therapists accessed the survey; 172 were included in the analysis. Most respondents could indicate the theory guiding their reasoning; half used standardised assessments. Regarding intervention, restorative and acquisitional models were preferred; specific strategies were identified. Intensity: 30-45 min 3-4 times/week in hospitals; 30-60 min 1-2 times/week in municipalities. CONCLUSIONS Therapists report to be guided by theory in their reasoning. Standardised assessments are used to a higher extend than previously reported. Still, the results invite critical reflections on correct use of assessment instruments, content and intensity of interventions, and how therapists keep themselves updated. SIGNIFICANCE The results document the need for practice improvements and may inform the definition of standard care in future trials.
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Affiliation(s)
- E Ghaziani
- Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - S S Christensen
- Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - C H Arens
- Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - E E Wæhrens
- Occupation-Centered Occupational Therapy, The Parker Institute, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Occupational Science, User Perspectives and Community-based Interventions, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Leff A, Doogan C, Bentley J, Makkar B, Zenobi-Bird L, Sherman A, Grobler S, Crinion J. More than one way to improve a CAT: Outcomes and reflections on two iterations of the Queen Square Intensive Comprehensive Aphasia Programme. APHASIOLOGY 2023:1-24. [PMID: 38652694 PMCID: PMC11027995 DOI: 10.1080/02687038.2023.2286703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/16/2023] [Indexed: 04/25/2024]
Abstract
Background The field of human expert performance teaches us that high quality, high-dose guided practice is required to make large gains in cognitively driven acts. The same also seems to be true for people with acquired brain injury, yet therapy services for people with aphasia (PWA) have traditionally not been designed with this in mind. Intensive Comprehensive Aphasia Programmes (ICAPs) are one way to address the chronic under-dosing of therapy that most PWA experience. Aims There are several ways to deliver an ICAP; here we describe two iterations of our Queen Square ICAP. There was a 20-month COVID-induced pause between the Year 1 (Y1) and Year 2 (Y2) ICAP groups. We analyse ICAP-induced changes in both groups of PWA on a series of key outcome measures that span the International Classification of Functioning, Disability and Health, covering language impairment and function as well as mood and social participation. Methods & Procedures Forty-six PWA took part in Y1 and 44 in Y2. The PWA were all in the chronic stage post stroke and varied in aphasia severity from mild to severe, with the Y2 group being more impaired than Y1. Quantitative data was collected before and after the ICAP. The Y2 therapy team provided independent reflections on their experiences of delivering an ICAP. Outcomes & Results ICAP-related changes in outcome measures (impairment, function and goal attainment) were generally comparable for the Y1 and Y2 groups, with both groups' speech production abilities improving the most. Both groups made clinically and statistically significant gains on the main quality of life measure. Participation in the ICAP made a big difference to PWAs' self-confidence ratings. Their mood ratings also improved significantly, although they were not, on average, in the depressed range at baseline (directly pre-ICAP). All improvements achieved in both groups were maintained at the 3-month follow-up, highlighting the lasting effects that ICAPs can provide. Conclusions Evidence continues to accrue that ICAPs are an efficient way of increasing the dose of expert coaching required for people with chronic aphasia to make clinically meaningful improvements in their communicative abilities and quality of life. The main challenge remaining is convincing health-care providers to invest in them.
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Affiliation(s)
- Alexander Leff
- UCL Queen Square Institute of Neurology, University College London, London, UK
- University College London Hospitals NHS Trust, London, UK
- Institute of Cognitive Neuroscience, University College London, London, UK
| | - Catherine Doogan
- UCL Queen Square Institute of Neurology, University College London, London, UK
- University College London Hospitals NHS Trust, London, UK
- St Georges, University of London
| | | | - Bani Makkar
- University College London Hospitals NHS Trust, London, UK
| | | | - Amy Sherman
- University College London Hospitals NHS Trust, London, UK
| | - Simon Grobler
- University College London Hospitals NHS Trust, London, UK
| | - Jennifer Crinion
- University College London Hospitals NHS Trust, London, UK
- Institute of Cognitive Neuroscience, University College London, London, UK
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Weerakkody A, Emmanuel R, White J, Godecke E, Singer B. Unlocking the restraint-Development of a behaviour change intervention to increase the provision of modified constraint-induced movement therapy in stroke rehabilitation. Aust Occup Ther J 2023; 70:661-677. [PMID: 37424149 DOI: 10.1111/1440-1630.12896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Strong evidence supports the provision of modified constraint-induced movement therapy (mCIMT) to improve upper limb function after stroke. A service audit identified that very few patients received mCIMT in a large subacute, early-supported discharge rehabilitation service. A behaviour change intervention was developed to increase the provision of mCIMT following an unsuccessful 'education only' attempt. This paper aims to systematically document the steps undertaken and to provide practical guidance to clinicians and rehabilitation services to implement this complex, yet effective, rehabilitation intervention. METHODS This clinician behaviour change intervention was developed over five stages and led by a working group of neurological experts (n = 3). Data collection methods included informal discussions with clinicians and an online survey (n = 35). The staged process included reflection on why the first attempt did not improve the provision of mCIMT (stage 1), mapping barriers and enablers to the Theoretical Domains Framework (TDF) and behaviour change wheel (BCW) to guide the behaviour change techniques (stages 2 and 3), developing a suitable mCIMT protocol (stage 4), and delivering the behaviour change intervention (stage 5). RESULTS Reflection among the working group identified the need for upskilling in mCIMT delivery and the use of a behaviour change framework to guide the implementation program. Key determinants of behaviour change operated within the TDF domains of knowledge, skills, environmental context and resources, social role and identity, and social influences. Following the development of a context-specific mCIMT protocol, the BCW guided the behaviour change intervention, which included education, training, persuasion, environmental restructuring, and modelling. CONCLUSION This paper provides an example of using the TDF and BCW to support the implementation of mCIMT in a large early-supported discharge service. It outlines the suite of behaviour change techniques used to influence clinician behaviour. The success of this behaviour change intervention will be explored in future research.
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Affiliation(s)
- Ashan Weerakkody
- Rehabilitation in the Home, South Metropolitan Health Service, Department of Health, Fremantle, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Robyn Emmanuel
- Rehabilitation in the Home, South Metropolitan Health Service, Department of Health, Fremantle, Australia
- Neurotherapy Occupational Therapy Services, Perth, Australia
| | - Jocelyn White
- Rehabilitation in the Home, South Metropolitan Health Service, Department of Health, Fremantle, Australia
| | - Erin Godecke
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
- Sir Charles Gairdner Hospital, North Metropolitan Health Service, Department of Health, Nedlands, Australia
| | - Barby Singer
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
- TRAining Centre in Subacute Care (TRACSWA), Department of Health, Fremantle, Australia
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Clark B, Burridge J, Whitall J, Turk R, Hughes AM, Truman J. Why do some people with stroke not receive the recommended 45 min of occupational therapy and physiotherapy after stroke? A qualitative study using focus groups. BMJ Open 2023; 13:e072275. [PMID: 37993170 PMCID: PMC10668261 DOI: 10.1136/bmjopen-2023-072275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 09/01/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVES To generate qualitative data on the views of Occupational Therapists and Physiotherapists about why people do not receive the Royal College of Physicians' recommended minimum of 45 minutes (min) of daily therapy after stroke, in order to inform a Delphi study. DESIGN Focus group study. SETTING Stroke services in the South of England. PARTICIPANTS A total of nine participants, in two groups, including therapists covering inpatient and Early Supported Discharge (ESD) services with awareness of the 45 min guideline. RESULTS Thematic analysis of focus group data identified five factors that influence the amount of therapy a person receives: The Person (with stroke), Individual Therapist, Stroke Multidisciplinary Team, the Organisation and the Guideline. Study findings suggest that the reasons why a person does not receive the therapy recommendation in inpatient and ESD services relate to either the suitability of the guideline for the person with stroke, or the ability of the service to deliver the guideline. CONCLUSION This study provides evidence for possible reasons why some people do not receive a minimum of 45 minutes of therapy, 5 days per week, related to (1) the suitability of the guideline for people with stroke and (2) services' ability to deliver this amount of intervention. These two factors are related; therapists decide who should receive therapy and how much in the context of (a) resource availability and (b) people's need and the benefit they will experience. The study findings, combined with the findings from other studies, will be used to initiate a Delphi study, which will establish consensus among therapists regarding the reasons why some people do not receive the guideline amount of therapy.
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Affiliation(s)
- Beth Clark
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jane Burridge
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jill Whitall
- Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Ruth Turk
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Ann-Marie Hughes
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Juliette Truman
- Department of Rehabilitation and Sports Sciences, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
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Clark B, Truman J, Whitall J, Hughes AM, Turk R, Burridge J. Why do some people who had a stroke not receive the recommended 45 min of occupational therapy and physiotherapy? A Delphi study. BMJ Open 2023; 13:e072276. [PMID: 37993160 PMCID: PMC10668297 DOI: 10.1136/bmjopen-2023-072276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 09/01/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVES To gain a consensus among therapists for reasons why a person who had a stroke may not receive the Royal College of Physicians' recommended minimum of 45 min of daily therapy. DESIGN Three-round remote e-Delphi study. SETTING National study, based in the UK. PARTICIPANTS Occupational therapists and physiotherapists with experience of delivering therapy after stroke and awareness of the 45 min guideline. RESULTS Forty-five therapists consented to participate in the study. Thirty-five (78%) completed round one, 29 of 35 (83%) completed round 2 and 26 of 29 (90%) completed round three. A consensus (75%) was reached for 32 statements. Reasons why a person may not receive 45 min were related to the suitability of the guideline for the individual (based on factors like therapy tolerance or medical status) or the capability of the service to provide the intervention. In addition to the statements for which there was a consensus, 32 concepts did not reach a consensus. Specifically, there was a lack of consensus concerning the suitability of the guideline for people receiving Early Supported Discharge (ESD) services and a lack of agreement about whether people who need more than 45 min of therapy actually receive it. CONCLUSION Some people do not receive 45 min of therapy as they are considered unsuitable for it and some do not receive it due to services' inability to provide it. It is unclear which reasons for guideline non-achievement are most common. Future research should focus on why the guideline is not achieved in ESD, and why people who require more than 45 min may not receive it. This could contribute to practical guidance for therapists to optimise therapy delivery for people after stroke.
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Affiliation(s)
- Beth Clark
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Juliette Truman
- Department of Rehabilitation and Sports Sciences, Faculty of Health and Social Sciences, Bournemouth University, Poole, UK
| | - Jill Whitall
- Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Ann-Marie Hughes
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Ruth Turk
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jane Burridge
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
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Monnelly K, Marshall J, Dipper L, Cruice M. Intensive and comprehensive aphasia therapy-a survey of the definitions, practices and views of speech and language therapists in the United Kingdom. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2023; 58:2077-2102. [PMID: 37394906 DOI: 10.1111/1460-6984.12918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 05/30/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Research evidence suggests aphasia therapy must be delivered at high intensity to effect change. Comprehensive therapy, addressing all domains of the International Classification of Functioning, Disability and Health, is also called for by people with aphasia and their families. However, aphasia therapy is rarely intense or comprehensive. Intensive Comprehensive Aphasia Programmes (ICAPs) were designed to address this challenge, but such programmes are not widely implemented. AIMS This study surveyed the views of UK-based speech and language therapists (SLTs) regarding intensive and comprehensive aphasia therapy. It explored definitions of intensive and comprehensive therapy, patterns of provision, views about candidacy and barriers/facilitators. It also investigated awareness of ICAPs and perceived potential of this service model. Differences across UK regions and workplace settings were explored. METHODS & PROCEDURES An e-survey ran for 5 months. Quantitative data were analysed using descriptive and inferential statistics. Qualitative free text comments were analysed using content analysis. OUTCOMES & RESULTS Two hundred twenty-seven respondents engaged in the e-survey. Definitions of intensive aphasia therapy did not reach UK clinical guideline/research-level thresholds for most of the sample. Those providing more therapy provided definitions with higher standards of intensity. Mean therapy delivered was 128 min/week. Geographical location and workplace setting influenced the amount of therapy delivered. The most frequently delivered therapy approaches were functional language therapy and impairment-based therapy. Cognitive disability and fatigue were concerns for therapy candidacy. Barriers included lack of resources and low levels of optimism that issues could be solved. 50% of respondents were aware of ICAPs and 15 had been involved in ICAP provision. Only 16.5% felt their service could be reconfigured to deliver an ICAP. CONCLUSIONS & IMPLICATIONS This e-survey evidences a mismatch between an SLT's concept of intensity and that espoused by clinical guidelines/research. Geographical variations in intensity are concerning. Although a wide range of therapy approaches are offered, certain aphasia therapies are delivered more frequently. Awareness of ICAPs was relatively high, but few respondents had experience of this model or felt it could be executed in their context. Further initiatives are needed if services are to move from a low-dose or non-comprehensive model of delivery. Such initiatives might include but not be confined to wider uptake of ICAPs. Pragmatic research might also explore which treatments are efficacious with a low-dose model of delivery, given that this model is dominant in the United Kingdom. These clinical and research implications are raised in the discussion. WHAT THIS PAPER ADDS What is already known on this subject There is a gap between the high intensity of aphasia treatment provided in research versus mainstream clinical settings. A lower standard of 45 min/day set by UK clinical guidelines is also not achieved. Although speech and language therapists (SLTs) provide a wide range of therapies, they typically focus on impairment-based approaches. What this study adds This is the first survey of UK SLTs asking about their concept of intensity in aphasia therapy and what types of aphasia therapy they provide. It explores geographical and workplace variations and barriers and facilitators to aphasia therapy provision. It investigates Intensive Comprehensive Aphasia Programmes (ICAPs) in a UK context. What are the clinical implications of this work? There are barriers to the provision of intensive and comprehensive therapy in the United Kingdom and reservations about the feasibility of ICAPs in a mainstream UK context. However, there are also facilitators to aphasia therapy provision and evidence that a small proportion of UK SLTs are providing intensive/comprehensive aphasia therapy). Dissemination of good practice is necessary and suggestions for increasing intensity of service provision are listed in the discussion.
