Factors affecting the delivery of complex rehabilitation interventions in research with neurologically impaired adults: a systematic review

Effectiveness of modified constraint-induced movement therapy on upper limb function of stroke survivors in inpatient hospital settings: a systematic review and meta-analysis

PURPOSE

To synthesise evidence on the effectiveness of modified constraint-induced movement therapy on upper limb function in stroke survivors within inpatient hospital settings.

METHODS

A systematic review was pre-registered in PROSPERO (CRD42023421715b) and searched six databases (EMBASE, AMED, MEDLINE, CINAHL, Cochrane Library, OTseeker) up to November 2024.

Articles included adults with stroke undergoing modified constraint-induced movement therapy in inpatient hospital settings. Article quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Homogenous data was synthesised in a meta-analysis and assessed using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Remaining data was synthesised descriptively.

RESULTS

Ten randomised controlled trials (364 participants) were included. Four (191 participants) were analysed in a meta-analysis, showing modified constraint-induced movement therapy improved upper limb function (standardised mean difference (SMD) 0.94, 95% confidence interval (CI) 0.40 to 1.48), based on low-quality evidence. Five articles included follow-up, with two (90 participants) reporting sustained improvements. Five articles assessed activities of daily living, with two (136 participants) reporting positive effects.

CONCLUSION

Modified constraint-induced movement therapy improves upper limb function in the acute and sub-acute stages of stroke recovery within inpatient hospital settings. Sustainability of improvements and the impact on activities of daily living remains uncertain.

Balance Interventions to Improve Upright Balance Control and Balance Confidence in People With Motor-Incomplete Spinal Cord Injury or Disease: A Systematic Review and Meta-analysis

OBJECTIVES

To assist with clinical decision making, evidence syntheses are needed to demonstrate the efficacy of available interventions and examine the intervention components and dosage parameters. This systematic review and meta-analysis described the efficacy, components and dosage of interventions targeting upright balance control, balance confidence, and/or falls in adults with motor-incomplete spinal cord injury/disease (SCI/D).

DATA SOURCES

A search strategy following the population, intervention, control, outcome framework was developed. Six databases were searched: APA PsychInfo, Cumulative Index to Nursing and Allied Health Literature, Embase, Emcare Nursing, Web of Science CC, and Medline.

STUDY SELECTION

Title, abstract, and full-text screening were conducted by 2 researchers independently. Inclusion criteria included the following: (1) adults with chronic, motor-incomplete SCI/D; (2) physical intervention targeting upright postural control; and (3) clinical and/or biomechanical measures of upright balance control and/or balance confidence and/or documentation of falls.

DATA EXTRACTION

Participant characteristics, balance intervention details, adverse events, and study results were extracted. The Downs and Black Checklist was used to assess methodological quality. Meta-analyses on pre-post intervention outcomes and a meta-regression of dosage were completed. Grading of Recommendations, Assessment, Development, and Evaluations approach was used to evaluate the quality of the evidence.

DATA SYNTHESIS

The search returned 1664 unique studies; 26 were included. Methodological quality was moderate to good. Participants were 500 individuals with SCI/D, aged 18-74 years (males: females = 2.4:1). Minor adverse events were reported in 8 studies (eg, muscle soreness and fatigue). Walking interventions and upright balance training with visual feedback had clinically meaningful and significant pooled effects on improving standing balance control. Only walking interventions had a significant pooled effect on improving balance confidence. There were no significant findings on dosage response. Few studies evaluated the effects of balance interventions on the occurrence of falls.

CONCLUSIONS

Walking interventions and upright balance training with visual feedback had greater effects on upright balance control than conventional physiotherapy; however, the quality of the evidence was very low.

The Bobath concept (NDT) in adult neurorehabilitation: a scoping review of conceptual literature

PURPOSE

This scoping review aims to describe how Bobath concept is conceptualized, operationalized, and studied in adult neurorehabilitation.

