Factors guiding therapist decision making in the rehabilitation of physical function after severely disabling stroke - an ethnographic study

PURPOSE

Whilst strong evidence supports rehabilitation to improve outcomes post-stroke, there is limited evidence to guide rehabilitation in the most severely disabled group. In an era of evidence-based practice, the aim of the study was to understand what factors guide physiotherapists (PTs) and occupational therapists (OTs) to select particular interventions in the rehabilitation of physical function after severely disabling stroke.

MATERIAL AND METHODS

An ethnographic study was undertaken over an 18-month period involving five London, UK stroke services. Seventy-nine primary participants (30 PTs, 22 OTs, and 27 stroke survivors) were recruited to the study. Over 400 h of observation, 52 semi-structured interviews were conducted. Study data were analysed through thematic analysis.

RESULTS

Key factors guiding therapist decision making were clinical expertise, professional role, stroke survivors' clinical presentation, therapist perspectives about stroke recovery, and clinical guidelines. Research evidence, stroke survivors' treatment preferences, organisational type, and pathway design were less influential factors. Therapy practice did not always address the physical needs of severely disabled stroke survivors.

CONCLUSIONS

Multiple factors guided therapist decision making after severely disabling stroke. Alternative ways of therapist working should be considered to address the physical needs of severely disabled stroke survivors more fully.Implications for rehabilitationMultiple factors guide therapist decision making after severely disabling stroke, some of which result in the use of interventions that do not fully address stroke survivors' clinical needs.Therapists should critically reflect upon their personal beliefs and attitudes about severely disabling stroke to reduce potential sources of bias on decision making.Therapists should consider the timing and intensity of therapy delivery as well as their treatment approach to optimise outcomes after severely disabling stroke.

Effect of Core Exercises on Motor Function Recovery in Stroke Survivors with Very Severe Motor Impairment

Paresis of the upper and lower limbs is a typical issue in stroke survivors. This study aims to determine whether core exercises help stroke survivors with very severe motor impairment recover their motor function. This study employed a within-subjects design. Eleven hemiparetic stroke patients with very severe motor impairment (FMA score < 35) and ages ranging from 24 to 52 years old were enrolled in this study. All participants engaged in supervised core exercise training twice a week for 12 weeks. The main outcome measures were Fugl-Meyer Assessment Lower Extremity (FMA-LE) and Fugl-Meyer Assessment Upper Extremity (FMA-UE), which were measured before training and at intervals of four weeks during training. Repeated measures ANOVA was used to analyze the effect of core exercises on motor function performance and lower extremity motor function and upper extremity motor function recovery. There were significant differences in the mean scores for motor function performance, lower extremity motor function, and upper extremity motor function throughout the four time points. A post-hoc pairwise comparison using the Bonferroni correction revealed that mean scores significantly increased and were statistically different between the initial assessment and follow-up assessments four, eight, and twelve weeks later. This study suggests that 12 weeks of core exercise training is effective for improving motor function recovery in patients with very severe motor impairment.

The UK FIM+FAM Extended Activities of Daily Living module: evaluation of scoring accuracy and reliability

PURPOSE

The UK Functional Assessment Measure (UK FIM+FAM) is a widely used outcome measure in brain injury rehabilitation. An Extended Activities of Daily Living (EADL) module was included in its original development, but has never been formally evaluated. This study evaluated its scoring accuracy and reliability using vignettes (short clinical scenarios).

METHOD

A set of vignettes was developed and tested by a panel of experienced UK FIM+FAM trainers to derive 'gold standard' scores. To evaluate scoring accuracy, these were subsequently compared with scores made by 12 rehabilitation professionals; first individually, and then together in four multi-disciplinary (MD) teams to reflect clinical practice. Scoring was repeated after 1 month. Inter-rater and intra-rater reliability were evaluated for both individual and MD team scores using weighted Cohen's kappa statistics.

RESULTS

Agreement with 'gold standard scores' was excellent, ranging from k(w) = 0.88-0.97 (individuals) and k(w) = 0.93-1.00 (MD teams). Inter-rater agreement was good to excellent, ranging from k = 0.68-0.92 (individuals) and k = 0.74-1.00 (MD teams). Test-retest agreement was excellent, ranging from k(w) = 0.92-1.00 (individuals) and k(w) = 0.89-0.99 (MD teams).

CONCLUSION

This vignette-based study demonstrated high levels of scoring accuracy and reliability for the EADL items of the UK FIM+FAM. Further testing in real-life situations is now warranted.