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Affiliation(s)
- Katie Monnelly
- Department of Language and Communication Science, City University of London, London, UK
| | - Jane Marshall
- Department of Language and Communication Science, City University of London, London, UK
| | - Lucy Dipper
- Department of Language and Communication Science, City University of London, London, UK
| | - Madeline Cruice
- Department of Language and Communication Science, City University of London, London, UK
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10
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Newton SP, Dalton EJ, Ang JY, Klaic M, Thijs V, Hayward KS. Dose, Content, and Context of Usual Care in Stroke Upper Limb Motor Interventions: A Systematic Review. Clin Rehabil 2023; 37:1437-1450. [PMID: 37151039 PMCID: PMC10492439 DOI: 10.1177/02692155231172295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 04/11/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE The objectives of this systematic review were to describe the current dose and content of usual care upper limb motor intervention for inpatients following stroke and examine if context factors alter dose and content. DATA SOURCES A systematic search (EMBASE, MEDLINE) was completed from January 2015 to February 2023 (PROSPERO CRD42021281986). METHODS Studies were eligible if they reported non-protocolised usual care upper limb motor intervention dose data for stroke inpatients. Studies were rated using the Johanna Briggs Institute critical appraisal tool. Data were descriptively reported for dose dimensions of time (on task or, in therapy) and intensity (repetitions, repetition/minute), content (intervention type/mode), and context (e.g., severity strata). RESULTS Eight studies were included from four countries, largely reflecting inpatient rehabilitation. Time in therapy ranged from 23 to 121 min/day. Time on task ranged from 8 to 44 min/day. Repetitions ranged from 36 to 57/session, and 15 to 282/day. Time on task was lowest in the stratum of people with severe upper limb impairment (8 min/day), the upper limit for this stratum was 41.5 min/day. There was minimal reporting of usual care content across all studies. CONCLUSION Upper limb motor intervention dose appears to be increasing in usual care compared to prior reports (e.g., average 21 min/day and 23 to 32 repetitions/session). Context variability suggests that doses are lowest in the stratum of patients with a severely impaired upper limb. Consistent reporting of the multiple dimensions of dose and content is necessary to better understand usual care offered during inpatient rehabilitation.
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Affiliation(s)
- Sarah P Newton
- Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Occupational Therapy, Austin Health, Melbourne, Australia
| | - Emily J Dalton
- Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Occupational Therapy, Austin Health, Melbourne, Australia
| | - Jia Y Ang
- Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Marlena Klaic
- Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neurosciences and Mental Health, Melbourne, Australia
- Department of Neurology, Austin Health, Melbourne, Australia
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Kathryn S Hayward
- Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
- Stroke Theme, Florey Institute of Neurosciences and Mental Health, Melbourne, Australia
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
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11
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Alhusayni AI, Cowey ES, Coulter E, Barber M, Paul L. Personalised Online Upper-Limb Physiotherapy for Stroke Survivors during the Inpatient Phase: A Feasibility Study. Healthcare (Basel) 2023; 11:2582. [PMID: 37761779 PMCID: PMC10531470 DOI: 10.3390/healthcare11182582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/07/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND After a stroke, inpatients often receive less than the recommended dose of therapy. Telerehabilitation may assist by providing personalised rehabilitation programmes without face-to-face therapy time. This study aimed to evaluate the acceptability and feasibility of an individualised programme of upper-limb rehabilitation that is delivered via an online rehabilitation platform for inpatient stroke survivors. METHODS Stroke survivors were recruited from three stroke units in one NHS Board in Scotland and randomised to the intervention (personalised upper-limb exercise programme delivered via an online physiotherapy platform for four weeks, up to 30 min five times per week, in addition to usual care) or the control group (usual care). The main outcomes are related to recruitment, attrition, adherence and safety. The clinical measures were the Action Research Arm Test, Trunk Impairment Scale and Modified Ashworth Scale. The intervention participants, their carers and physiotherapists completed questionnaires on the acceptability of the intervention. RESULTS Twenty-six participants, 42% males, were recruited around three weeks post-stroke, on average. There were 13 participants in each group, with a mean age of 69 years (SD of 12) and 67 years (SD of 11) for the control and intervention groups, respectively. Overall, 47% of those screened for eligibility were randomised, and attrition was 23% in the intervention group mainly due to discharge before the end of the intervention. Participants who adhered to their programme (completed more than two-thirds), generally those with an engaged carer, demonstrated a trend toward improved clinical outcomes. Overall, the patients, carers and physiotherapists were positive regarding the intervention. There was a total of five reported adverse events, none of which were related to the study. CONCLUSION An upper-limb unsupervised exercise intervention using an online physiotherapy platform for inpatient stroke survivors is feasible, safe and acceptable to patients, carers and physiotherapists. A fully powered RCT is warranted to investigate the clinical- and cost-effectiveness of such interventions for this patient group.
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Affiliation(s)
| | | | - Elaine Coulter
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow G4 0BA, UK; (E.C.); (L.P.)
| | | | - Lorna Paul
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow G4 0BA, UK; (E.C.); (L.P.)
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12
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Twose P, Terblanche E, Jones U, Firshman P, Merriweather J, Rock C, Wallace S. Protected therapy services for critical care: A subanalysis of the UK-wide workforce survey. Aust Crit Care 2023; 36:821-827. [PMID: 36604266 DOI: 10.1016/j.aucc.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/07/2022] [Accepted: 11/13/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The existing United Kingdom (UK) allied health professional (AHP) workforce in critical care does not meet national standards, with widespread variation in the source of funding, service availability, and regularity of input. OBJECTIVES The aim of this subanalysis was to determine the impact of protected services on the involvement of AHPs on direct and nondirect aspects of patient care. METHODS This is a subanalysis of the previously published AHPs in critical care UK-wide workforce survey, an observational study using online surveys distributed to 245 critical care units across the UK. RESULTS/FINDINGS Services with protected funding provided more daily input within critical care. This was most apparent for occupational therapy where daily input varied from 82.1% of units with protected services compared to just 10.3% in those without (p < 0.001). For all professions, most notably occupational therapy and speech and language therapy, protected services increased the regularity in which specific interventions were completed and had impact on involvement in nonclinical aspects of care including involved in multidisciplinary team meetings, clinical governance, and research. CONCLUSIONS The absence of protected AHP services reduces compliance with national standards for therapy workforce. Based on these findings, UK and international critical care guidelines should promote protected AHP services for critical care.
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Affiliation(s)
- Paul Twose
- School of Healthcare Sciences, Cardiff University, UK; Physiotherapy Department, Cardiff and Vale UHB, UK.
| | - Ella Terblanche
- Kings College London, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London SE1 8WA, UK.
| | - Una Jones
- School of Healthcare Sciences, Cardiff University, UK.
| | | | | | - Claire Rock
- Mid and South Essex NHS Foundation Trust, UK.
| | - Sarah Wallace
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, UK.
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13
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Broderick M, O'Shea R, Burridge J, Demain S, Johnson L, Bentley P. Examining Usability, Acceptability, and Adoption of a Self-Directed, Technology-Based Intervention for Upper Limb Rehabilitation After Stroke: Cohort Study. JMIR Rehabil Assist Technol 2023; 10:e45993. [PMID: 37603405 PMCID: PMC10477927 DOI: 10.2196/45993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/25/2023] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Upper limb (UL) recovery after stroke is strongly dependent upon rehabilitation dose. Rehabilitation technologies present pragmatic solutions to dose enhancement, complementing therapeutic activity within conventional rehabilitation, connecting clinicians with patients remotely, and empowering patients to drive their own recovery. To date, rehabilitation technologies have been poorly adopted. Understanding the barriers to adoption may shape strategies to enhance technology use and therefore increase rehabilitation dose, thus optimizing recovery potential. OBJECTIVE We examined the usability, acceptability, and adoption of a self-directed, exercise-gaming technology within a heterogeneous stroke survivor cohort and investigated how stroke survivor characteristics, technology usability, and attitudes toward technology influenced adoption. METHODS A feasibility study of a novel exercise-gaming technology for self-directed UL rehabilitation in early subacute stroke survivors (N=30) was conducted in an inpatient, acute hospital setting. Demographic and clinical characteristics were recorded; participants' performance in using the system (usability) was assessed using a 4-point performance rating scale (adapted from the Barthel index), and adherence with the system was electronically logged throughout the trial. The technology acceptance model was used to formulate a survey examining the acceptability of the system. Spearman rank correlations were used to examine associations between participant characteristics, user performance (usability), end-point technology acceptance, and intervention adherence (adoption). RESULTS The technology was usable for 87% (n=26) of participants, and the overall technology acceptance rating was 68% (95% CI 56%-79%). Participants trained with the device for a median of 26 (IQR 16-31) minutes daily over an enrollment period of 8 (IQR 5-14) days. Technology adoption positively correlated with user performance (usability) (ρ=0.55; 95% CI 0.23-0.75; P=.007) and acceptability as well as domains of perceived usefulness (ρ=0.42; 95% CI 0.09-0.68; P=.03) and perceived ease of use (ρ=0.46; 95% CI 0.10-0.74; P=.02). Technology acceptance decreased with increased global stroke severity (ρ=-0.56; 95% CI -0.79 to -0.22; P=.007). CONCLUSIONS This technology was usable and acceptable for the majority of the cohort, who achieved an intervention dose with technology-facilitated, self-directed UL training that exceeded conventional care norms. Technology usability and acceptability were determinants of adoption and appear to be mediated by stroke severity. The results demonstrate the importance of selecting technologies for stroke survivors on the basis of individual needs and abilities, as well as optimizing the accessibility of technologies for the target user group. Facilitating changes in stroke survivors' beliefs and attitudes toward rehabilitation technologies may enhance adoption. Further work is needed to understand how technology can be optimized to benefit those with more severe stroke.
