Contextualized perceptions of movement as a source of expanded insight: People with multiple sclerosis' experience with physiotherapy

A comparison of the effects of occupation-based interventions with and without responsibility feedback and conventional interventions on participation in people with idiopathic Parkinson's disease: study protocol for a randomized controlled trial

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disorder with debilitating motor and non-motor symptoms which affect participation in meaningful occupations. Occupation-based interventions can improve participation in people with PD. Evidence for incorporating structured and intensive occupational therapy by considering the concept of responsibility is lacking for this population. This trial will compare the effects of occupation-based interventions with and without responsibility feedback and conventional interventions on participation in people with idiopathic PD.

METHODS

A total of 45 people with PD, between 35 and 85 years old and Hoehn and Yahr stages between I to III, will be recruited from movement disorder centers for this three-armed study. Participants will be randomized into three groups (occupation-based interventions with responsibility feedback, occupation-based interventions without responsibility feedback, and conventional interventions). All participants will receive intervention for 24 sessions during a period of 12 weeks (2 sessions per week). The primary outcome measure will be participation satisfaction. Participation frequency and restriction, self-perceived performance, performance satisfaction, motivation, volition, sense of agency, responsibility, physical activity, community integration, activities of daily living (ADL), instrumental ADL, upper extremity function, balance, fatigue, and quality of life will be measured as secondary outcome measures. All outcomes will be measured at baseline, session 9, session 17, post-intervention (week 13), and follow-up (week 25).

DISCUSSION

This home-based high-intensity, structured, client-centered, and occupation-based intervention will be conducted by utilizing the concept of responsibility. This proposed trial may result in enhanced participation that would benefit other motor and non-motor symptoms in people living with PD. Findings from this proposed study are expected to expand the knowledge of clinicians and help them in evidence-based decision-making processes.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20140304016830N13. Registered on August 19, 2022.

Consensus on Feedback Statements That Create Responsibility Among People With Parkinson's Disease: A Delphi Study

IMPORTANCE

Sense of agency is associated with a sense of responsibility, which is essential to performing goal-directed occupations.

OBJECTIVE

To reach consensus on a set of extrinsic feedback statements that have the potential to create a sense of responsibility among patients with neurological disorders in the course of performing daily or social occupations.

DESIGN

Anonymous Delphi study with two rounds with international experts and one round with Irani patients with Parkinson's disease (PD).

SETTING

Electronic survey.

PARTICIPANTS

One hundred experts and 73 patients with idiopathic PD.

OUTCOMES AND MEASURES

Experts and patients anonymously rated (5 = strongly agree/very effective, 4 = agree/effective, 3 = neither agree nor disagree/uncertain, 2 = disagree/ineffective, 1 = strongly disagree/very ineffective) their level of agreement with each survey statement and the effectiveness of each statement in creating a sense of responsibility in the course of performing daily or social occupations. Consensus was set as an interquartile range of ≤1 and ≥70% agreement in two adjacent categories of a Likert scale.

RESULTS

In the experts' first round, consensus was reached on the level of agreement and effectiveness of 18 statements. In the second round, final consensus was achieved on all statements. In the one patient round, patients reached consensus on all statements. Finally, 34 statements were rated as 4 or 5 in terms of agreement and effectiveness, based on the opinions of experts and patients.

CONCLUSIONS AND RELEVANCE

This study has produced a collection of feedback statements that might be useful in occupation-based interventions. What This Article Adds: Extrinsic responsibility feedback delivered while administering occupation-based interventions may increase volition, motivation, and engagement.

Embodiment, tailoring, and trust are important for co-construction of meaning in physiotherapy after stroke: A qualitative study

Background and Purpose

Physiotherapy, with an emphasis on high intensity, individually tailored, and person‐centered treatment, is an effective route for recovery after a stroke. No single approach, however, has been deemed paramount, and there is limited knowledge about the patient experience of assessment, goal‐setting, and treatment in physiotherapy. In this study, we seek to report patient experiences of I‐CoreDIST—a new physiotherapy intervention that targets recovery—and those of usual care. The purpose is to investigate how individuals with stroke experience the bodily and interactive course of physiotherapy during their recovery process.

