Method: Two independent expert teams analyzed medical records on 299 consecutive patients admitted for CSS or DSS rehabilitation. One team provided a golden standard for the patient referrals, and the other team provided RCS-E scores. Models for predicting referrals from RCS-E scores were developed on data for 149 patients and tested on the remaining 150 patients.
Results: The optimal RCS-E sum score threshold for referral prediction was 11, predicting the golden standard for patient referral with sensitivity 88%, specificity 78% and correct classification rate 81%. Improved referral prediction performance was achieved by using RCS-E item-wise score thresholds (sensitivity 81%, specificity 89%, correct classification rate 87%). The RCS-E sum score range for patients referred CSS and DSS by the item-wise model was, respectively, 0–12 and 2–22 suggesting strong non-linear interaction of the RCS-E items.
Conclusions: We found excellent referral decision support in the RCS-E and the item specific threshold model, when patients with acquired brain injury are to be referred to CSS or DSS as their primary rehabilitation.
- Implications for Rehabilitation
Efficient rehabilitation after acquired brain injury requires rehabilitation settings that meet patient needs.
Validated tools for referral decision support make the process more transparent.
Patient rehabilitation complexity can be stratified by the RCS-E with high sensitivity, specificity and predictive value of positive test.
RCS-E is an excellent tool for referral decision support.
Materials and methods: An exploratory qualitative study consisting of in-depth interviews and six-month follow-up with 11 men and women with RA employed at disease onset.
Results: We expand upon previous models of sickness presenteeism by distinguishing between presenteeism that occurs voluntarily (wanting to work despite illness) and involuntarily (feeling pressured to work when ill). RA onset affected participants’ ability to work, yet motivation to remain working remained high. The implementation of workplace adjustments enabled participants to stay working and restore their work capacity. Conversely, managers’ misinterpretation of organizational sickness absence policies could lead to involuntary presenteeism or delayed return to work, conflicting with the notion of work as an aid to recovery.
Conclusion: Workplace adjustments can facilitate voluntary sickness presenteeism. To reduce work disability and sickness absence, organizational policies should be sufficiently flexible to accommodate the needs of workers with fluctuating conditions.
- Implications for rehabilitation
Individuals with rheumatoid arthritis (RA) are at high risk of work disability.
Individuals’ motivation to remain in work following onset of RA remains high, yet sickness presenteeism (working while ill) has received largely negative attention.
It is important to distinguish between voluntary and involuntary forms of sickness presenteeism.
Workplace adjustments facilitate voluntary sickness presenteeism (wanting to work despite illness) and improve job retention and productivity among workers with RA.
Involuntary presenteeism (feeling pressured to work while ill) may occur if organizational policies are not sufficiently flexible to accommodate the needs of workers with RA.
Design: We conducted focus groups (FGs) with 17 GPs.
Setting: Norwegian primary health care.
Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.
Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.
Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.
- KEY POINTS
Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:
There is a lack of preparation and formal training for the leadership role.
GPs experience tensions between the clinical and leadership role.
GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.
Methods: It was performed with an extensive literature review, mainly clinical practice guidelines, randomized controlled trials, reviews, focusing on the rehabilitation management.
Results: There are few clinical practice guidelines that address GHOA as a pathology with unique characteristics. Evidence based treatment recommendations are mostly supported by low-quality evidence and experts’ opinions, with few high levels of evidence studies guiding treatment decisions.
Conclusions: Despite the lack of good quality evidence, rehabilitation programs have proven to be efficient and reliable, and this revision provides information and recommendations in this field.
- Implication of Rehabilitation
Glenohumeral osteoarthritis is a common cause of pain and functional disability of the shoulder
There are few clinical practice guidelines that address Glenohumeral Osteoarthritis as a pathology with unique characteristics, and recommendations for rehabilitation and therapeutic exercise are poor
The paper provides current information on the characteristics of the disease, its rehabilitation process, and could be of interest for rehabilitation professionals to direct their practices in this field
Method: We provide a summary of models of psychological adjustment to chronic disease. We also evaluate various options for incorporating categories of psychological adjustment into the ICF.