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Affiliation(s)
- Michelle Broderick
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Robert O'Shea
- Department of Cancer Imaging, Kings College London, London, United Kingdom
| | - Jane Burridge
- School of Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Sara Demain
- School of Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Louise Johnson
- School of Life Sciences, University of Southampton, Southampton, United Kingdom
- University Hospitals Dorset NHS Foundation Trust, Bournemouth, United Kingdom
| | - Paul Bentley
- Department of Brain Sciences, Imperial College London, London, United Kingdom
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14
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Cormican A, Hirani SP, McKeown E. Healthcare professionals' perceived barriers and facilitators of implementing clinical practice guidelines for stroke rehabilitation: A systematic review. Clin Rehabil 2023; 37:701-712. [PMID: 36475911 PMCID: PMC10041573 DOI: 10.1177/02692155221141036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 10/26/2022] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
| | | | - Eamonn McKeown
- Health Services Research & Management Division, School of Health Sciences City, University of London, London, UK
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15
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Janssen H, Bird ML, Luker J, Sellar B, Berndt A, Ashby S, McCluskey A, Ada L, Blennerhassett J, Bernhardt J, Spratt NJ. Impairments, and physical design and culture of a rehabilitation unit influence stroke survivor activity: qualitative analysis of rehabilitation staff perceptions. Disabil Rehabil 2022; 44:8436-8441. [PMID: 35113761 DOI: 10.1080/09638288.2021.2019840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Heidi Janssen
- School of Health Sciences, University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute and Hunter New England Local Health District, New Lambton Heights, Australia
| | - Marie-Louise Bird
- School of Health Sciences, University of Tasmania, Launceston, Australia
| | - Julie Luker
- Allied Health & Human Performance, University of South Australia, Adelaide, Australia
| | - Ben Sellar
- Allied Health & Human Performance, University of South Australia, Adelaide, Australia
| | - Angela Berndt
- International Centre for Allied Health Evidence (iCAHE), Adelaide, Australia.,Occupational Therapy Australia (OTA), Fitzroy, Australia
| | - Samantha Ashby
- School of Health Sciences, University of Newcastle, Newcastle, Australia
| | - Annie McCluskey
- School of Health Sciences, The University of Sydney, Sydney, Australia.,The StrokeEd Collaboration, Sydney, Australia
| | - Louise Ada
- School of Health Sciences, The University of Sydney, Sydney, Australia
| | | | - Julie Bernhardt
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Recovery, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Melbourne Australia
| | - Neil J Spratt
- School of Biomedical Sciences and Pharmacy, University of Newcastle and Hunter New England Local Health District, New Lambton Heights, Australia
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16
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Moore SA, Boyne P, Fulk G, Verheyden G, Fini NA. Walk the Talk: Current Evidence for Walking Recovery After Stroke, Future Pathways and a Mission for Research and Clinical Practice. Stroke 2022; 53:3494-3505. [PMID: 36069185 PMCID: PMC9613533 DOI: 10.1161/strokeaha.122.038956] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Achieving safe, independent, and efficient walking is a top priority for stroke survivors to enable quality of life and future health. This narrative review explores the state of the science in walking recovery after stroke and potential for development. The importance of targeting walking capacity and performance is explored in relation to individual stroke survivor gait recovery, applying a common language, measurement, classification, prediction, current and future intervention development, and health care delivery. Findings are summarized in a model of current and future stroke walking recovery research and a mission statement is set for researchers and clinicians to drive the field forward to improve the lives of stroke survivors and their carers.
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Affiliation(s)
- Sarah A Moore
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK, and Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom (S.A.M.)
| | - Pierce Boyne
- Department of Rehabilitation Exercise and Nutritional Science, University of Cincinnati, OH (P.B.)
| | - George Fulk
- Department of Rehabilitation Medicine, Emory University, Atlanta, GA (G.F.)
| | - Geert Verheyden
- Department of Rehabilitation Sciences, KU Leuven, University of Leuven, Belgium (G.V.)
| | - Natalie A Fini
- Medicine Dentistry and Health Sciences, The University of Melbourne, Australia (N.A.F.)
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17
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Roberts S, Bruce RM, Lim L, Woodgate H, Ledingham K, Anderson S, Lorca-Puls DL, Gajardo-Vidal A, Leff AP, Hope TMH, Green DW, Crinion JT, Price CJ. Better long-term speech outcomes in stroke survivors who received early clinical speech and language therapy: What's driving recovery? Neuropsychol Rehabil 2022; 32:2319-2341. [PMID: 34210238 DOI: 10.1080/09602011.2021.1944883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Establishing whether speech and language therapy after stroke has beneficial effects on speaking ability is challenging because of the need to control for multiple non-therapy factors known to influence recovery. We investigated how speaking ability at three time points post-stroke differed in patients who received varying amounts of clinical therapy in the first month post-stroke. In contrast to prior studies, we factored out variance from: initial severity of speaking impairment, amount of later therapy, and left and right hemisphere lesion size and site. We found that speaking ability at one month post-stroke was significantly better in patients who received early therapy (n = 79), versus those who did not (n = 64), and the number of hours of early therapy was positively related to recovery at one year post-stroke. We offer two non-mutually exclusive interpretations of these data: (1) patients may benefit from the early provision of self-management strategies; (2) therapy is more likely to be provided to patients who have a better chance of recovery (e.g., poor physical and/or mental health may impact suitability for therapy and chance of recovery). Both interpretations have implications for future studies aiming to predict individual patients' speech outcomes after stroke, and their response to therapy.
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Affiliation(s)
- Sophie Roberts
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - Rachel M Bruce
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - Louise Lim
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - Hayley Woodgate
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - Kate Ledingham
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - Storm Anderson
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - Diego L Lorca-Puls
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - Andrea Gajardo-Vidal
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK.,Faculty of Health Sciences, Universidad del Desarrollo, Concepcion, Chile
| | - Alexander P Leff
- Institute of Cognitive Neuroscience, University College London, London, UK.,Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Thomas M H Hope
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - David W Green
- Department of Experimental Psychology, University College London, London, UK
| | - Jennifer T Crinion
- Institute of Cognitive Neuroscience, University College London, London, UK
| | - Cathy J Price
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
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18
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Moore SA, Flynn D, Jones S, Price CIM, Avery L. Feasibility, acceptability, and fidelity of Physical Activity Routines After Stroke (PARAS): a multifaceted behaviour change intervention targeting free-living physical activity and sedentary behaviour in community-dwelling adult stroke survivors. Pilot Feasibility Stud 2022; 8:197. [PMID: 36057723 PMCID: PMC9440503 DOI: 10.1186/s40814-022-01139-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low levels of habitual physical activity and high levels of sedentary behaviour are commonly observed post-stroke. We aimed to assess the feasibility, acceptability and fidelity of a multifaceted, theory- and evidence-informed supported self-management intervention targeting physical activity and sedentary behaviour after stroke: Physical Activity Routines After Stroke (PARAS). METHODS Adult stroke survivors and healthcare professionals were recruited from North East England stroke services. Stroke survivor physical activity and sedentary behaviour were targeted by a self-management behavioural intervention supported by healthcare professionals trained in intervention delivery. The main outcomes were protocol and intervention acceptability and feasibility and fidelity of intervention delivery. RESULTS Eleven healthcare professionals (9 physiotherapists; 2 occupational therapists) participated in the study. Stroke survivor recruitment was lower than anticipated (19 versus target of up to 35). The healthcare professional training programme was feasible, with fidelity assessment of delivery supporting this finding. Data completeness was acceptable according to a priori criteria (>60%), except for stroke survivor questionnaire return rate (59%) and interview uptake (52%). No serious adverse events occurred. Healthcare professionals and stroke survivors perceived intervention delivery to be feasible and acceptable with minor modifications highlighted including the potential for earlier delivery in the stroke pathway. CONCLUSIONS The study protocol and intervention delivery were feasible and acceptable to stroke survivors and healthcare professionals with modifications required before large-scale evaluation. TRIAL REGISTRATION ISRCTN35516780 . Registered on October 24, 2018.
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Affiliation(s)
- Sarah A Moore
- Stroke Research Group, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK. .,Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Shields, Tyne and Wear, NE29 8NH, UK. .,Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK.
| | - Darren Flynn
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK
| | - Susan Jones
- Centre for Rehabilitation, School of Health & Life Sciences, Teesside University, Middlesbrough, TS1 3BX, UK
| | | | - Leah Avery
- Centre for Rehabilitation, School of Health & Life Sciences, Teesside University, Middlesbrough, TS1 3BX, UK
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19
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Aloraini SM. Effects of constraint-induced movement therapy for the lower extremity among individuals post-stroke: A randomized controlled clinical trial. NeuroRehabilitation 2022; 51:421-431. [DOI: 10.3233/nre-220139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Stroke often leads to lower extremity impairments that significantly hinders functional recovery. OBJECTIVE: To investigate the effectiveness of constraint-induced movement therapy for the lower extremity (CIMT-LE) for improving balance and ambulation among people post-stroke. METHODS: A randomized controlled, single-blinded clinical trial was conducted. Participants were recruited and randomized into one of two groups: CIMT-LE group and control. Outcome measures were the Fugl-Meyer assessment of lower extremity, Berg balance scale, ten-meter walk test and six-minute walk test. Outcome measures were collected at baseline, following the conclusion of the therapeutic programs and after three months. RESULTS: 38 participants were enrolled in the study (19 in each group). No significant differences were found between groups at baseline. At the conclusion of therapeutic programs, both groups showed significant changes compared to baseline. However, changes seen in the CIMT-LE were clinically significant. Further, at three months following the conclusion of the program, the recorded improvements were retained by participants. CONCLUSION: A CIMT-LE program compared to an intensity-matched conventional program yielded significant clinical improvements among people post-stroke. These improvements were seen in lower extremity motor recovery, postural balance and gait speed. Furthermore, these improvements were retained three months following the conclusion of the therapeutic program.
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Affiliation(s)
- Saleh M. Aloraini
- Department of Physical Therapy, College of Medical Rehabilitation, Qassim University, Buraydah 51452, Saudi Arabia
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20
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Aliprandi M, Pan Y, Mosley C, Gough S. What is the cost of including virtual reality in neurological rehabilitation? A scoping review. PHYSICAL THERAPY REVIEWS 2022. [DOI: 10.1080/10833196.2022.2094102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Martina Aliprandi
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Yvonne Pan
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Chiara Mosley
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK
| | - Suzanne Gough
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
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21
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Baker A, Cornwell P, Gustafsson L, Stewart C, Lannin NA. Developing tailored theoretically informed goal-setting interventions for rehabilitation services: a co-design approach. BMC Health Serv Res 2022; 22:811. [PMID: 35733190 PMCID: PMC9214993 DOI: 10.1186/s12913-022-08047-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/21/2022] [Indexed: 11/11/2022] Open
Abstract
Background Several active ingredients contribute to the purposes and mechanisms of goal-setting in rehabilitation. Active ingredients in the goal-setting process include, interdisciplinary teamworking, shared decision-making, having meaningful and specific goals, and including action planning, coping planning, feedback, and review. Clinicians have expressed barriers and enablers to implementing these active ingredients in rehabilitation teams. Interventions designed to improve goal-setting practices need to be tailored to address context specific barriers and enablers. Attempts to understand and enhance goal-setting practices in rehabilitation settings should be supported using theory, process models and determinant frameworks. Few studies have been undertaken to enhance goal-setting practices in varied case-mix rehabilitation settings. Methods This study is part of a larger program of research guided by the Knowledge to Action (KTA) framework. A multisite, participatory, codesign approach was used in five sites to address three stages of the KTA. (1) Focus groups were conducted to understand barriers and enablers to implementing goal-setting at each site. Following the focus groups three staff co-design workshops and one consumer workshop were run at each site to (2) adapt knowledge to local context, and to (3) select and tailor interventions to improve goal-setting practices. Focus groups were analysed using the Theoretical Domains Framework (TDF) and informed the selection of behaviour change techniques incorporated into the implementation plan. Results Barriers and enablers identified in this study were consistent with previous research. Clinicians lacked knowledge and understanding of the differences between a goal and an action plan often confusing both terms. Clinicians were unable to demonstrate an understanding of the importance of comprehensive action planning and review processes that extended beyond initial goal-setting. Interventions developed across the sites included staff training modules, a client held workbook, educational rehabilitation service flyers, interdisciplinary goal-based case conference templates, communication goal boards and a key worker model. Implementation plans were specifically established for each site. Conclusions Rehabilitation teams continue to struggle to incorporate a truly client-centred, interdisciplinary model of goal-setting in rehabilitation. Whilst clinicians continue to lack understanding of how they can use aspects of goal-setting to enhance client outcomes and autonomy in rehabilitation settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08047-6.
