Moving Stroke Rehabilitation Research Evidence into Clinical Practice: Consensus-Based Core Recommendations From the Stroke Recovery and Rehabilitation Roundtable

Comparative global analysis of stroke rehabilitation recommendations across income levels

OBJECTIVE

Successful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC).

STUDY DESIGN AND SETTING

We conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P's, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC.

RESULTS

The inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P's criteria) and integration of ethical, legal, social, and economic considerations.

CONCLUSION

There are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.

Rapid real-world implementation of pulmonary telerehabilitation: good fortune or COVID-19 luck?

"Real-world" telerehabilitation achieves clinically meaningful outcomes for patients and may improve access to pulmonary rehabilitation, but implementation into practice may have been aided by COVID-19-related support for telehealth https://bit.ly/3NqYdCC.

Consensus on Prioritisation of Actions for Reducing the Environmental Impact of a Large Tertiary Hospital: Application of the Nominal Group Technique

Hospitals are the largest greenhouse gas producers within the Australian healthcare sector due to the large amounts of energy, resource utilization, equipment and pharmaceuticals required to deliver care. In order to reduce healthcare emissions, healthcare services must take multiple actions to address the broad range of emissions produced when delivering patient care. The goal of this study was to seek consensus on the priority actions needed to reduce the environmental impact of a tertiary Australian hospital. A nominal group technique was utilized within a multidisciplinary, executive-led environmental sustainability committee to find consensus on the 62 proposed actions to reduce the environmental impact of a tertiary Australian hospital. Thirteen participants joined an online workshop during which an educational presentation was delivered, 62 potential actions were privately ranked according to two domains of 'amenability to change' and 'scale of climate impact' and a moderated group discussion ensued. The group achieved verbal consensus on 16 actions that span staff education, procurement, pharmaceuticals, waste, transport and advocacy on all-electric capital works upgrades. In addition, the individual ratings of potential actions according to each domain were ranked and shared with the group. Despite a large number of actions and varied perspectives within the group, the nominal group technique can be used to focus a hospital leadership group on priority actions to improve environmental sustainability.

The influence of seated exercises on balance, mobility, and cardiometabolic health outcomes in individuals living with a stroke: A systematic review and meta-analysis

OBJECTIVE

Seated exercises could prove a safe alternative to traditional weight-bearing exercises in stroke, but its effects on mobility and modifiable risk factors of stroke are limited. The objective is to investigate the effects of seated exercises on balance, mobility, and cardiometabolic health in individuals living with a stroke.

DATA SOURCES

Medline, EMBASE, CINAHL, and Cochrane library were searched up to October 2022, in addition to the 2018 Evidence-Based Review of Stroke Rehabilitation.

METHODS

Trials that incorporated predominantly seated exercises and outcomes of balance, mobility, or cardiometabolic health in those living with a stroke were included. Quality assessments of randomized controlled trials were done using the Cochrane Risk-of-Bias Tool.

RESULTS

Seven trials were included in the review (n  =  337) with five trials including participants < 6 months post-stroke. Seated exercises improved balance (standard mean difference (SMD)  =  0.76; 95% confidence interval (CI), 0.50, 1.02) and mobility (SMD  =  0.68; 95% CI, 0.24,1.13) outcomes compared with control. Sensitivity analysis of gait speed found no significant change (mean difference (MD)  =  0.33 m/s; 95% CI, -0.23, 0.89) following seated exercises compared with control. One trial found no significant changes in blood pressure. Most trials (78%) were assessed as having some concern for bias.

CONCLUSION

These findings suggest beneficial effects of seated exercises on balance and mobility outcomes in those with a stroke, compared with standard therapy or an attention control. However, there is limited evidence on the effects of seated exercises on outcomes of cardiometabolic health, particularly prominent modifiable risk factors for stroke.

PROSPERO REGISTRATION NUMBER

CRD42022307426.

Evaluating the impact of a training program to support transitioning from the hospital to the community for people after stroke: a community case study

Background

The transitions in care along the stroke recovery path are challenging, particularly in finding mechanisms to continue one’s recovery once at home. We aim to evaluate the impact of training physiotherapists and fitness instructors from one regional community together to deliver an evidence-based group exercise program starting in the hospital and transitioning to the community using an implementation approach.