Results: Acute and ongoing illness stressors; emotional, cognitive and behavioral responses; personal background; and social and environmental background are major categories in the adjustment process. These categories could, in principle, be integrated with various components of the ICF. Any future revision of the ICF should explicitly incorporate psychological adjustment and its (sub)categories.
Conclusion: The ICF could incorporate categories of psychological adjustment to chronic disease, although several adaptations and clarifications will be required.
- Implications for Rehabilitation
In the context of an ageing society and large numbers of people living with chronic diseases, it is essential to understand psychological adjustment to chronic disease.
However, the classification of psychological adjustment to chronic disease is unclear in the current version of the International Classification of Functioning, Disability and Health (ICF).
We demonstrate that the ICF could incorporate categories of psychological adjustment to chronic disease, although several adaptations and clarifications would first be required.
We suggest that these adaptations and clarifications should be considered in any future revision of the ICF.
Method: Grounded theory methodology was employed. Clinicians, representing six disciplines across seven services, were recruited and interviewed until theoretical saturation was achieved. A total of 22 clinicians were interviewed.
Results: A theoretical framework was developed to explain how clinicians support clients to actively engage in goal setting in routine practice. The framework incorporates three phases: a needs identification phase, a goal operationalisation phase, and an intervention phase. Contextual factors, including personal and environmental influences, also affect how clinicians and clients engage in this process. Clinicians use additional strategies to support clients with impaired self-awareness. These include structured communication and metacognitive strategies to operationalise goals. For clients with emotional distress, clinicians provide additional time and intervention directed at new identity development.
Conclusions: The goal setting practice framework may guide clinician’s understanding of how to engage in client-centred goal setting in brain injury rehabilitation. There is a predilection towards a client-centred goal setting approach in the community setting, however, contextual factors can inhibit implementation of this approach.
- Implications for Rehabilitation
The theoretical framework describes processes used to develop achievable client-centred goals with people with brain injury.
Building rapport is a core strategy to engage clients with brain injury in goal setting.
Clients with self-awareness impairment benefit from additional metacognitive strategies to participate in goal setting.
Clients with emotional distress may need additional time for new identity development.
Methods: Semi-structured interviews, subject to general inductive analysis with 20 Clinicians’ working in three UK based stroke rehabilitation teams (one in-patient ward and two community based rehabilitation teams).
Results: There were three key themes that impacted on the patients active involvement in setting goals for rehabilitation after stroke: Patient barriers to goal setting (knowledge of the patient and family, who is the patient and the stroke’s impact); How we work as a team (the role of the patient in setting goals, the effect of clinician attributes on goal setting); and How systems impact goal setting (goal-setting practice, home versus hospital, and professional/funder expectations of clinicians’).
Conclusions: Goal setting served a range of different, sometimes conflicting, functions within rehabilitation. Clinicians’ identified the integral nature of goals to engage and motivate patients and to provide direction and purpose for rehabilitation. Further, there was an identified need to consider the impact of prioritizing clinician-derived goals at the expense of patient-identified goals. Lastly the reliance on the SMART goal format requires further consideration, both in terms of the proposed benefits and whether they disempower the patient during rehabilitation.
- Implications for rehabilitation
Goal setting is often promoted as a relatively simple, straightforward way to structure interactions with patients
Patient-related factors together with resourcing constraints are significant barriers to patient-centered goal setting, particularly during inpatient rehabilitation
Clinicians need to have pragmatic tools that can be integrated into practice to ensure that goal-setting practice can be maximized for patients with different intrinsic characteristics
Design: A historical population-based cohort study.
Setting: The Danish CRC screening programme and general practice.
Subjects: The 376,198 individuals invited to the Danish CRC screening programme from 1 March to 31 December 2014.
Main outcome Measures: The diagnostic activity (consultations and haemoglobin measures) in general practice in the year preceding the screening invitation and the cumulated incidence of CRC in the year following the screening invitation.