METHODS

The Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) guidelines were adopted. Non-scientific and research articles were searched in electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science, ScienceDirect, and Physiotherapy Evidence Database (PEDro), with the keywords "Bobath" or "Neurodevelopmental Treatment", published in English, Spanish, and Portuguese, between 2013 and 2023.

RESULTS

Of the 78 publications identified, 31 articles addressed the conceptual underpinnings of Bobath concept (seven theoretical papers, seven Delphi/surveys/mixed methods studies, four qualitative studies, one scoping review, 10 letters to the editor, and two editorials), comprising five themes: (a) theoretical principles; (b) clinical principles; (c) clinical reasoning; (d) conceptualizing movement; and, current (e) evidence debate. The revised definition and the Model of Bobath Clinical Practice provide a clarification of the unique aspects of Bobath concept. A new clinical skill was identified beyond facilitation - visuospatial kinesthetic perception - as well as how Bobath experts conceptualize movement, which are all integral to clinical reasoning.

CONCLUSIONS

This review provides an updated Bobath clinical framework that gathers the theoretical foundations and clinical practice principles that require careful consideration in the design of future intervention studies. Implications for rehabilitationThis scoping review consolidates the clinical and theoretical principles of contemporary Bobath practice, providing a clear framework for clinicians.The Model of Bobath Clinical Practice (MBCP) framework enables detailed documentation of movement analysis and movement diagnosis, guiding clinical reasoning and interventions.This review identifies fundamental principles and practices to inform future Bobath intervention studies, ensuring their clinical relevance.A framework with specific recommendations has been developed to guide Bobath intervention studies, enhancing the integration of clinical practice, education, and research.

Errorless Learning for Everyday Functioning in Adults With Brain Injury: A Scoping Review

BACKGROUND

Errorless learning is an intervention technique used in acquired brain injury (ABI) rehabilitation. To support the use of this intervention within occupational therapy practice, it is important to know how errorless learning has been applied to (re)train daily functions.

OBJECTIVES

To describe the empirical literature on errorless learning applied to everyday functioning in adults with ABI.

METHOD

A scoping review was conducted with systematic searching of four databases (i.e., AMED, CINAHL, MEDLINE, PsycINFO) and screening by independent reviewers.

FINDINGS

41 experiments from 34 papers met eligibility criteria. Errorless learning has been heterogeneously delineated, described, and applied. Operationalization of everyday functioning has been poorly reported, and mostly applied to technology use and instrumental activities of daily living.

IMPLICATIONS

Greater clarity and detail of errorless learning interventions are required, and more research is needed on its applications to everyday functioning.

Several methods for assessing research waste in reviews with a systematic search: a scoping review

Background

Research waste is present in all study designs and can have significant consequences for science, including reducing the reliability of research findings and contributing to the inefficient use of resources. Estimates suggest that as much as 85% of all biomedical research is wasted. However, it is uncertain how avoidable research waste is assessed in specific types of study designs and what methods could be used to examine different aspects of research waste. We aimed to investigate which methods, systematic reviews, scoping reviews, and overviews of reviews discussing research waste, have used to assess avoidable research waste.

Materials and Methods

We published a protocol in the Open Science Framework prospectively (https://osf.io/2fbp4). We searched PubMed and Embase with a 30-year limit (January 1993-August 2023). The concept examined was how research waste and related synonyms (e.g., unnecessary, redundant, duplicate, etc.) were assessed in reviews with a systematic search: systematic, scoping, or overviews of reviews. We extracted data on the method used in the review to examine for research waste and for which study design this method was applied.

Results

The search identified 4,285 records of which 93 reviews with systematic searches were included. The reviews examined a median of 90 (range 10-6,781) studies, where the study designs most commonly included were randomized controlled trials (48%) and systematic reviews (33%). In the last ten years, the number of reports assessing research waste has increased. More than 50% of examined reviews reported evaluating methodological research waste among included studies, typically using tools such as one of Cochrane Risk of Bias tools (n = 8) for randomized controlled trials or AMSTAR 1 or 2 (n = 12) for systematic reviews. One fourth of reviews assessed reporting guideline adherence to e.g., CONSORT (n = 4) for randomized controlled trials or PRISMA (n = 6) for systematic reviews.