Methods

A qualitative study, nested within a randomized controlled trial, consisting of in‐depth interviews with 19 stroke survivors who received either I‐CoreDIST or usual care. Data were analyzed using systematic text condensation, and this analysis was informed by enactive theory.

Results

Interaction with the physiotherapist, which was guided by perceived bodily changes, fluctuated between being, on the one hand, formal/explicit and, on the other, tacit/implicit. The experiences of participants in the intervention group and the usual care group differed predominantly with regards to the content of therapy sessions and the means of measuring progress; divergences in levels of satisfaction with the treatment were less pronounced. The perception of positive bodily changes, as well as the tailoring of difficulty and intensity, were common and essential features in generating meaning and motivation. An embodied approach seemed to facilitate sense‐making in therapy situations. In the interaction between the participants and their physiotherapists, trust and engagement were important but also multifaceted, involving both interpersonal skills and professional expertise.

Conclusion

The embodied nature of physiotherapy practice is a source for sense‐making and meaning‐construction for patients after a stroke. Trust in the physiotherapist, along with emotional support, is considered essential. Experiencing progress and individualizing approaches are decisive motivators.

A qualitative interview study on how people with incomplete spinal cord injury experience high-intensity walking exercise

STUDY DESIGN

Qualitative, in-depth research interviews.

OBJECTIVE

To provide new insight into how people with a recent incomplete spinal cord injury (SCI) experience high-intensity walking exercise after discharge from subacute inpatient rehabilitation.

SETTING

Informants for this interview study participated in a previous randomized controlled trial (RCT) that was conducted at Sunnaas Rehabilitation Hospital, Norway.

METHODS

Four individual face-to-face interviews were conducted with the participants in natural setting. The interviews were analyzed through systematic text condensation and discussed in the context of experiences of bodily changes.

RESULTS

Four themes emerged that described positive but also challenging bodily experiences related to performing high-intensity walking exercise: "Expectations and motivation"-reasons for participating, "Challenging bodily changes"-impacts on walking ability, "Adaptation strategies"-achieving the high-intensity target level, and "Integrating exercise into a new daily life"-combining participation, new body and new life.

CONCLUSIONS

This study indicates the importance of participating in a specific exercise program at discharge from subacute inpatient rehabilitation for ambulant people with SCI. However, high-intensity walking exercise may be too demanding to perform during this time period. The insights from the study provide new knowledge that can contribute to improving clinical rehabilitation practice.

Group dynamics in a group-based, individualized physiotherapy intervention for people with multiple sclerosis: A qualitative study

OBJECTIVE

Group-based physiotherapy is a common and beneficial intervention for people with multiple sclerosis (MS). Most group interventions are not individually adapted to each participant's needs. Evidence on how individualization and group elements can be combined in a clinical setting is lacking. The objective of this study is to expand the knowledge base in neurological physiotherapy by investigating the nature of group dynamics in a group-based, individualized intervention for people with MS.

METHODS

This qualitative study included 13 nonparticipatory video observations (14 hr 38 min) of GroupCoreDIST exercise sessions complemented by 13 interviews (12 hr 37 min) with physiotherapists (PTs). The purposively sampled participants included 40 patients with MS (expanded disability scale of 1.0-6.5) and six PTs with expertise in neurological physiotherapy. Data were analysed using systematic text condensation in an enactive theoretical framework.

RESULTS

Two main categories emerged from the material. (a) Individual systems affect group dynamics: Individual perceptions of success through adapted and embodied approaches positively affected the dynamics of the group. (b) Disease and exercise peer support: Social support was a substantial product of dynamic group processes and was enhanced through the PTs' strategic focus on experience sharing.

CONCLUSION

The results revealed that group dynamics benefit from individualization and the PTs' focus on experience sharing. These findings are contrary to the prevailing view that individualization and group-based interventions are mutually exclusive and thus should be considered in group-based interventions for people with MS.