Results: Screening participants had significantly higher diagnostic activity than non-participants. Individuals with a positive faecal immunochemical test (FIT) had higher diagnostic activity compared to individuals with a negative FIT, and a small increase in the months leading up to the invitation. Individuals with a screen-detected CRC had lower diagnostic activity than individuals with no CRC. In total, 308 (25.3%) of CRCs diagnosed in the invited population were diagnosed outside the screening programme. Non-participants with CRC more often had low socio-economic status, high comorbidity and stage IV CRC than participants with CRC.
Conclusions: There was a tendency that participants and those with a positive FIT had a higher diagnostic activity the year before the screening. This was not seen for those with CRC detected through screening. CRC must still be diagnosed in general practice in the invited population and non-participants are of special interest as they have higher risk of late stage CRC.
- Key Points
Current awareness:Individuals with colorectal cancer (CRC) in screening may be symptomatic and CRC may still occur outside screening in the invited population.
Most important points:The majority of individuals with CRC in screening cannot be expected to be diagnosed on symptomatic presentation in general practice
GPs have to be aware that CRC still occurs outside screening in the invited population
Non-participants with CRC are often deprived and have late stage CRC
Method: Meta-ethnography was used to inform the review, and 21 studies were included.
Findings: The analysis identified a core theme of “engaging in care: struggling through”, as carers, who wanted to be involved in caring, learnt to live with the intense and stressful impact of caring and changes to their life. The core theme is represented through three themes (1) Helping another to live, (2) Adapting ways of living and (3) Negotiating the unknown.
Conclusions: The discussion identified a focus on carers of people suffering from a hip fracture, the willingness of informal carers to engage in caring and the intense experience of adapting to changes in relationships and dependency alongside a steep experiential learning curve. Tensions exist in negotiations with complex health care systems as carers do not feel their expertise is valued and struggle to find and understand information.
- Implications for Rehabilitation
Including relatives/carers in the umbrella of care within a family-centred approach.
Involving relatives/carers within shared decision-making about care requirements and rehabilitation goals.
Utilizing forms of experiential learning to help the development of relatives/carers skills in relation to their role as carer.
Providing opportunities for carers to explore ways of sustaining their own health through self-compassion.
Method: A narrative review was completed regarding integrative intervention that could potentially apply to aphasia population.
Results: Through this article we have explored various treatment options for integrative health care in aphasiology. Integrative treatments including brain specific antioxidants, progesterone and estradiol therapy, nutrition, synbiotic treatment, exercise, yoga, meditation and positive mood states have demonstrated positive changes in health and behavior in healthy aging or disorders such as stroke and aphasia. Offering integrative treatment for people with aphasia allows potential for high impact gains when combined with current speech language therapeutic practices.
Conclusion: This paper highlights the rehabilitation possibilities for aphasia therapy. Combining complementary and traditional treatment approaches could be viewed as one of the contemporary approaches to clinical practice and research for practitioners and health care systems.
- Implications for Rehabilitation
There has been very little research that explores the potential of various types of integrative treatment for individuals with aphasia.
An integrative approach to the treatment of aphasia has potential for future clinical application.
Combining treatment approaches could be viewed as a viable approach to clinical practice and in the health care system.
Method: Two in-depth semi-structured interviews were conducted six months apart with 21 people aged 18 to 65 with high-care needs of varying etiology and living in different housing settings. Nineteen family members involved in decision-making about housing and supports were also interviewed.
Results: Thematic data analysis yielded five themes: (1) Traveling in different directions; (2) “the fight, the battle and the war”; (3) willing but wanting; (4) uncertainty and vulnerability; and (5) redefining social roles and relationships.
Conclusions: Current disability policy is not satisfying the housing and support requirements of adults with high-care needs and their families. The findings provide rigorous, empirical evidence which indicate the urgent need to improve access to affordable, individualized housing and support packages, including financial, practical and informational support for family members involved in caring roles.
- Implications for Rehabilitation
Individual preferences are an important consideration in housing and support arrangements for younger people with high-care needs alongside needs-based solutions.
Individualized funding approaches may provide flexibility of care and choice in housing and support for people with disability.
Family members willingly provide substantial informal care, support and advocacy for younger people with high needs but perceive their role as a constant “battle”.