Conclusion

Reviews with systematic searches focus on methodological quality and reporting guideline adherence when examining research waste. However, this scoping review revealed that a wide range of tools are used, which may pose difficulties in comparing examinations and performing meta-research. This review aids researchers in selecting methodologies and contributes to the ongoing discourse on optimizing research efficiency.

Implementation of a multimodal home-based rehabilitation intervention after discharge from inpatient geriatric rehabilitation (GeRas): an early qualitative process evaluation

BACKGROUND

Geriatric rehabilitation aims at increasing physical and social activity and maintaining the functional reserve of older people. However, the continuity of geriatric rehabilitation in the outpatient setting is limited due to a lack of structured aftercare programs. In order to overcome this, a three-month multimodal home-based intervention program (GeRas) was implemented. The aim of this early qualitative process evaluation was to assess GeRas in terms of perceived reach, effectiveness/efficacy, adoption/uptake, implementation, and maintenance/sustainability (Domains within the RE-AIM Framework) from the perspective of patients who received the intervention and healthcare providers who were involved in the delivery of the intervention.

METHODS

In a qualitative process evaluation, 13 healthcare providers and 10 patients were interviewed throughout the beginning of the implementation period of GeRas to capture early experiences using a semi-structured interview guide. The interview guide and qualitative content analysis was guided by the RE-AIM Framework.

RESULTS

The GeRas program was perceived to be largely well implemented and beneficial by healthcare providers and patients. According to healthcare providers, GeRas showed more advantages compared to usual care. Additionally, outcome expectations were mainly met (Domain 1: Effectiveness). However, the implementation of the intervention delivered via the eHealth system was perceived as challenging (Domain 2: Adoption). Nevertheless, the outpatient physical exercise, the outpatient counselling, and the continuous care after discharge improved perceived well-being regardless of the intervention type (Domain 3: Implementation). To facilitate the continued use of GeRas, technical requirements should be created to increase user-friendliness and to motivate patients to continue the training in the long term (Domain 4: Maintenance).

CONCLUSION

Although initial experiences with the implementation and effectiveness of GeRas were positive in general, organisational and technical issues need to be resolved to enhance sustainable and successful implementation of the GeRas program.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00029559). Registered 5/10/2022.

Patient responsiveness as a safewards fidelity indicator: a qualitative interview study on an acute psychiatric in-patient ward

BACKGROUND

The Safewards model aims to reduce conflict and use of containment on psychiatric wards. To evaluate the implementation of Safewards and understand why it is effective in some settings but not in others, it is important to assess the level of implementation fidelity. To do this, the Safewards Fidelity Checklist (SFC) is often used, which focuses on objective visual observations of interventions but does not include patient responsiveness. The latter is a key indicator of implementation fidelity and includes engagement, relevance, acceptability and usefulness. The aim of the present study was to investigate the fidelity of Safewards implementation on an acute psychiatric ward from the perspective of patient responsiveness.

METHOD

The study was conducted on a ward for patients with mainly affective disorders. To assess the general level of fidelity the SFC was used together with a detailed ward walkthrough. Ten patients were interviewed with a focus on patient responsiveness to each of the seven interventions implemented on the ward. Data were analysed using qualitative descriptive analysis.

RESULTS

The findings indicate high implementation fidelity, which was reflected in the SFC assessment, walkthrough and patient responsiveness. Patients gave examples of improvements that had happened over time or of the ward being better than other wards. They felt respected, less alone, hopeful and safe. They also described supporting fellow patients and taking responsibility for the ward climate. However, some patients were unfamiliar with a ward where so much communication was expected. Several suggestions were made about improving Safewards.

CONCLUSIONS

This study confirms previous research that patient responsiveness is an important factor for achieving fidelity in a prevention programme. The patients' descriptions of the acceptability, relevance and usefulness of the specific interventions reflected to a high degree the objective visual observations made by means of the SFC and ward walkthrough. Patient engagement was demonstrated by several suggestions about how to adapt the interventions. There is potential to obtain valuable input from patients when adapting Safewards in practice. This study also presents many examples of practical work with these interventions and the effects it can have on patients' experiences of care.