Group-based, individualized exercises can provide perceived bodily changes and strengthen aspects of self in individuals with MS: a qualitative interview study

Background: Group-based physiotherapy is effective for individuals with MS; nevertheless individualization within groups is questioned and little is known regarding individuals´ experiences with individualization in small groups.Objective: We aimed to explore the short- and long-term experiences of individuals with MS participating in a 6-week, group-based, individualized physiotherapy-intervention.Methods: Within a randomized controlled trial (RCT), 25 in-depth interviews with a strategic sample of 13 people (9 women; age 25-79 years old; European Disability Status Scale (EDSS) 1-6.5) were conducted at weeks 7 and 30 using systematic text condensation, with dynamic systems theory and phenomenology as analytical frameworks.Results: The main categories were: 1) movement control, orientation and insights: Bodily improvements were associated with targeted exercises, specific adjustments by the physiotherapist, emotional engagement and re-access to activities; and 2) the individual within the group: Equal distributions of one-to-one interactions and attention were important for experiencing success. Less attention and improvements turned attention toward own disability. Physical changes felt particularly emotional short term, implying that individuals' feelings of ownership and control of body and movement, new views of themselves and changed affordances in daily life were involved.Conclusion: Equally distributed attention and engagement, targeted exercises and hands-on adjustments resulting in visible and perceived bodily changes were experienced as key factors of individualization in small groups.

A group-based, individualized physiotherapy intervention for people with multiple sclerosis-A qualitative study

BACKGROUND AND PURPOSE

Group-based interventions for people with multiple sclerosis (MS) have gained increased attention in the field of physiotherapy research. However, no studies have investigated whether or how the prevailing principle of individualization is embedded in such interventions. The purpose of this study was to investigate how professional actions and interactions affect individualized exercise adaptations in a group intervention for people with MS.

METHODS

This study had a qualitative design and investigated and analysed the actions and interactions of six different physiotherapists (PTs) with expertise in neurology and 40 patients (27 female and 13 male, mean age 52.2 years, mean Expanded Disability Status Scale 2.45) in a group-based exercise intervention (GroupCoreDIST) for people with MS. We performed nonparticipatory video observations of 13 group exercise sessions, each consisting of three patients, followed by 13 semistructured in-depth interviews with the PTs. Systematic text condensation analysis was conducted within an enactive theoretical framework.

RESULTS

The results of our study indicated that the extent of embodied interaction and patient participation affect the possibilities and challenges regarding individualization within a group intervention. Handling, facilitation, emphasis on movement quality, and PTs who invited their patients to play an active role in the encounter enriched the reasoning and decision-making processes and yielded opportunities to adapt exercises to the specific patient's impairments. However, the combination of individuality and collectivity within a group context brings forth challenges in which the PTs are obligated to both preserve the benefits of being in a group and simultaneously attend to individual patients.

CONCLUSIONS

Our study indicates that despite challenges, the PTs' integration of embodied interaction and mutual participation enables the patients to concurrently benefit from individualization and being in a group. These findings contribute to the question regarding the significance of individual adaptations in group interventions and point toward a need for future effect studies that compare standardized and individualized exercise protocols.

Physiotherapy assessment of individuals with multiple sclerosis prior to a group intervention - A qualitative observational and interview study

Assessment prior to both individual and group interventions is fundamental to neurological physiotherapy practice. However, knowledge is limited regarding how assessments are carried out, particularly assessments conducted prior to group interventions, which have recently gained increasing attention in clinical research. In this qualitative study, we investigated how physiotherapy assessments of patients with multiple sclerosis prior to a group exercise intervention were carried out and what physiotherapists considered vital elements in the assessment process. Data were gathered through 12 qualitative non-participatory video observations followed by in-depth interviews of physiotherapists. Systematic text condensation analysis was conducted within an enactive theoretical framework of participatory sense making. In the assessments, patients' bodily perceptions of movement changes appeared to be vital in establishing patient expectations for the forthcoming intervention. The extent of patient participation and an embodied approach to communication influenced both the physiotherapists' and patients' insights into the patients' movement problems, which were further utilized in the initial intervention planning. Significant differences in context from the assessment to the intervention require a systematic completion of the assessments in the course of the first clinical meeting, which should be considered in the further development of research and clinical practices.

Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences

PURPOSE

This systematic review was conducted to provide rich and deep evidence of the perceived determinants and consequences of physical activity and exercise based on qualitative research in multiple sclerosis (MS).

METHOD

Electronic databases and article reference lists were searched to identify qualitative studies of physical activity and exercise in MS. Studies were included if they were written in English and examined consequences/determinants of physical activity in persons with MS. Content analysis of perceived determinants and consequences of physical activity and exercise was undertaken using an inductive analysis guided by the Physical Activity for people with Disabilities framework and Social Cognitive Theory, respectively.

RESULTS

Nineteen articles were reviewed. The most commonly identified perceived barriers of physical activity and exercise were related to the environmental (i.e. minimal or no disabled facilities, and minimal or conflicting advice from healthcare professionals) and related to personal barriers (i.e. fatigue, and fear and apprehension). The most commonly identified perceived facilitators of physical activity were related to the environment (i.e. the type of exercise modality and peer support) and related to personal facilitators (i.e. appropriate exercise and feelings of accomplishment). The most commonly identified perceived beneficial consequences of physical activity and exercise were maintaining physical functions, increased social participation and feelings of self-management and control. The most commonly identified perceived adverse consequences were increased fatigue and feelings of frustration and lost control.

CONCLUSIONS

Results will inform future research on the perceived determinants and consequences of physical activity and exercise in those with MS and can be adopted for developing professional education and interventions for physical activity and exercise in MS.

IMPLICATIONS FOR REHABILITATION

Physical activity and exercise behaviour in people with multiple sclerosis (MS) is subject to a number of modifiable determinants. Healthcare professionals working to promote physical activity and exercise in those with MS should choose to endorse the positive benefits of participation. Future physical activity interventions for those with MS may be improved by incorporating behavioural management strategies.

Embodied-enactive clinical reasoning in physical therapy

Clinical reasoning is essential in physical therapy practice. Instrumental approaches and more recent narrative approaches to clinical reasoning guide physical therapists in their understanding of the patient's movement disturbances and help them to plan strategies to improve function. To the extent that instrumental and/or narrative models of clinical reasoning represent impairments as mere physical disturbances, we argue that such models remain incomplete. We draw on a phenomenologically inspired approach to embodied cognition (termed "enactivism") to suggest that the dynamics of lived bodily engagement between physical therapist and patient contribute to and help to constitute the clinical reasoning process. This article outlines the phenomenologically informed enactive perspective on clinical reasoning, with special reference to clinical work that addresses impairments as sequelae of neurological diseases.

Embodiment and self in reorientation to everyday life following severe traumatic brain injury

People with severe traumatic brain injury (sTBI) are often young and need long-term follow-up as many suffer complex motor, sensory, perceptual and cognitive impairments. This paper aims to introduce phenomenological notions of embodiment and self as a framework to help understand how people with sTBI experience reorientation to everyday life, and to inform clinical practice in neurological physiotherapy. The impairments caused by the sTBI may lead to a sense of alienation of one's own body and changes in operative intentionality and in turn disrupt the reorganization of self, identity, everyday life and integration/co-construction of meaning with others. Applying a first-person conception of the body may extend insights into the importance of an adapted and individualized approach to strengthen the sensory, perceptual and motor body functions, which underpin the pre-reflective and reflective aspects of the self. It seems important to integrate these aspects, while also paying attention to optimizing co-construction of meaning for the person with sTBI in the treatment context. This requires understanding the patient as an experiencing and expressive body, a lived body (body-as-subject) and not just the body-as-object as is favored in more traditional frameworks of physiotherapy.