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Affiliation(s)
- Amanda Baker
- School of Allied Health Sciences, Griffith University, Brisbane, Australia. .,Clinical Excellence Division, Statewide Rehabilitation Clinical Network, Queensland Health, Brisbane, Australia. .,Physiotherapy Department, Sunshine Coast University Hospital, Allied Health, Sunshine Coast Hospital and Health Service, Sunshine Coast, QLD, Australia.
| | - Petrea Cornwell
- School of Allied Health Sciences, Griffith University, Brisbane, Australia
| | - Louise Gustafsson
- School of Allied Health Sciences, Griffith University, Brisbane, Australia
| | - Claire Stewart
- Physiotherapy Department, Sunshine Coast University Hospital, Allied Health, Sunshine Coast Hospital and Health Service, Sunshine Coast, QLD, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia.,Alfred Health, Melbourne, Australia
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22
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Teng CH, Phonyiam R, Davis LL, Anderson RA. Adaptation to poststroke fatigue in stroke survivors and their care partners: a scoping review. Disabil Rehabil 2022:1-15. [PMID: 35723869 DOI: 10.1080/09638288.2022.2084775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE Fatigue is a long-term symptom for stroke survivors. This scoping review synthesized how survivors achieve fatigue adaptation. METHODS Four databases were searched for studies between 2012 and 2021. Qualitative studies or qualitative findings from mixed-methods studies were included if they described survivors' experiences with fatigue and/or care partners' experiences in helping survivors adapt to fatigue. Studies were excluded if they were poster abstracts, reviews, or editorials. RESULTS Thirty-six articles were analyzed. Survivors with fatigue described different adaptive challenges - fatigue made them less productive, brought emotional distress, and was indiscernible to others. To respond to these challenges, stroke survivors did adaptive work including conserving energy, changing mindset, and restructuring normality. Care partners, employers, and colleagues showed adaptive leadership by adjusting daily routines or role responsibilities. Most survivors described that the current clinical practice did not meet their needs to address fatigue. CONCLUSIONS Stroke survivors had many types of challenges and strategies for fatigue adaptation. Survivors received family, employer, and colleague support but how care partners help survivors develop new skills is unknown. Stroke survivors expressed that healthcare professionals need to teach survivors and care partners basic knowledge of fatigue that meet their personal needs and provide adaptive interventions for survivors. Implications for rehabilitationThe challenges of poststroke fatigue are multifaceted because fatigue influences stroke survivors' physical, cognitive, mental, and social aspects of recovery.Stroke survivors need support from their care partners such as helping them adapt to the fatigue, adapt to new life routine, and adjust role responsibilities.Healthcare professionals, stroke survivors, and care partners need to work together to develop strategies about poststroke fatigue that meet stroke survivors' personal needs.
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Affiliation(s)
- Chiao-Hsin Teng
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ratchanok Phonyiam
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Leslie L Davis
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ruth A Anderson
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Thompson N, Bloska J, Abington A, Masterson A, Whitten D, Street A. The Feasibility and Acceptability of Neurologic Music Therapy in Subacute Neurorehabilitation and Effects on Patient Mood. Brain Sci 2022; 12:brainsci12040497. [PMID: 35448028 PMCID: PMC9029413 DOI: 10.3390/brainsci12040497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
Music interventions support functional outcomes, improve mood, and reduce symptoms of depression in neurorehabilitation. Neurologic music therapy (NMT) has been reported as feasible and helpful in stroke rehabilitation but is not commonly part of multidisciplinary services in acute or subacute settings. This study assessed the feasibility and acceptability of delivering NMT one-day-per-week in a subacute neurorehabilitation centre over 15 months. Data were collected on the number of referrals, who referred, sessions offered, attended, and declined, and reasons why. Staff, patients, and their relatives completed questionnaires rating the interventions. Patients completed the Visual Analog Mood Scales (VAMS) pre and post a single session. Forty-nine patients received 318 NMT sessions (83% of sessions offered). NMT was rated as helpful or very helpful as part of the multidisciplinary team (n = 36). The highest ratings were for concentration, arm and hand rehabilitation, and motivation and mood. VAMS scores (n = 24) showed a reduction in ‘confused’ (−8.6, p = 0.035, effect size 0.49) and an increase in ‘happy’ (6.5, p = 0.021, effect size = 0.12) post NMT. The data suggest that a one-day-per-week NMT post in subacute neurorehabilitation was feasible, acceptable, and helpful, supporting patient engagement in rehabilitation exercises, mood, and motivation.
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Affiliation(s)
- Naomi Thompson
- Cambridge Institute for Music Therapy Research, Anglia Ruskin University, Cambridge CB1 1PT, UK; (J.B.); (A.S.)
- Correspondence:
| | - Jodie Bloska
- Cambridge Institute for Music Therapy Research, Anglia Ruskin University, Cambridge CB1 1PT, UK; (J.B.); (A.S.)
| | - Alison Abington
- The Marbrook Centre, St Neots PE19 8EP, UK; (A.A.); (A.M.); (D.W.)
| | - Amber Masterson
- The Marbrook Centre, St Neots PE19 8EP, UK; (A.A.); (A.M.); (D.W.)
| | - David Whitten
- The Marbrook Centre, St Neots PE19 8EP, UK; (A.A.); (A.M.); (D.W.)
| | - Alexander Street
- Cambridge Institute for Music Therapy Research, Anglia Ruskin University, Cambridge CB1 1PT, UK; (J.B.); (A.S.)
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Dür M, Wenzel C, Simon P, Tucek G. Patients' and professionals' perspectives on the consideration of patients' convenient therapy periods as part of personalised rehabilitation: a focus group study with patients and therapists from inpatient neurological rehabilitation. BMC Health Serv Res 2022; 22:372. [PMID: 35313879 PMCID: PMC8939130 DOI: 10.1186/s12913-022-07755-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/07/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Research on the optimal period for administering health services, especially rehabilitation interventions, is scarce. The aims of this study were to explore the construct of patients' convenient therapy periods and to identify indicators based on the perspectives of patients and different health professionals from inpatient neurological rehabilitation clinics. METHODS This study was part of a larger project on patients' convenient therapy periods following a mixed methods approach. In the current study a grounded theory approach was employed based on the use of focus group interviews. Focus group interviews were conducted in three different inpatient neurological rehabilitation clinics. Patients and therapists from inpatient neurological rehabilitation clinics who were able to speak and to participate in conversations were included. RESULTS A total of 41 persons, including 23 patients and 18 therapists, such as music and occupational therapists, participated in a total of six focus group interviews. The analysis of the focus group interviews resulted in the identification of a total of 1261 codes, which could be summarised in fifteen categories. However, these categories could be divided into five indicators and ten impact factors of convenient therapy periods. Identified indicators were verbal and non-verbal communication, mental functions, physiological needs, recreational needs, and therapy initiation. CONCLUSIONS The results provide initial evidence that convenient therapy periods are clinically relevant for patients and therapists. Different states of patients' ability to effectively participate in a rehabilitation intervention exist. A systematic consideration of patients' convenient therapy periods could contribute to a personalised and more efficient delivery of intervention in neurological rehabilitation. To our knowledge, this study is one of the first attempts to research convenient therapy periods.
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Affiliation(s)
- Mona Dür
- Department of Health Sciences, IMC University of Applied Sciences, Applied Health Sciences Master Degree Programme, Piaristengasse 1, 3500, Krems, Austria. .,IMC University of Applied Sciences, Josef Ressel Centre for Horizons of personalised music therapy, University of Applied Sciences Krems, Piaristengasse 1, 3500, Krems, Austria. .,Duervation, Spitalgasse 6/1, 3500, Krems, Austria.
| | - Claudia Wenzel
- IMC University of Applied Sciences, Josef Ressel Centre for Horizons of personalised music therapy, University of Applied Sciences Krems, Piaristengasse 1, 3500, Krems, Austria.,Department of Health Sciences, IMC University of Applied Sciences, Music Therapy Bachelor and Master Degree Programme, Piaristengasse 1, 3500, Krems, Austria
| | - Patrick Simon
- IMC University of Applied Sciences, Josef Ressel Centre for Horizons of personalised music therapy, University of Applied Sciences Krems, Piaristengasse 1, 3500, Krems, Austria.,Department of Health Sciences, IMC University of Applied Sciences, Music Therapy Bachelor and Master Degree Programme, Piaristengasse 1, 3500, Krems, Austria
| | - Gerhard Tucek
- IMC University of Applied Sciences, Josef Ressel Centre for Horizons of personalised music therapy, University of Applied Sciences Krems, Piaristengasse 1, 3500, Krems, Austria.,Department of Health Sciences, IMC University of Applied Sciences, Music Therapy Bachelor and Master Degree Programme, Piaristengasse 1, 3500, Krems, Austria
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25
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Logan A, Freeman J, Kent B, Pooler J, Creanor S, Enki D, Vickery J, Barton A, Marsden J. Functional standing frame programme early after severe sub-acute stroke (SPIRES): a randomised controlled feasibility trial. Pilot Feasibility Stud 2022; 8:50. [PMID: 35241176 PMCID: PMC8892736 DOI: 10.1186/s40814-022-01012-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 02/20/2022] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Angela Logan
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK. .,Stroke Rehabilitation Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Jennifer Freeman
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK
| | - Bridie Kent
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK
| | - Jill Pooler
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK
| | - Siobhan Creanor
- Peninsula Clinical Trials Unit, Faculty of Health, University of Plymouth, Plymouth, UK.,Medical Statistics, Faculty of Health, University of Plymouth, Plymouth, UK.,Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Doyo Enki
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Jane Vickery
- Peninsula Clinical Trials Unit, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Andrew Barton
- NIHR Research Design Service, Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Jonathan Marsden
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK
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26
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Kenah K, Bernhardt J, Spratt NJ, Oldmeadow C, Janssen H. Depression and a lack of socialization are associated with high levels of boredom during stroke rehabilitation: An exploratory study using a new conceptual framework. Neuropsychol Rehabil 2022; 33:497-527. [PMID: 35142257 DOI: 10.1080/09602011.2022.2030761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Katrina Kenah
- School of Health Sciences, The University of Newcastle, Newcastle, Australia.,Monash Health, Cheltenham, Australia
| | - Julie Bernhardt
- The Florey Institute of Neuroscience and Mental Health, NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Heidelberg, Australia
| | - Neil J Spratt
- Hunter Medical Research Institute, NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, The University of Newcastle, Newcastle, Australia.,Department Neurology, John Hunter Hospital, Newcastle, Australia
| | | | - Heidi Janssen
- Hunter Medical Research Institute, NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, The University of Newcastle, Newcastle, Australia.,Hunter Stroke Service, Hunter New England Local Health District, Newcastle, Australia
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27
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Yan Q, Wang X, Zhang Y, Zhang H, Zhao L. Analysis of influencing factors of rehabilitation treatment effect in patients with first-episode stroke. Am J Transl Res 2021; 13:14046-14056. [PMID: 35035747 PMCID: PMC8748090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/30/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To explore the influencing factors of rehabilitation treatment effect in patients with first-episode stroke and provide a theoretical basis for clinical practice. METHODS The clinical data of patients with first-episode stroke who received rehabilitation treatment in our hospital from January 2015 to January 2019 were collected and analyzed retrospectively. The Modified Barthel Index (MBI) and Frenchay Activity Scale (FAS) were used to evaluate the rehabilitation treatment effect. Spearman rank correlation analysis was carried out to investigate the relationship between the data characteristics and rehabilitation treatment effect, and univariate and multivariate logistic regression analyses were conducted to explore the independent factors influencing the rehabilitation treatment effect in the first-episode stroke group. RESULTS In this study, 786 cases of 873 patients with first-episode stroke were included, with an effective inclusion rate of 90.0%. Univariate analysis showed that MBI and FAS scores were statistically different among patients with different ages, history of hypertension, the number of residual symptoms, depression status, attitude towards rehabilitation, starting time of rehabilitation, rehabilitation treatment duration, and family environment scores (all P<0.05). According to the Spearman rank correlation analysis, age, residual symptoms, depressive status, and starting time of rehabilitation were all negatively correlated with MBI score (r = -0.584, -0.683, -0.573, -0.783) and FAS score (r = -0.438, -0.771, -0.552, -0.599), while the scores of MBI (r = 0.683, 0.572, 0.662) and FAS (r = 0.735, 0.603, 0.724) were positively correlated with the scores of rehabilitation treatment attitude, rehabilitation treatment duration and family environment (all P<0.05). Moreover, according to multivariate logistic regression analysis, age, the number of remaining symptoms, depression status, attitude towards rehabilitation treatment, starting time of rehabilitation treatment, rehabilitation treatment duration, and family environment score could independently affect MBI and FAS scores of patients with stroke (all P<0.05). CONCLUSION Age, the number of residual symptoms, depression status, attitude towards rehabilitation treatment, starting time of rehabilitation treatment, rehabilitation treatment duration, and family environment score are independent factors for rehabilitation treatment effect in patients with first-episode stroke.