How does mentoring occupational therapists improve intervention fidelity in a randomised controlled trial? A realist evaluation

BACKGROUND

Integrating complex interventions within healthcare settings can be challenging. Mentoring can be embedded within a randomised controlled trial (RCT) to upskill and support those delivering the intervention. This study aimed to understand, from a realist perspective, how mentoring worked to support implementation fidelity for occupational therapists (OTs) delivering a vocational rehabilitation (VR) intervention within the context of an RCT.

METHODS

A realist evaluation using secondary data (emails, mentoring record forms, interviews) collected as part of an RCT. Three researchers coded the data following content analysis, focused on refining or refuting an initial programme theory by exploring the interactions between context, mechanisms, and outcomes. The research team met to further refine the programme theories.

RESULTS

Data from 584 emails, 184 mentoring record forms, and 25 interviews were analysed following a realist approach. We developed a programme theory consisting of two contexts (trial set-up, ongoing mentoring), nine mechanisms (collective understanding, monitoring, timely support, positive reinforcement, reflective practice, support data completeness, facilitation strategy, shared learning experience, management of research and clinical duties), and three outcomes (improved confidence, improved fidelity, reduced contamination).

CONCLUSIONS

Offering mentoring support to OTs delivering a VR intervention as part of an RCT improves intervention fidelity and reduces the risk of contamination. It improves OTs' understanding of the differences between their clinical and research roles and increases their confidence and competence in trial paperwork completion and identification of potential contamination issues.

Co-design for stroke intervention development: Results of a scoping review

BACKGROUND

Co-design methodology seeks to actively engage end-users in developing interventions. It is increasingly used to design stroke interventions; however, limited guidance exists, particularly with/for individuals with stroke who have diverse cognitive, physical and functional abilities. Thus, we describe 1) the extent of existing research that has used co-design for stroke intervention development and 2) how co-design has been used to develop stroke interventions among studies that explicitly used co-design, including the rationale, types of co-designed stroke interventions, participants involved, research methodologies/approaches, methods of incorporating end-users in the research, co-design limitations, challenges and potential strategies reported by researchers.

MATERIALS AND METHODS

A scoping review informed by Joanna Briggs Institute and Arksey & O'Malley methodology was conducted by searching nine databases on December 21, 2022, to locate English-language literature that used co-design to develop a stroke intervention. Additional data sources were identified through a hand search. Data sources were de-duplicated, and two research team members reviewed their titles, abstracts and full text to ensure they met the inclusion criteria. Data relating to the research objectives were extracted, analyzed, and reported numerically and descriptively.

RESULTS

Data sources used co-design for stroke intervention development with (n = 89) and without (n = 139) explicitly using the term 'co-design.' Among studies explicitly using co-design, it was commonly used to understand end-user needs and generate new ideas. Many co-designed interventions were technology-based (65%), and 48% were for physical rehabilitation or activity-based. Co-design was commonly conducted with multiple participants (82%; e.g., individuals with stroke, family members/caregivers and clinicians) and used various methods to engage end-users, including focus groups and workshops. Limitations, challenges and potential strategies for recruitment, participant-engagement, contextual and logistical and ethics of co-designed interventions were described.

CONCLUSIONS

Given the increasing popularity of co-design as a methodology for developing stroke interventions internationally, these findings can inform future co-designed studies.

Diabetes Specialists Value Continuous Glucose Monitoring Despite Challenges in Prescribing and Data Review Process

BACKGROUND

Diabetes clinicians are key facilitators of continuous glucose monitoring (CGM) provision, but data on provider behavior related to CGM use and CGM generated data are limited.

METHODS

We conducted a national survey of providers caring for people with diabetes on CGM-related opinions, facilitators and barriers to prescription, and data review practices.