Payment of family members in recognition of caring work was perceived as a solution to relieve family hardship and ensure optimal care.
Method: Semi-structured interviews were completed with 18 neurological physiotherapists (2–22 years experience) from SCI centres in the United Kingdom and Ireland. Framed by interpretivism, an inductive thematic analysis was conducted.
Results: Three themes were identified: (1) perceived importance of PA; (2) inconsistent PA promotion efforts; and (3) concern regarding community PA.
Conclusions: This article makes a significant contribution to the literature by identifying that although physiotherapists value PA, active promotion of PA remains largely absent from their practice. To enable physiotherapists to promote and prescribe PA as a structured and integral component of their practice, effective knowledge strategies need designing and implementing at the macro, meso, and micro levels of healthcare.
- Implications for Rehabilitation
Physiotherapists are well placed to promote a physically active lifestyle and are perceived as valued and trusted messengers of physical activity (PA).
The importance of PA for patients with spinal cord injury (SCI) is valued by physiotherapists yet PA promotion is largely absent from their practice.
Physiotherapists lack specific education and training on PA and SCI and hold certain beliefs which restrict their promotion of PA.
Knowledge translation across the macro, meso, and micro levels of healthcare are essential to facilitate effective PA promotion.
Design and setting: Discussion paper based on placebo–nocebo and pain studies conducted in the western world.
Main outcome measures: Literature-based theory about impact of communication elements on seriousness of symptoms in clinical practice.
Results: The therapeutic outcome seems to be impacted by rituals around a clinical encounter and by the doctor patient communication and relation. A warm, friendly and empathic attitude is crucial in the first contact with the practice and during the consultation as it influences the patient’s perceived outcome. It is important to raise positive expectations when discussing the prognosis, conducting treatment and prescribing medications as the effect may be reduced if the physician expresses doubt about the effectiveness of the medication. Additionally, overly focus on side effects in the doctor–patient conversation about proposed treatments seems to influence the magnitude of perceived side effects in the patient. Thus, shared decision-making might be a desirable tool for ensuring better expectations in the patient and successful symptom relief.
Conclusions: The context of the doctor–patient interplay matters. Placebo–nocebo research provides strong evidence for this link. The therapeutic context induces biomedical processes in the patient’s brain that may enhance or reduce the effects of chosen interventions. The context thus works as a drug, with real effects and side effects.
- KEY POINTS
Increased awareness of the context drug may help GPs alleviate symptoms and better motivate patients for treatment.
Treatment is affected by multiple types of context, as also confirmed by placebo–nocebo research.
The therapeutic context influences the biomedical processes, which may enhance or reduce intervention effects on symptoms.
The impact of context should be considered in daily general practice as it may serve as a drug, with real effects and side effects.
Method: Nine children with disabilities, nine regular and nine special education teachers participated in the study. Teachers adapted academic activities so they could also be performed by the children with disabilities using the IAMCAT. An inductive content analysis of the teachers’ interviews before and after the intervention was performed.
Results: Teachers considered the IAMCAT to be a useful resource that can be integrated into the regular class dynamics respecting their curricular planning. It had a positive impact on children with disabilities and on the educational community. However, teachers pointed out the difficulties in managing the class, even with another adult present, due to the extra time required by children with disabilities to complete the activities.
Conclusions: The developed assistive technologies enable children with disabilities to participate in academic activities but full inclusion would require another adult in class and strategies to deal with the additional time required by children to complete the activities.
- Implications for Rehabilitation
Integrated augmentative manipulation and communication assistive technologies are useful resources to promote the participation of children with motor and speech impairments in classroom activities.
Virtual tools, running on a computer screen, may be easier to use but further research is needed in order to evaluate its effectiveness when compared to physical tools.
Full participation of children with motor and speech impairments in academic activities using these technologies requires another adult in class and adequate strategies to manage the extra time the child with disabilities may require to complete the activities.
Materials and methods: Eleven adolescents and adults were interviewed using Talking Mats and interview data was analyzed qualitatively with systematic text condensation.