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Affiliation(s)
- Qianfeng Yan
- Tongren Hospital Affiliated to Medical College of Shanghai Jiaotong University Shanghai 200336, China
| | - Xiangming Wang
- Tongren Hospital Affiliated to Medical College of Shanghai Jiaotong University Shanghai 200336, China
| | - Yun Zhang
- Tongren Hospital Affiliated to Medical College of Shanghai Jiaotong University Shanghai 200336, China
| | - Huijun Zhang
- Tongren Hospital Affiliated to Medical College of Shanghai Jiaotong University Shanghai 200336, China
| | - Lipeng Zhao
- Tongren Hospital Affiliated to Medical College of Shanghai Jiaotong University Shanghai 200336, China
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28
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Dynamic Analysis of a Spherical Parallel Robot Used for Brachial Monoparesis Rehabilitation. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app112411849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This paper presents studies on the dynamic analysis of the ASPIRE robot, which was designed for the medical recovery of brachial monoparesis. It starts from the virtual model of the existing version of the ASPIRE robot, which is analysed kinematically and dynamically by numerical simulations using the MSC.ADAMS software. For this purpose, this paper presents theoretical aspects regarding the kinematics and dynamics of the markers attached to the flexible bodies built in a specifically developed MSC.ADAMS model. Three simulation hypotheses are considered: (a) rigid kinematic elements without friction in couplings, (b) rigid kinematic elements with friction in couplings, and (c) kinematic elements as deformable solids with friction in couplings. Experimental results obtained by using the physical prototype of ASPIRE are presented. Results such as the connecting forces in the kinematic joints and the torques necessary to operate the ASPIRE robot modules have been obtained by dynamic simulation in MSC.ADAMS and compared with those determined experimentally. The comparison shows that the allure of the variation curve of the moment obtained by simulation is similar to that obtained experimentally. The difference between the maximum experimental value and that obtained by simulation is less than 1%. A finite element analysis (FEA) of the structurally optimized flexion/extension robot module is performed. The results demonstrate the operational safety of the ASPIRE robot, which is structurally capable of supporting the stresses to which it is subjected.
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29
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Tay SS, Visperas CA, Bin Zainul Abideen A, Tan MMJ, Zaw EM, Lai H, Neo EJR. Effectiveness of Adjunct Robotic Therapy With a Patient-Guided Suspension System for Stroke Rehabilitation Using a 7-Days-a-Week Model of Care: A Comparison With Conventional Rehabilitation. Arch Rehabil Res Clin Transl 2021; 3:100144. [PMID: 34589694 PMCID: PMC8463454 DOI: 10.1016/j.arrct.2021.100144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To determine and compare the effectiveness of robotic therapy with a patient-guided suspension system for stroke rehabilitation using a 7-days-a-week model of care with that of conventional rehabilitation. Design Retrospective cohort study. Setting Inpatient rehabilitation unit of an acute general hospital. Participants A total of 100 consecutive patients with stroke (N=100) admitted within a 7-month period who fulfilled the criteria to undergo robotic therapy with a patient-guided suspension system were enrolled in this study. Interventions Patients either underwent robotic therapy in addition to conventional therapy (robotic group) or conventional therapy only (control group). There were 50 patients in each cohort. Main Outcome Measures FIM and its derivatives (FIM gain and FIM efficiency); Berg Balance Scale (BBS), functional ambulation category (FAC); modified Rankin Scale (mRS); and National Institutes of Health Stroke Scale. Results The average FIM gains in both groups were statistically significant (P<.01). The robotic group had greater improvement in FAC scores (1.24 vs 0.78, P=.007). However, other measurements such as FIM efficiency, BBS, and mRS were not significantly different between the 2 groups. The robotics group reported high patient satisfaction rates, with most patients finding the intervention both beneficial and desirable. Conclusions Adjunct robotic therapy has the potential to increase the efficacy of stroke rehabilitation. However, further studies are needed to strengthen the evidence.
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Affiliation(s)
- San San Tay
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore
- Corresponding author San San Tay, MBBS, Department of Rehabilitation Medicine, Changi General Hospital, 2 Simei St 3, Singapore 529889.
| | | | | | - Mark Min Jian Tan
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore
| | - Ei Mon Zaw
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore
| | - Hsuan Lai
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore
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30
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Broderick M, Almedom L, Burdet E, Burridge J, Bentley P. Self-Directed Exergaming for Stroke Upper Limb Impairment Increases Exercise Dose Compared to Standard Care. Neurorehabil Neural Repair 2021; 35:974-985. [PMID: 34449290 PMCID: PMC8593287 DOI: 10.1177/15459683211041313] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background. One of the strongest modifiable determinants of rehabilitation outcome is exercise dose. Technologies enabling self-directed exercise offer a pragmatic means to increase dose, but the extent to which they achieve this in unselected cohorts, under real-world constraints, is poorly understood. Objective. Here we quantify the exercise dose achieved by inpatient stroke survivors using an adapted upper limb (UL) exercise gaming (exergaming) device and compare this with conventional (supervised) therapy. Methods. Over 4 months, patients presenting with acute stroke and associated UL impairment were screened at a single stroke centre. Participants were trained in a single session and provided with the device for unsupervised use during their inpatient admission. Results. From 75 patients referred for inpatient UL therapy, we recruited 30 (40%), of whom 26 (35%) were able to use the device meaningfully with their affected UL. Over a median enrolment time of 8 days (IQR: 5–14), self-directed UL exercise duration using the device was 26 minutes per day (median; IQR: 16–31), in addition to 25 minutes daily conventional UL therapy (IQR: 12–34; same cohort plus standard care audit; joint n = 50); thereby doubling total exercise duration (51 minutes; IQR: 32–64) relative to standard care (Z = 4.0, P <.001). The device enabled 104 UL repetitions per day (IQR: 38–393), whereas conventional therapy achieved 15 UL repetitions per day (IQR: 11–23; Z = 4.3, P <.001). Conclusion. Self-directed adapted exergaming enabled participants in our stroke inpatient cohort to increase exercise duration 2-fold, and repetitions 8-fold, compared to standard care, without requiring additional professional supervision.
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Affiliation(s)
- Michelle Broderick
- Department of Brain Sciences, 4615Imperial College London, Charing Cross Hospital Campus, London, UK
| | - Leeza Almedom
- Department of Brain Sciences, 4615Imperial College London, Charing Cross Hospital Campus, London, UK
| | - Etienne Burdet
- Department. of Bioengineering, Human Robotics Group, Imperial College, South Kensington Campus, London, UK
| | - Jane Burridge
- Department of Restorative Neuroscience, University of Southampton, Southampton, UK
| | - Paul Bentley
- Department of Brain Sciences, 4615Imperial College London, Charing Cross Hospital Campus, London, UK
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31
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McGlinchey MP, McKevitt C, Faulkner-Gurstein R, Sackley CM. The rehabilitation of physical function after severely disabling stroke: a survey of UK therapist practice. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2021. [DOI: 10.12968/ijtr.2020.0143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/aims Individuals who are severely disabled from stroke (survivors of severely disabling stroke) experience poorer outcomes compared to those who are less disabled from stroke. However, there is a paucity of evidence describing current therapy practice in the management of severely disabling stroke. The aim of the study was to describe intervention and outcome measure use by physiotherapists and occupational therapists in the rehabilitation of physical function of survivors of severely disabling stroke. Methods A mixed-methods survey was conducted, involving an online questionnaire and follow-up interviews. Survey participants were UK-based physiotherapists and occupational therapists with experience treating stroke. Questionnaire data were analysed with descriptive and inferential statistics. Interview data were analysed using content analysis. Results A total of 452 therapists (59% physiotherapists) responded to the questionnaire. Out of the respondents, 18 self-selected therapists participated in follow-up interviews to explain questionnaire data. Whole body positioning, training of upper limb handling and positioning, and sitting balance practice were the most frequently used interventions. Inpatient-based therapists performed more active rehabilitation interventions, whereas community-based therapists performed more training and education. The Barthel Index, Modified Rankin Scale and National Institutes for Health Stroke Scale were the most frequently used outcome measures. Outcome measure use was generally low and was more likely to be completed when it was part of a national audit. Reasons for low outcome measure use were perceived lack of time and insensitivity to detect clinical change. Conclusions A variety of interventions and outcome measures are used in the rehabilitation of survivors of severely disabling stroke. There is a need to evaluate the effectiveness of frequently used interventions and identify outcome measures that are sensitive to the needs of survivors of severely disabling stroke.
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Affiliation(s)
- Mark P McGlinchey
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Physiotherapy Department, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher McKevitt
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Rachel Faulkner-Gurstein
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Catherine M Sackley
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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32
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de Jong AU, Smith M, Callisaya ML, Schmidt M, Simpson DB. Sedentary time and physical activity patterns of stroke survivors during the inpatient rehabilitation week. Int J Rehabil Res 2021; 44:131-137. [PMID: 33724969 DOI: 10.1097/mrr.0000000000000461] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Physical activity is recommended after stroke. However, the rehabilitation day is largely spent sedentary. Understanding patterns of physical activity across the rehabilitation week may help identify opportunities to improve participation. We aimed to examine: (1) differences between weekday and weekend sedentary time and physical activity, (2) the pattern of 24-h rehabilitation activity. Participants with stroke (n = 29) wore an activity monitor continuously during the final 7-days of inpatient rehabilitation. Linear mixed models (adjusted for waking hours) were performed with activity (sedentary, steps per day, walking time) as the dependent variable, and day type (weekday or weekend) as the independent variable. Patterns of upright time during the 24-h period were determined by averaging daily activity in 60-min intervals and generating a heat map of activity levels as a function of time. Participant mean age was 69 (SD 13) years (52% male) and mean National Institutes of Health Stroke Scale score was 7.0 (SD, 5.5). There was no significant difference in sedentary time between weekdays and weekends. At the weekend, participants spent 8.4 min less time walking (95% CI, -12.1 to -4.6) taking 624 fewer steps/day (95% CI, -951 to -296) than during the week. Activity patterns showed greatest upright time in the morning during the week. Afternoon and evening activities were low on all days. Sedentary time did not change across the 7-day rehabilitation week, but less walking activity occurred on the weekend. There are opportunities for stroke survivors to increase physical activity during afternoons and evenings and on weekend mornings during rehabilitation.
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Affiliation(s)
- Amy U de Jong
- Physiotherapy Department, Royal Hobart Hospital, Hobart, Tasmania
| | - Moira Smith
- College of Healthcare Sciences, James Cook University, Townsville
| | - Michele L Callisaya
- Menzies Institute for Medical Research, University of Tasmania, Hobart
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria
| | - Matthew Schmidt
- School of Health Sciences, University of Tasmania, Hobart, Tasmania
| | - Dawn B Simpson
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, New South Wales, Australia
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33
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Doogan C, Leff AP. The cost to see the Wizard: buy-ins and trade-offs in neurological rehabilitation. Brain 2021; 144:1627-1628. [PMID: 33974065 DOI: 10.1093/brain/awab169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This scientific commentary refers to ‘A decision-neuroscientific intervention to improve cognitive recovery after stroke’ by Studer et al. (doi:10.1093/brain/awab128).