RESULTS

Of 182 survey respondents, 73.2% worked at academic centers, 70.6% were endocrinologists, and 70.7% practiced in urban settings. Nearly 70% of providers reported CGM use in the majority of their patients with type 1 diabetes. Half of the providers reported CGM use in 10% to 50% of their patients with type 2 diabetes. All respondents believed CGM improved quality of life and could optimize diabetes control. We found no differences in reported rates of CGM use based on providers' years of experience, patient volume, practice setting, or clinic type. Most providers reviewed CGM data each visit (97.7%) and actively involved patients in the data interpretation (98.8%). Only 14.1% of clinicians reported reviewing CGM data without any prompting from patients or their family members outside of visits. Most providers (80.7%) reported their CGM data review was valued by patients although only half reported having adequate time (45.1%) or an efficient process (56.1%) to do so.

CONCLUSIONS

Despite uniform support for CGM by providers, ongoing challenges related to cost, insurance coverage, and difficulties with prescription were major barriers to CGM use. Increased use of CGM in appropriate populations will necessitate improvements in data access and integration, clearly defined workflows, and decreased administrative burden to obtain CGM.

Barriers and facilitators to implementing priority setting and resource allocation tools in hospital decisions: A systematic review

Health care budgets in high-income countries are having issues coping with unsustainable growth in demand, particularly in the hospital setting. Despite this, implementing tools systematising priority setting and resource allocation decisions has been challenging. This study answers two questions: (1) what are the barriers and facilitators to implementing priority setting tools in the hospital setting of high-income countries? and (2) what is their fidelity? A systematic review using the Cochrane methods was conducted including studies of hospital-related priority setting tools reporting barriers or facilitators for implementation, published after the year 2000. Barriers and facilitators were classified using the Consolidated Framework for Implementation Research (CFIR). Fidelity was assessed using priority setting tool's standards. Out of thirty studies, ten reported program budgeting and marginal analysis (PBMA), twelve multi-criteria decision analysis (MCDA), six health technology assessment (HTA) related frameworks, and two, an ad hoc tool. Barriers and facilitators were outlined across all CFIR domains. Implementation factors not frequently observed, such as 'evidence of previous successful tool application', 'knowledge and beliefs about the intervention' or 'external policy and incentives' were reported. Conversely, some constructs did not yield any barrier or facilitator including 'intervention source' or 'peer pressure'. PBMA studies satisfied the fidelity criteria between 86% and 100%, for MCDA it varied between 36% and 100%, and for HTA it was between 27% and 80%. However, fidelity was not related to implementation. This study is the first to use an implementation science approach. Results represent the starting point for organisations wishing to use priority setting tools in the hospital setting by providing an overview of barriers and facilitators. These factors can be used to assess readiness for implementation or to serve as the foundation for process evaluations. Through our findings, we aim to improve the uptake of priority setting tools and support their sustainable use.

Trauma- and Violence-Informed Care: Orienting Intimate Partner Violence Interventions to Equity

Purposeof Review

Intimate partner violence (IPV) is a complex traumatic experience that often co-occurs, or is causally linked, with other forms of structural violence and oppression. However, few IPV interventions integrate this social-ecological perspective. We examine trauma- and violence-informed care (TVIC) in the context of existing IPV interventions as an explicitly equity-oriented approach to IPV prevention and response.

Recent Findings

Systematic reviews of IPV interventions along the public health prevention spectrum show mixed findings, with those with a theoretically grounded, structural approach that integrates a trauma lens more likely to show benefit.

Summary

TVIC, embedded in survivor-centered protocols with an explicit theory of change, is emerging as an equity-promoting approach underpinning IPV intervention. Explicit attention to structural violence and the complexity of IPV, systems and sites of intervention, and survivors' diverse and intersectional lived experiences has significant potential to transform policy and practice.

Developing a method to assess fidelity to a complex vocational rehabilitation intervention in the FRESH trial: a feasibility study

BACKGROUND

Determining whether complex rehabilitation interventions are delivered with fidelity is important. Implementation fidelity can differ between sites, therapists delivering interventions and, over time, threatening trial outcomes and increasing the risk of type II and III errors. This study aimed to develop a method of assessing occupational therapists' fidelity to deliver a complex, individually tailored vocational rehabilitation (VR) intervention to people with traumatic brain injury (TBI) and assess the feasibility of its use in a randomised controlled trial.