Methods

The evidenced based exercise program Fitness and Mobility Exercise (FAME) for stroke was chosen as the intervention. Data from interviews with stakeholders (community centre and health authority hospital staff including a physiotherapy navigator) was transcribed and themes evaluated using the RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) framework. These data were supplemented by information collected as a quality assurance project within the health authority.

Results

Two programs were established; one in the community centre (run over 15 months by fitness instructors) and one in the regional hospital (run over 12 months by a rehabilitation assistant under the direction from a physiotherapist). Transitions in care were facilitated by implementing the same evidence-based group exercise class in both the hospital and community setting, so people living with stroke could seamlessly move from one to another. An existing physiotherapist navigator service also was valued as a support for the transitions between the two centres for people with stroke. The hospital group accessed group-based physiotherapy service on average 31 days earlier than they were able to in a one-to-one format.

Conclusions

This case study described the implementation of the Fitness and Mobility Exercise (FAME) program in one community and the use of a physiotherapist navigator to assist transition between them. After a community training workshop, FAME programs were established within the health authority and the community centre. FAME program participants within the health authority benefited from reduced wait times to access hospital outpatient physiotherapy service. Improvements in function were measured in and reported by the people after stroke attending either the health authority or community centre FAME groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07436-7.

Who, what, when, where, why, and how: a systematic review of the quality of post-stroke cognitive rehabilitation protocols

BACKGROUND

. Rehabilitation research findings are not routinely incorporated into clinical practice. A key barrier is the quality of reporting in the original study, including who provided the intervention, what it entailed, when and where it occurred, how patient outcomes were monitored, and why the intervention was efficacious.

OBJECTIVES

. To facilitate clinical implementation of post-stroke cognitive rehabilitation research, we undertook a review to examine the quality of intervention reporting in this literature.

METHODS

. Four databases were systematically searched, identifying 27 randomised controlled trials of post-stroke cognitive rehabilitation. The quality of intervention protocol descriptions in each study was independently rated by 2 of the authors using the 12-item Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

.Why, when, and where items were reported in more than 70% of interventions, what materials and procedures used was described in 50% to 70%, how items were described in approximately half of the interventions, and who provided interventions was reported in 22% of studies. No study addressed all 12 TIDieR items. "Active ingredients" that may further characterise an intervention and the potential mechanisms of action included restorative training, massed practice, feedback, and tailoring demands (present in approximately 50% of studies).

CONCLUSIONS

. Descriptions of intervention protocols are variable and frequently insufficient, thereby restricting the ability to understand, replicate, and implement evidence-based cognitive rehabilitation. Use of reporting checklists to address this barrier to research translation is a readily achievable and effective means to advance post-stroke care.

Effectiveness of Rehabilitation Nursing versus Usual Therapist-Led Treatment in Patients with Acute Ischemic Stroke: A Randomized Non-Inferiority Trial

Purpose

To determine the effectiveness of rehabilitation nursing program interventions in patients with acute ischemic stroke.

Patients and Methods

An assessment-blinded randomized controlled trial was conducted at a tertiary referral hospital in China. Eligible patients were stratified according to their weighted corticospinal tract lesion load and then randomly assigned to an experimental group (n = 121) or a control group (n = 103). The experimental group received rehabilitation nursing from well-trained, qualified nurses (30 minutes per session, two sessions per day for seven consecutive days). The control group received therapist-led rehabilitation with the same timing and frequency. Comparative analysis of the primary outcomes was performed to determine non-inferiority with a predetermined non-inferiority margin. The primary outcomes were the Motor Assessment Scale, Fugl-Meyer Assessment, and the Action Research Arm Test assessed at baseline and after seven days of treatment. The secondary outcomes were the modified Barthel Index, the National Institutes of Health Stroke Scale, and the modified Rankin Scale, evaluated before and after the intervention and at 4 and 12 weeks of follow-up.

Results

Two hundred participants completed the trial. In both groups, all outcomes improved significantly after seven days and at follow-ups. The rehabilitation nursing program was non-inferior to therapist-led treatment with lower 95% confidence limits beyond the margins for primary outcomes (P < 0.001).

Conclusion

Both treatments had comparable effects; however, no definite conclusion could be drawn. Adequately powered studies are required.