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Affiliation(s)
| | - Alex P Leff
- UCL Queen Square Institute of Neurology, London, UK
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34
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Janssen H, Ada L, Middleton S, Pollack M, Nilsson M, Churilov L, Blennerhassett J, Faux S, New P, McCluskey A, Spratt NJ, Bernhardt J. Altering the rehabilitation environment to improve stroke survivor activity: A Phase II trial. Int J Stroke 2021; 17:299-307. [PMID: 33739202 DOI: 10.1177/17474930211006999] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Environmental enrichment involves organization of the environment and provision of equipment to facilitate engagement in physical, cognitive, and social activities. In animals with stroke, it promotes brain plasticity and recovery. AIMS To assess the feasibility and safety of a patient-driven model of environmental enrichment incorporating access to communal and individual environmental enrichment. METHODS A nonrandomized cluster trial with blinded measurement involving people with stroke (n = 193) in four rehabilitation units was carried out. Feasibility was operationalized as activity 10 days after admission to rehabilitation and availability of environmental enrichment. Safety was measured as falls and serious adverse events. Benefit was measured as clinical outcomes at three months, by an assessor blinded to group. RESULTS The experimental group (n = 91) spent 7% (95% CI -14 to 0) less time inactive, 9% (95% CI 0-19) more time physically, and 6% (95% CI 2-10) more time socially active than the control group (n = 102). Communal environmental enrichment was available 100% of the time, but individual environmental enrichment was rarely within reach (24%) or sight (39%). There were no between-group differences in serious adverse events or falls at discharge or three months or in clinical outcomes at three months. CONCLUSIONS This patient-driven model of environmental enrichment was feasible and safe. However, the very modest increase in activity by people with stroke, and the lack of benefit in clinical outcomes three months after stroke do not provide justification for an efficacy trial.
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Affiliation(s)
- Heidi Janssen
- 5260Hunter New England Local Health District, Australia.,Hunter Medical Research Institute, Australia.,College of Health, Medicine and Wellbeing, University of Newcastle, Australia
| | - Louise Ada
- Faculty of Medicine and Health, University of Sydney, Australia
| | - Sandy Middleton
- Faculty of Health Sciences Department, Nursing Research Institute, Australia.,Department of Medicine, University of Melbourne, Australia
| | - Michael Pollack
- 5260Hunter New England Local Health District, Australia.,Hunter Medical Research Institute, Australia.,College of Health, Medicine and Wellbeing, University of Newcastle, Australia
| | - Michael Nilsson
- Hunter Medical Research Institute, Australia.,College of Health, Medicine and Wellbeing, University of Newcastle, Australia
| | | | | | - Steven Faux
- Departments of Rehabilitation Medicine and Pain Medicine, St Vincent's Hospital, Australia
| | - Peter New
- Department of Medicine & Rehabilitation and Aged Services Program, 2538Monash Health, Australia.,Monash Medical School & Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Australia
| | - Annie McCluskey
- Faculty of Medicine and Health, University of Sydney, Australia
| | - Neil J Spratt
- 5260Hunter New England Local Health District, Australia.,Hunter Medical Research Institute, Australia.,College of Health, Medicine and Wellbeing, University of Newcastle, Australia
| | - Julie Bernhardt
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia
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James J, McGlinchey MP. How active are stroke patients in physiotherapy sessions and is this associated with stroke severity? Disabil Rehabil 2021; 44:4408-4414. [PMID: 33794718 DOI: 10.1080/09638288.2021.1907459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Exercise improves functional outcome post-stroke, but how long patients with differing severity spend undertaking active exercise within physiotherapy sessions is unknown. We aimed to investigate if stroke severity is associated with time undertaking active exercise in physiotherapy sessions, and if any differences between planned and actual physiotherapy session length existed. MATERIALS AND METHODS A prospective observational study of 107 stroke rehabilitation sessions in a UK acute stroke unit. Data recorded included patient demographics (age, gender, time post-stroke and Barthel Index score) and session attributes (planned and actual session length, time undertaking active exercise, grade of treating therapist). RESULTS There was a significant negative association between increasing stroke severity and percentage of time undertaking active exercise in physiotherapy sessions (p < 0.001). No other observed factors were associated with time undertaking active exercise. Mean session length across all levels of stroke severity was 32 min (SD 9.26) which was significantly less than planned (p < 0.05). There was no difference in mean session length or between planned and actual physiotherapy session length between patients of differing severity. CONCLUSIONS Patients with greater stroke severity participate in less active exercise in physiotherapy sessions than those with lesser stroke severity. Reasons for this disparity warrant further investigation.Implications for rehabilitationStroke patients with higher levels of severity engage in less active exercise during rehabilitation.A discrepancy exists between patients' planned physiotherapy session lengths and actual session lengths during stroke rehabilitation.Physiotherapists should be mindful in how to adapt their sessions (particularly with severe stroke patients) to maximise the amount of activity they undertake.Physiotherapists should be flexible in their delivery of rehabilitation to ensure that the length of patient sessions reflect patients' needs.
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Affiliation(s)
- Jimmy James
- Department of Physiotherapy, St. Thomas' Hospital, London, UK
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Gittins M, Lugo-Palacios D, Vail A, Bowen A, Paley L, Bray B, Tyson S. Stroke impairment categories: A new way to classify the effects of stroke based on stroke-related impairments. Clin Rehabil 2021; 35:446-458. [PMID: 33131321 PMCID: PMC7944424 DOI: 10.1177/0269215520966473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 09/25/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To create a classification system based on stroke-related impairments. DATA SOURCE All adults with stroke admitted for at least 72 hours in England, Wales and Northern Ireland from July 2013 to July 2015 extracted from the Sentinel Stroke National Audit Programme. ANALYSIS Impairments were defined using the National Institute of Health Stroke Scale scores at admission. Common combinations of impairments were identified based on geometric coding and expert knowledge. Validity of the classification was assessed using standard descriptive statistics to report and compare patients' characteristics, therapy received and outcomes in each group. RESULTS Data from 94,905 patients were extracted. The items of the National Institute of Health Stroke Scale (on admission) were initially grouped into four body systems: Cognitive, Motor, Sensory and Consciousness. Seven common combinations of these impairments were identified (in order of stroke severity); Patients with Loss of Consciousness (n = 6034, 6.4%); those with Motor + Cognitive + Sensory impairments (n = 28,226, 29.7%); Motor + Cognitive impairments (n = 16,967, 17.9%); Motor + Sensory impairments (n = 9882, 10.4%); Motor Only impairments (n = 20,471, 21.6%); Any Non-Motor impairments (n = 7498, 7.9%); and No Impairments (n = 5827, 6.1%). There was a gradation of age, premorbid disability, mortality and disability on discharge. People with the most and least severe categories were least likely to receive therapy, and received least therapy (-20 minutes/day of stay) compared to -35 minutes/day of stay for the moderately severe categories. CONCLUSIONS A classification system of seven Stroke Impairment Categories has been presented.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, School of Health Sciences University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David Lugo-Palacios
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, UK
| | - Andy Vail
- Centre for Biostatistics, School of Health Sciences University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Audrey Bowen
- Division of Neuroscience & Experimental Psychology, School of Biological Sciences University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College, London, UK
| | - Benjamin Bray
- School of Economics University Queensland, Brisbane, Australia
| | - Sarah Tyson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Clarke D, Gombert-Waldron K, Honey S, Cloud G, Harris R, Macdonald A, McKevitt C, Robert G, Jones F. Co-designing organisational improvements and interventions to increase inpatient activity in four stroke units in England: a mixed-methods process evaluation using normalisation process theory. BMJ Open 2021; 11:e042723. [PMID: 33500286 PMCID: PMC7839845 DOI: 10.1136/bmjopen-2020-042723] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To explore facilitators and barriers to using experience-based co-design (EBCD) and accelerated EBCD (AEBCD) in the development and implementation of interventions to increase activity opportunities for inpatient stroke survivors. DESIGN Mixed-methods process evaluation underpinned by normalisation process theory (NPT). SETTING Four post-acute rehabilitation stroke units in England. PARTICIPANTS Stroke survivors, family members, stroke unit staff, hospital managers, support staff and volunteers. Data informing our NPT analysis comprised: ethnographic observations, n=366 hours; semistructured interviews with 76 staff, 53 stroke survivors and 27 family members pre-EBCD/AEBCD implementation or post-EBCD/AEBCD implementation; and observation of 43 co-design meetings involving 23 stroke survivors, 21 family carers and 54 staff. RESULTS Former patients and families valued participation in EBCD/AEBCD perceiving they were equal partners in co-design. Staff engaged with EBCD/AEBCD, reporting it as a valuable improvement approach leading to increased activity opportunities. The structured EBCD/AEBCD approach was influential in enabling coherence and cognitive participation and legitimated staff involvement in the change process. Researcher facilitation of EBCD/AEBCD supported cognitive participation, collective action and reflexive monitoring; these were important in implementing and sustaining co-design activities. Observations and interviews post-EBCD/AEBCD cycles confirmed creation and use of new social spaces and increased activity opportunities in all units. EBCD/AEBCD facilitated engagement with wider hospital resources and local communities, further enhancing activity opportunities. However, outside of structured group activity, many individual staff-patient interactions remained task focused. CONCLUSIONS EBCD/AEBCD facilitated the development and implementation of environmental changes and revisions to work routines which supported increased activity opportunities in stroke units providing post-acute and rehabilitation care. Former stroke patients and carers contributed to improvements. NPT's generative mechanisms were instrumental in analysis and interpretation of facilitators and barriers at the individual, group and organisational level, and can help inform future implementations of similar approaches.
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Affiliation(s)
- David Clarke
- Academic Unit for Ageing and Stroke Research, Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Karolina Gombert-Waldron
- Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London, London, UK
| | - Stephanie Honey
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Geoffrey Cloud
- Department of Clinical Neuroscience, CCS, Monash University Melbourne and Alfred Health, Melbourne, Victoria, Australia
| | - Ruth Harris
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | | | | | - Glenn Robert
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Fiona Jones
- Faculty of Health Social Care and Education, St Georges University of London, London, UK
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Jones F, Gombert-Waldron K, Honey S, Cloud G, Harris R, Macdonald A, McKevitt C, Robert G, Clarke D. Using co-production to increase activity in acute stroke units: the CREATE mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Stroke is the most common neurological disability in the UK. Any activity contributes to recovery, but stroke patients can be inactive for > 60% of their waking hours. This problem remains, despite organisational changes and targeted interventions. A new approach to addressing post-stroke inactivity is needed. Experience-based co-design has successfully initiated improvements for patients and staff in other acute settings. Experience-based co-design uses observational fieldwork and filmed narratives with patients to trigger different conversations and interactions between patients and staff to improve health-care services.
Objectives
To complete a rapid evidence synthesis of the efficacy and effectiveness of co-production as an approach to quality improvement in acute health-care settings; to evaluate the feasibility and impact of patients, carers and staff co-producing and implementing interventions to increase supervised and independent therapeutic patient activity in acute stroke units; and to understand the experience of participating in experience-based co-design and whether or not interventions developed and implemented in two units could transfer to two additional units using an accelerated experience-based co-design cycle.
Design
A mixed-methods case comparison using interviews, observations, behavioural mapping and self-report surveys (patient-reported outcome measure/patient-reported experience measure) pre and post implementation of experience-based co-design cycles, and a process evaluation informed by normalisation process theory.
Setting
The setting was two stroke units (acute and rehabilitation) in London and two in Yorkshire.
Participants
In total, 130 staff, 76 stroke patients and 47 carers took part.
Findings
The rapid evidence synthesis showed a lack of rigorous evaluation of co-produced interventions in acute health care, and the need for a robust critique of co-production approaches. Interviews and observations (365 hours) identified that it was feasible to co-produce and implement interventions to increase activity in priority areas including ‘space’ (environment), ‘activity’ and, to a lesser extent, ‘communication’. Patients and families reported benefits from participating in co-design and perceived that they were equal and valued members. Staff perceived that experience-based co-design provided a positive experience, was a valuable improvement approach and led to increased activity opportunities. Observations and interviews confirmed the use of new social spaces and increased activity opportunities. However, staff interactions remained largely task focused, with limited focus on enabling patient activity. Behavioural mapping indicated a mixed pattern of activity pre and post implementation of co-designed changes. Patient-reported outcome measure/patient-reported experience measure response rates were low, at 12–38%; pre- and post-experience-based co-design cohorts reported dependency, emotional and social limitations consistent with national statistics. Post-experience-based co-design patient-reported experience measure data indicated that more respondents reported that they had ‘enough things to do in their free time’. The use of experience-based co-design – full and accelerated – legitimised and supported co-production activity. Staff, patients and families played a pivotal role in intervention co-design. All participants recognised that increased activity should be embedded in everyday routines and in work on stroke units.