METHODS

Using mixed methods and drawing on the intervention logic model, we developed data collection tools to measure fidelity to early specialist TBI VR (ESTVR). Fidelity was measured quantitatively using intervention case report forms (CRF), fidelity checklists and clinical records. Qualitative data from mentoring records, interviews with intervention therapists, participants with TBI, employers and NHS staff at trial sites explored moderators of implementation fidelity. The conceptual framework of implementation fidelity (CFIF) guided measurement and analysis of and factors affecting fidelity. Data were triangulated and benchmarked against an earlier cohort study.

RESULTS

Fidelity to a complex individually tailored VR intervention could be measured. Overall, OTs delivered ESTVR with fidelity. Different fidelity measures answered different questions, offering unique insights into fidelity. Fidelity was best assessed using a fidelity checklist, intervention CRFs and clinical notes. The OT clinical notes and mentoring records were best at identifying fidelity moderating factors. Interviews added little insight into fidelity moderating factors over and above mentoring or clinical records. Data triangulation offered a comprehensive assessment of fidelity, highlighting limitations of measurement methods and learning for future trials but was resource intensive. Interviews, fidelity visits and analysing clinical notes were also resource intense. Comparing fidelity data to a benchmark and using CFIF as a framework for organising the fidelity assessment helped.

CONCLUSIONS

OTs delivered the VR intervention with fidelity. A fidelity checklist and benchmark plus mentoring may offer a practical and effective way of measuring fidelity and identifying fidelity moderating factors in trials of complex individually-tailored rehabilitation interventions. Mentoring provided real-time indicators of and reasons for fidelity deviations. These methods require further evaluation.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN38581822 (Registered: 02/01/2014).

Embedding mentoring to support trial processes and implementation fidelity in a randomised controlled trial of vocational rehabilitation for stroke survivors

BACKGROUND

Little guidance exists regarding how best to upskill and support those delivering complex healthcare interventions to ensure robust trial outcomes and implementation fidelity. Mentoring was provided to occupational therapists (OTs) delivering a complex vocational rehabilitation (VR) intervention to stroke survivors. This study aimed to explore mentors' roles in supporting OTs with intervention delivery and fidelity, and to describe factors affecting the mentoring process and intervention delivery.

METHODS

Quantitative data (duration, mode and total time of mentoring support) was extracted from mentoring records and emails between mentors and OTs, alongside qualitative data on barriers and facilitators to intervention delivery. Semi-structured interviews with mentors (n = 6) and OTs (n = 19) explored experiences and perceptions of intervention training, delivery and the mentoring process. Mean total and monthly time spent mentoring were calculated per trial site. Qualitative data were analysed thematically.

RESULTS

Forty-one OTs across 16 sites were mentored between March 2018 and April 2020. Most mentoring was provided by phone or Microsoft Teams (range: 88.6-100%), with the remainder via email and SMS (Short Message Service) text messages. Mentors suggested strategies to enhance trial recruitment, improved OTs' understanding of- and adherence to trial processes, intervention delivery and fidelity, and facilitated independent problem-solving. Barriers to mentoring included OT non-attendance at mentoring sessions and mentors struggling to balance mentoring with clinical roles. Facilitators included support from the trial team and mentors having protected time for mentoring.

CONCLUSIONS

Mentoring supported mentee OTs in various ways, but it remains unclear to what extent the OTS would have been able to deliver the intervention without mentoring support, or how this might have impacted fidelity. Successful implementation of mentoring alongside new complex interventions may increase the likelihood of intervention effectiveness being observed and sustained in real-life contexts. Further research is needed to investigate how mentors could be selected, upskilled, funded and mentoring provided to maximise impact. The clinical- and cost-effectiveness of mentoring as an implementation strategy and its impact on fidelity also requires testing in a future trial.

TRIAL REGISTRATION

ISRCTN, ISRCTN12464275 . Registered on 13th March 2018.