The Prevalence of Joint Contractures, Pressure Sores, Painful Shoulder, Other Pain, Falls, and Depression in the Year After a Severely Disabling Stroke

Background and Purpose— Complications after stroke have been shown to impede rehabilitation, lead to poor functional outcome, and increase cost of care. This inception cohort study sought to investigate the prevalence of immobility-related complications during the first year after severely disabling stroke in relation to functional independence and place of residence.

Methods— Over a 7-month period, 600 stroke survivors were identified in the hospital through the Nottingham Stroke Register. Those who had a Barthel Index score ≤10 3 months poststroke and did not have a primary diagnosis of dementia were eligible to participate in the study. Assessments of complications were carried out at 3, 6, and 12 months poststroke.

Results— Complications were recorded for 122 stroke survivors (mean age, 76 years; 57% male). Sixty-three (52%) had significant language impairment and of the remaining 59 who were able to complete an assessment of cognitive function, 10 (8%) were cognitively impaired. The numbers of reported complications over 12 months, in rank order, were falls, 89 (73%); contracture, 73 (60%); pain, 67 (55%); shoulder pain, 64 (52%); depression, 61 (50%); and pressure sores, 26 (22%). A negative correlation was found between Barthel Index score and the number of complications experienced (low scores on the Barthel Index correlate with a high number of complications). The highest relative percentages of complications were experienced by patients who were living in a nursing home at the time of their last completed assessment.

Conclusions— Immobility-related complications are very common in the first year after a severely disabling stroke. Patients who are more functionally dependent in self-care are likely to experience a greater number of complications than those who are less dependent. Trials of techniques to limit and prevent complication are required.

Reliability and validity of functional balance tests post stroke

OBJECTIVE

To contribute to the reliability and validity of a series of functional balance tests for use post stroke.

DESIGN

Within-session, test-retest and intertester reliability was tested using the kappa coefficient and intraclass correlations. The tests were performed three times and the first and third attempts compared to test the within-session reliability. The tests were repeated a few days later to assess test-retest reliability and were scored simultaneously by two physiotherapists to assess the intertester reliability. To test criterion-related validity the tests were compared with the sitting section of the Motor Assessment Scale, Berg Balance Scale and Rivermead Mobility Index using Spearman's rho.

SETTING

Stroke physiotherapy services of six National Health Service hospitals.

PARTICIPANTS

People with a post stroke hemiplegia attending physiotherapy who had no other pathology affecting their balance took part. Thirty-five people participated in the reliability testing and 48 people took part in the validity testing.

MAIN OUTCOME MEASURES

The following functional balance tests were used: supported sitting balance, sitting arm raise, sitting forward reach, supported standing balance, standing arm raise, standing forward reach, static tandem standing, weight shift, timed 5-m walk with and without an aid, tap and step-up tests.

RESULTS

The ordinal level tests (supported sitting and standing balance and static tandem standing tests) showed 100% agreement in all aspects of reliability. Intraclass correlations for the other tests ranged from 0.93 to 0.99. All the tests showed significant correlations with the appropriate comparator tests (r = 0.32-0.74 p < 0.05), except the weight shift test and step-up tests which did not form significant relationship with Berg Balance Scale (r = 0.26 and 0.19 respectively).

CONCLUSION

These functional balance tests are reliable and valid measures of balance disability post stroke.

Can young severely disabled stroke patients regain the ability to walk independently more than three months post stroke?

OBJECTIVE

To investigate the acquisition of ability to walk independently in young severely disabled stroke patients unable to walk three months after onset.

SETTING

A regional rehabilitation unit providing post-acute neurorehabilitation mainly for patients aged 16-65 years.

SUBJECTS AND METHODS

A retrospective analysis of records was undertaken for 152 stroke patients admitted consecutively over a three-year period. All had a combination of physical, cognitive and language impairments; male/female 98/54; median age 54 (IQR 47-60) years.

MAIN OUTCOME MEASURES

Time taken from stroke onset to regain the ability to walk safely and independently at least 5 metres around the hospital bay.

RESULTS

Seventy-five (49%) regained the ability to walk independently between 3 and 11 months post onset. Patients with cognitive impairments and neglect took longer to walk. Time from stroke onset to admission was longer in patients who did not walk (median 16.3 weeks), than in those who regained walking (median 12.7 weeks; p = 0.009). Independent positive associations were found between the time taken to walk and time from onset to referral for rehabilitation (p = 0.55; p < 0.001), and time from acceptance to admission (p = 0.30; p = 0.008).

CONCLUSION

With intensive specialist input, significant numbers of severely disabled young stroke patients can regain independent walking many months after onset, though late walkers may follow a slower recovery course. These results argue for investment in appropriate rehabilitation for these patients. Waiting list delays may prolong rehabilitation and potentially compromise cost effectiveness.