Limitations
Communication by staff that enabled patient activity was challenging to initiate and sustain.
Conclusions
It was feasible to implement experience-based co-design in stroke units. This resulted in some positive changes in unit environments and increased activity opportunities for patients. There was no discernible difference in experiences or outcomes between full and accelerated experience-based co-design. Future work should consider multiple ways to embed increased patient activity into everyday routines in stroke units.
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. 35. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Fiona Jones
- Centre for Health and Social Care Research, Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, London, UK
| | - Karolina Gombert-Waldron
- Centre for Health and Social Care Research, Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, London, UK
| | - Stephanie Honey
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Ruth Harris
- Department of Adult Nursing, King’s College London, London, UK
| | | | - Chris McKevitt
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Glenn Robert
- Department of Adult Nursing, King’s College London, London, UK
| | - David Clarke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Gittins M, Vail A, Bowen A, Lugo-Palacios D, Paley L, Bray B, Gannon B, Tyson S. Factors influencing the amount of therapy received during inpatient stroke care: an analysis of data from the UK Sentinel Stroke National Audit Programme. Clin Rehabil 2020; 34:981-991. [PMID: 32508132 PMCID: PMC7324910 DOI: 10.1177/0269215520927454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To understand why most stroke patients receive little therapy. We investigated the factors associated with the amount of stroke therapy delivered. METHODS Data regarding adults admitted to hospital with stroke for at least 72 hours (July 2013-July 2015) were extracted from the UK's Sentinel Stroke National Audit Programme. Descriptive statistics and multilevel mixed effects regression models explored the factors that influenced the amount of therapy received while adjusting for confounding. RESULTS Of the 94,905 patients in the study cohort (mean age: 76 (SD: 13.2) years, 78% had a mild or moderate severity stroke. In all, 92% required physiotherapy, 87% required occupational therapy, 57% required speech therapy but only 5% were considered to need psychology. The average amount of therapy ranged from 2 minutes (psychology) to 14 minutes (physiotherapy) per day of inpatient stay. Unmodifiable characteristics (such as stroke severity) dominated the variation in the amount of therapy. However important, modifiable organizational factors were the day and time of admission, type of stroke team, timely therapy assessments, therapy and nursing staffing levels (qualified and support staff), and presence of weekend or early supported discharge services. CONCLUSION The amount of stroke therapy is associated with unmodifiable patient-related characteristics and modifiable organizational factors in that more therapy was associated with higher therapy and nurse staffing levels, specialist stroke rehabilitation services, timely therapy assessments, and the presence of weekend and early discharge services.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, School of Health Sciences, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, School of Health Sciences, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
| | - Audrey Bowen
- Division of Neuroscience & Experimental Psychology, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David Lugo-Palacios
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK
| | | | | | - Brenda Gannon
- School of Economics and Centre for the Business and Economics of Health, University of Queensland, Brisbane, QLD, Australia
| | - Sarah Tyson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
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40
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McGlinchey MP, Buttery C. Effect of a 7-day acute inpatient neurophysiotherapy service on physiotherapy provision, length of stay, and patient experience. J Eval Clin Pract 2020; 26:777-785. [PMID: 31309670 DOI: 10.1111/jep.13237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/26/2019] [Accepted: 07/01/2019] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES National policy, guided by research, suggests several patient and service benefits achieved by providing 7-day health care. Therefore, a 7-day inpatient neurophysiotherapy service was introduced at a large teaching hospital in London. The study's aim was to evaluate the effect of the 7-day service on physiotherapy provision, length of stay (LOS), and patient experience. METHOD Baseline data from the 5-day service were collected for 6 months. Data included time to first neurophysiotherapy assessment, average number of sessions per week, total number of physiotherapy minutes provided, physiotherapy LOS, and hospital LOS. Once 7-day working (7DW) commenced, involving daily physiotherapy for all patients applicable for physiotherapy, data were collected for 6 months and compared with the 5-day service. Patient and carer feedback were also obtained through structured interviews from a sample of patients and their carers. RESULTS Data from 286 patients (148 patients pre and 138 patients post 7DW) were analysed. Post 7DW, the percentage of patients seen by a physiotherapist within 24 hours increased from 69.9% to 94.9%. Patients also received more physiotherapy sessions per week during their hospital LOS. For demographically similar patients, physiotherapy LOS (24.8-17.4 d, P = .02) and total hospital LOS (32-23.4 d, P = .04) significantly reduced. Twenty-four structured interviews were completed (17 patients and seven carers). Carers preferred a 7-day physiotherapy service as it was perceived to provide more physiotherapy for patients. However, patients valued the consistency of seeing the same therapist during the 5-day service, as this was perceived to develop therapeutic relationships and result in faster treatment progression. CONCLUSIONS This study has demonstrated that 7DW can improve timely access to more intensive physiotherapy whilst reducing LOS for demographically similar patients. Whilst patients and carers liked having daily physiotherapy, consideration is required to ensure consistency of therapists treating patients.
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Affiliation(s)
- Mark P McGlinchey
- Physiotherapy Department, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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41
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Shaw L, Bhattarai N, Cant R, Drummond A, Ford GA, Forster A, Francis R, Hills K, Howel D, Laverty AM, McKevitt C, McMeekin P, Price C, Stamp E, Stevens E, Vale L, Rodgers H. An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT. Health Technol Assess 2020; 24:1-202. [PMID: 32468989 DOI: 10.3310/hta24240] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There is limited evidence about the effectiveness of rehabilitation in meeting the longer-term needs of stroke patients and their carers. OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS). DESIGN A pragmatic, observer-blind, parallel-group, multicentre randomised controlled trial with embedded health economic and process evaluations. Participants were randomised (1 : 1) to receive EXTRAS or usual care. SETTING Nineteen NHS study centres. PARTICIPANTS Patients with a new stroke who received early supported discharge and their informal carers. INTERVENTIONS Five EXTRAS reviews provided by an early supported discharge team member between 1 and 18 months post early supported discharge, usually over the telephone. Reviewers assessed rehabilitation needs, with goal-setting and action-planning. Control treatment was usual care post early supported discharge. MAIN OUTCOME MEASURES The primary outcome was performance in extended activities of daily living (Nottingham Extended Activities of Daily Living Scale) at 24 months post randomisation. Secondary outcomes at 12 and 24 months included patient mood (Hospital Anxiety and Depression Scale), health status (Oxford Handicap Scale), experience of services and adverse events. For carers, secondary outcomes included carers' strain (Caregiver Strain Index) and experience of services. Cost-effectiveness was estimated using resource utilisation costs (adaptation of the Client Service Receipt Inventory) and quality-adjusted life-years. RESULTS A total of 573 patients (EXTRAS, n = 285; usual care, n = 288) with 194 carers (EXTRAS, n = 103; usual care, n = 91) were randomised. Mean 24-month Nottingham Extended Activities of Daily Living Scale scores were 40.0 (standard deviation 18.1) for EXTRAS (n = 219) and 37.2 (standard deviation 18.5) for usual care (n = 231), giving an adjusted mean difference of 1.8 (95% confidence interval -0.7 to 4.2). The mean intervention group Hospital Anxiety and Depression Scale scores were not significantly different at 12 and 24 months. The intervention did not improve patient health status or carer strain. EXTRAS patients and carers reported greater satisfaction with some aspects of care. The mean cost of resource utilisation was lower in the intervention group: -£311 (95% confidence interval -£3292 to £2787), with a 68% chance of EXTRAS being cost-saving. EXTRAS was associated with 0.07 (95% confidence interval 0.01 to 0.12) additional quality-adjusted life-years. At current conventional thresholds of willingness to pay for a quality-adjusted life-year, there is a 90% chance that EXTRAS is cost-effective. CONCLUSIONS EXTRAS did not improve stroke survivors' performance in extended activities of daily living but did improve their overall satisfaction with services. Given the impact on costs and quality-adjusted life-years, there is a high chance that EXTRAS could be considered cost-effective. FUTURE WORK Further research is required to identify whether or not community-based interventions can improve performance of extended activities of daily living, and to understand the improvements in health-related quality of life and costs seen by provision of intermittent longer-term specialist review. TRIAL REGISTRATION Current Controlled Trials ISRCTN45203373. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Nawaraj Bhattarai
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Robin Cant
- Service user, c/o Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Avril Drummond
- School of Health Sciences, Medical School, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Gary A Ford
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Medical Sciences Division, University of Oxford and John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anne Forster
- Academic Unit of Elderly Care and Rehabilitation, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Katie Hills
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Anne Marie Laverty
- Stroke Service, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK
| | - Christopher McKevitt
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Peter McMeekin
- Department of Nursing, Midwifery and Health, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Christopher Price
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Stroke Service, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK
| | - Elaine Stamp
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Eleanor Stevens
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Stroke Service, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK.,Royal Victoria Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Grimley RS, Rosbergen IC, Gustafsson L, Horton E, Green T, Cadigan G, Kuys S, Andrew NE, Cadilhac DA. Dose and setting of rehabilitation received after stroke in Queensland, Australia: a prospective cohort study. Clin Rehabil 2020; 34:812-823. [PMID: 32389061 DOI: 10.1177/0269215520916899] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aims of this study were to describe patterns and dose of rehabilitation received following stroke and to investigate their relationship with outcomes. DESIGN This was a prospective observational cohort study. SETTING A total of seven public hospitals and all subsequent rehabilitation services in Queensland, Australia, participated in the study. SUBJECTS Participants were consecutive patients surviving acute stroke between July 2016 and January 2017. METHODS We tracked rehabilitation for six months following stroke and obtained 90- to 180-day outcomes from the Australian Stroke Clinical Registry. MEASURES Dose of rehabilitation - time in therapy by physiotherapy, occupational therapy and speech pathology; modified Rankin Scale (mRS)- premorbid, acute care discharge and 90- to 180-day follow-up. RESULTS We recruited 504 patients, of whom 337 (median age = 73 years, 41% female) received 643 episodes of rehabilitation in 83 different services. Initial rehabilitation was predominantly inpatient (260/337, 77%) versus community-based (77/337, 21%). Therapy time was greater within inpatient services (median = 29 hours) compared to community-based (6 hours) or transition care (16 hours). Median (Quartile 1, Quartile 3) six-month cumulative therapy time was 73 hours (40, 130) when rehabilitation commenced in stroke units and continued in inpatient rehabilitation units; 43 hours (23, 78) when commenced in inpatient rehabilitation units; and 5 hours (2, 9) with only community rehabilitation. In 317 of 504 (63%) with follow-up data, improvement in mRS was most likely with inpatient rehabilitation (OR = 3.6, 95% CI = 1.7-7.7), lower with community rehabilitation (OR = 1.6, 95% CI = 0.7-3.8) compared to no rehabilitation, after adjustment for baseline factors. CONCLUSION Amount of therapy varied widely between rehabilitation pathways. Amount of therapy and chance of improvement in function were highest with inpatient rehabilitation.
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Affiliation(s)
- Rohan S Grimley
- Sunshine Coast Clinical School, Griffith University, Birtinya, QLD, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Queensland State-wide Stroke Clinical Network, Clinical Excellence Division, Queensland Department of Health, Brisbane, QLD, Australia
| | - Ingrid Cm Rosbergen
- Queensland State-wide Stroke Clinical Network, Clinical Excellence Division, Queensland Department of Health, Brisbane, QLD, Australia.,Allied Health Services, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia.,School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Louise Gustafsson
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia.,School of Allied Health Sciences, Griffith University, Brisbane, QLD, Australia
| | - Eleanor Horton
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Maroochydore, QLD, Australia
| | - Theresa Green
- Faculty of Health School of Nursing, The University of Queensland, Brisbane, QLD, Australia.,Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Greg Cadigan
- Queensland State-wide Stroke Clinical Network, Clinical Excellence Division, Queensland Department of Health, Brisbane, QLD, Australia
| | - Suzanne Kuys
- Faculty of Health Sciences, Australian Catholic University, Brisbane, QLD, Australia
| | - Nadine E Andrew
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston, VIC, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
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43
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Stewart C, Power E, McCluskey A, Kuys S, Lovarini M. 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. Clin Rehabil 2020; 34:607-616. [PMID: 32204599 DOI: 10.1177/0269215520911420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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 (rpbs = 0.00, 95% CI = (-0.4, 0.4), P = 1.000) or observed active practice (rpbs = -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.
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Affiliation(s)
- Claire Stewart
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Allied Health Services, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Emma Power
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,University of Technology Sydney, Graduate School of Health, Speech Pathology, Sydney, NSW, Australia
| | - Annie McCluskey
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,The StrokeEd Collaboration, Sydney, NSW, Australia
| | - Suzanne Kuys
- School of Allied Health, Australian Catholic University, Banyo, QLD, Australia
| | - Meryl Lovarini
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Gittins M, Lugo-Palacios D, Vail A, Bowen A, Paley L, Bray B, Gannon B, Tyson SF. Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David Lugo-Palacios
- Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Audrey Bowen
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Benjamin Bray
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Brenda Gannon
- School of Economics, The University of Queensland, Brisbane, QLD, Australia
| | - Sarah F Tyson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Chouliara N, Fisher R, Crosbie B, Guo B, Sprigg N, Walker M. How do patients spend their time in stroke rehabilitation units in England? The REVIHR study. Disabil Rehabil 2019; 43:2312-2319. [PMID: 34315309 DOI: 10.1080/09638288.2019.1697764] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM To examine how patients spend their time in stroke rehabilitation units in England. METHODS We recruited 144 patients within a month after stroke from four stroke rehabilitation units and observed their activity type, interactions and location. Each participant was observed for 1 min every 10-minutes, for a total of 20 h, over three consecutive days. Multilevel modelling was performed to assess differences across sites. RESULTS Across the four sites a total of 12,248 observations were performed. Patients spent on average 37% of the observed time inactive and 60% alone. A health care professional was present for 18% of the observations and patients' most frequent contact was with family members (19%). Patients were mainly physically active in the presence of therapists, but they practiced self-care activities of daily living most frequently in the presence of nursing staff. There were limited opportunities for activity away from the bedside. Significant differences were found between the units, including patients' level of contact with rehabilitation assistants and nursing staff, but not in their time with occupational therapists and physiotherapists. CONCLUSIONS Stroke patients in England spend a large proportion of their day inactive and alone. Opportunities to promote a rehabilitation focused environment may include: a) enhancing the role of rehabilitation assistants, b) supporting nursing staff in maximising opportunities for the practice of activities of daily living and c) involving family members in the rehabilitation process.IMPLICATIONS FOR REHABILITATIONClinicians need to consider stroke patients' activity levels and rehabilitation experience outside formal therapy.The role of rehabilitation assistants and nursing staff can be key in promoting patient activity and practice of self-care ADL tasks.Pragmatic strategies to encourage family involvement in the rehabilitation process need to be developed.
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Affiliation(s)
- Niki Chouliara
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rebecca Fisher
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Brian Crosbie
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Boliang Guo
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingha, UK
| | - Nikola Sprigg
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Marion Walker
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
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Abstract
OBJECTIVES To survey the reported content, frequency and duration of upper limb treatment provided by occupational and physiotherapists for people after stroke in the UK. DESIGN A cross-sectional online survey was used. Description and analysis of the data were based on items from the Template for Intervention Description and Replication (Who, Where, What and How much). SETTING The online survey was distributed via professional and social networks to UK-based therapists. PARTICIPANTS Respondents were occupational or physiotherapists currently working clinically in the UK with people after stroke. Over the 6 week data collection period, 156 respondents opened the survey, and 154 completed it. Respondents comprised 85 physiotherapists and 69 occupational therapists. RESULTS Respondents reported treating the upper limb a median of three times a week (range: 1 to 7) for a mean of 29 min (SD: 18). Most (n=110) stated this was supplemented by rehabilitation assistants, family and/or carers providing additional therapy a median of three times a week (range 1 to 7). Functional training was the most commonly reported treatment for people with mild and moderate upper limb deficits (>40%). There was much less consistency in treatments reported for people with severe upper limb deficits with less than 20% (n=28) reporting the same treatments. CONCLUSIONS This study provides a contemporaneous description of reported therapy in the UK for people with upper limb deficits after stroke and a detailed template to inform standard therapy interventions in future research. Several evidence-based therapies were reported to be used by respondents (eg, constraint induced movement therapy), but others were not (eg, mental imagery). The findings also highlight that the current reported provision of upper limb therapy is markedly less than what is likely to be effective. This underlines an urgent need to configure and fund services to empower therapists to deliver greater amounts of evidence-based treatment for people with upper limb deficits after stroke.
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Affiliation(s)
- Rachel Stockley
- School of Nursing, University of Central Lancashire, Preston, UK
| | - Rosemary Peel
- School of Health Sciences, University of Central Lancashire, Preston, UK
| | - Kathryn Jarvis
- School of Health Sciences, University of Central Lancashire, Preston, UK
| | - Louise Connell
- School of Health Sciences, University of Central Lancashire, Preston, UK
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Vratsistas-Curto A, Sherrington C, McCluskey A. Dosage and predictors of arm practice during inpatient stroke rehabilitation: an inception cohort study. Disabil Rehabil 2019; 43:640-647. [PMID: 31311348 DOI: 10.1080/09638288.2019.1635215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Angela Vratsistas-Curto
- School of Public Health, Institute of Musculoskeletal Health, The University of Sydney, Sydney, Australia
| | - Catherine Sherrington
- School of Public Health, Institute of Musculoskeletal Health, The University of Sydney, Sydney, Australia
| | - Annie McCluskey
- Discipline of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
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Longley V, Peters S, Swarbrick C, Rhodes S, Bowen A. Does pre-existing cognitive impairment impact on amount of stroke rehabilitation received? An observational cohort study. Clin Rehabil 2019; 33:1492-1502. [PMID: 31020850 PMCID: PMC6716203 DOI: 10.1177/0269215519843984] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine whether stroke survivors in inpatient rehabilitation with pre-existing cognitive impairment receive less therapy than those without. DESIGN Prospective observational cohort. SETTING Four UK inpatient stroke rehabilitation units. PARTICIPANTS A total of 139 stroke patients receiving rehabilitation, able to give informed consent/had an individual available to act as personal consultee. In total, 33 participants were categorized with pre-existing cognitive impairment based on routine documentation by clinicians and 106 without. MEASURES Number of inpatient therapy sessions received during the first eight weeks post-stroke, referral to early supported discharge, and length of stay. RESULTS On average, participants with pre-existing cognitive impairment received 40 total physiotherapy and occupational therapy sessions compared to 56 for those without (mean difference = 16.0, 95% confidence interval (CI) = 2.9, 29.2), which was not fully explained by adjusting for potential confounders (age, sex, National Institutes of Health Stroke Scale (NIHSS), and pre-stroke modified Rankin Scale (mRS)). While those with pre-existing cognitive impairment received nine fewer single-discipline physiotherapy sessions (95% CI = 3.7, 14.8), they received similar amounts of single-discipline occupational therapy, psychology, and speech and language therapy; two more non-patient-facing occupational therapy sessions (95% CI = -4.3, -0.6); and nine fewer patient-facing occupational therapy sessions (95% CI = 3.5, 14.9). There was no evidence to suggest they were discharged earlier, but of the 85 participants discharged within eight weeks, 8 (42%) with pre-existing cognitive impairment were referred to early supported discharge compared to 47 (75%) without. CONCLUSION People in stroke rehabilitation with pre-existing cognitive impairments receive less therapy than those without, but it remains unknown whether this affects outcomes.
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Affiliation(s)
- Verity Longley
- 1 Division of Neuroscience and Experimental Psychology, MAHSC, The University of Manchester, Manchester, UK.,2 CLAHRC Greater Manchester, Manchester, UK
| | - Sarah Peters
- 3 Manchester Centre for Health Psychology, MAHSC, The University of Manchester, Manchester, UK
| | | | - Sarah Rhodes
- 2 CLAHRC Greater Manchester, Manchester, UK.,5 Centre for Biostatistics, MAHSC, The University of Manchester, Manchester, UK
| | - Audrey Bowen
- 1 Division of Neuroscience and Experimental Psychology, MAHSC, The University of Manchester, Manchester, UK.,2 CLAHRC Greater Manchester, Manchester, UK
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Taylor E, Jones F, McKevitt C. How is the audit of therapy intensity influencing rehabilitation in inpatient stroke units in the UK? An ethnographic study. BMJ Open 2018; 8:e023676. [PMID: 30552266 PMCID: PMC6303655 DOI: 10.1136/bmjopen-2018-023676] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/10/2018] [Accepted: 10/16/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Occupational therapy, physiotherapy and speech and language therapy are central to rehabilitation after a stroke. The UK has introduced an audited performance target: that 45 min of each therapy should be provided to patients deemed appropriate. We sought to understand how this has influenced delivery of stroke unit therapy. DESIGN Ethnographic study, including observation and interviews. The theoretical framework drew on the work of Lipsky and Power, framing therapists as 'street level bureaucrats' in an 'audit society'. SETTING Stroke units in three English hospitals. PARTICIPANTS Forty-three participants were interviewed, including patients, therapists and other staff. RESULTS There was wide variation in how therapy time was recorded and in decision-making regarding which patients were 'appropriate for therapy' or auditable. Therapists interpreted their roles differently in each stroke unit. Therapists doubted the validity of the audit results and did not believe their results reflected the quality of services they provided. Some assumed their audit results would inform commissioning decisions. Senior therapy leaders shaped priorities and practices in each therapy team. Patients were inactive outside therapy sessions. Patients differed regarding the quantity of therapy they felt they needed but consistently wanted to be more involved in decisions and treated as individuals.
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Affiliation(s)
- Elizabeth Taylor
- Faculty of Health, Social Care and Education, Department of Rehabilitation Sciences, Kingston University and St George’s University of London, London, UK
| | - Fiona Jones
- Faculty of Health, Social Care and Education, Department of Rehabilitation Sciences, Kingston University and St George’s University of London, London, UK
| | - Christopher McKevitt
- School of Population Health and Environmental Sciences, King’s College London, London, UK
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Tyson SF, Woodward-Nutt K, Plant S. How are balance and mobility problems after stroke treated in England? An observational study of the content, dose and context of physiotherapy. Clin Rehabil 2018; 32:1145-1152. [DOI: 10.1177/0269215518777789] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To describe the dose, intensity and context of physiotherapy for balance and mobility problems after stroke. Design: Process mapping to describe the context and non-participant observation of therapy sessions to describe the dose and content of therapy. Setting: Four inpatient stroke units in North-West England. Participants: Therapy staff and previously mobile stroke survivors who were treating, or receiving treatment for balance and mobility problems in the participating units. Results: Two units were stand-alone rehabilitation units; two offered a service at the weekends. One had no access to community-based rehabilitation. All had dedicated treatment facilities but often did not use them because of lack of space and difficulty transporting patients. Twenty-two patients participated and 100 treatment sessions were observed. Practicing walking, sit-to-stand and transfers were the most frequent objectives and interventions usually with the therapist(s) physically facilitating the patient’s movements. The dose of practise was low; mean repetitions of sit-to-stand per session was 5 (SD 6.4); mean time spent upright per session was 11.24 (SD = 7) minutes, and mean number of steps per session was 202 (SD 118). The mean number of staff per patient was 2.1 (SD = 0.6, mode = 2), usually involving two qualified therapists. Falls prevention or management, wheelchair skills and bed mobility were not practised. Conclusion: Stroke physiotherapy for balance and mobility problems features low-dose, low-intensity therapist-led practice, mainly of walking and sit-to-stand. Staff:patient ratios were high. Therapists need to organize treatment sessions to maximize the intensity of functional task practice.
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Affiliation(s)
- Sarah F Tyson
- Stroke Research Centre, The University of Manchester, Manchester, UK
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Kate Woodward-Nutt
- Stroke Research Centre, The University of Manchester, Manchester, UK
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Plant
- Stroke Research Centre, The University of Manchester, Manchester, UK
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
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