Results: The use of remote communication varies between the participants. The participants also value remote communication differently. Having the possibility to choose between different means of remote communication is important. Being able to determine whether to communicate independently or with support from another person is also valued as relevant. Strategies used to manage remote communication include facilitating for the communication partner and preparing for future communication situations. Those who are able to use writing as an alternative to problematic spoken remote communication like phone calls, for example by using chat or text messaging. Decisions regarding means of communication and human support relate to the concept of self-determination.
Conclusion: Better access to remote communication trough assistive technology such as speech synthesis and picture symbols would make remote communication easier and facilitate participation for people with communicative and cognitive disabilities.
- Implications for rehabilitation
People with communicative and cognitive disabilities face challenges with access to remote communication.
Access to communication technology including remote communication is important for self-determination, for personal safety and for overall participation in society.
Communication technology should be considered in the rehabilitation process and training is crucial.
To understand the possible benefits of remote communication, people with communicative and cognitive disability need to get the possibility to practice.
Professionals play a key role in the assessment and intervention of remote communication for their patients.
Method: The paper uses vignettes to illustrate attention in patient-practitioner interaction.
Results: Attention is a precursor to understanding the patient as a unique individual and the problems the patient brings to the therapy experience.
Conclusions: The capacity of practitioners to attend to their patients has an impact on patient satisfaction and recovery.
- Implications for Rehabilitation
Attention is the precursor to establishing positive therapeutic alliances with patients.
It is essential to attend to the patient as a person with unique experiences, perspectives, and attitudes and to modify treatment based on the person’s priorities and desires.
Practitioners need to develop the interaction skills necessary to understand their patients as unique individuals.
Methods: A systematic search was conducted, of articles published between January 1996 and February 2016, using selected electronic databases followed by crosschecking of reference and citation lists. Articles were selected on the basis of the research reported relating to knowledge, behaviors, attitudes or beliefs of physiotherapists towards using a number of different psychological interventions. Quality assessment was conducted by three reviewers independently, and thematic analysis of the included studies was performed.
Results: Fifteen studies were included in the analysis. Results indicate that physiotherapists are aware of psychological interventions, are using a variety within practice, and have positive attitudes and beliefs towards their use. However, there are barriers to the incorporation of psychological interventions into their practice, including lack of knowledge, time constraints, and role clarity. The desire for further training was also evident.
Conclusion: Notwithstanding the reported awareness and use of psychological interventions in physiotherapy practice, barriers to implementation exist indicating that further research is necessary to address how to effectively equip physiotherapists, to employ such techniques within their scope of practice.
- Implications for rehabilitation
Physiotherapists use and have positive attitudes and beliefs towards a variety of psychological interventions including goal setting, positive, and motivational talk, cognitive behavioral therapy strategies and offering social support.
Barriers preventing the incorporation of psychological interventions in practice include, lack of knowledge, time constraints, and role clarity.
Despite the use of such interventions, physiotherapists identify the need for further training, to be better equipped to confidently utilize these in practice.
These results justify the incorporation of training in psychological interventions in physiotherapist qualifying studies, but also as continued professional development opportunities for physiotherapists currently working in the field.
Methods: An iterative user-centered design was conducted in co-creation with the physiotherapists and patients, in three phases. Their needs and preferences were identified by means of group meetings and questionnaires. The new method was tested in several field tests in physiotherapy practices.
Results: Four main objectives for improvement were formulated: clear instructions for the administration procedure, targeted use across the physiotherapy process, client-activating communication skills, and a client-centered attitude of the physiotherapist. A theoretical goal-setting framework and elements of shared decision making were integrated into the new-called, Patient-Specific Goal-setting method, together with a practical training course.
Conclusions: The user-centered approach resulted in a goal-setting method that is fully integrated in the physiotherapy process. The new goal-setting method contributes to a more structured approach to goal setting and enables patient participation and goal-oriented physiotherapy. Before large-scale implementation, its feasibility in physiotherapy practice needs to be investigated.
- Implications for rehabilitation
Involving patients and physiotherapists in the development and testing of a goal-setting method, increases the likelihood of its feasibility in practice.
The integration of a goal-setting method into the physiotherapy process offers the opportunity to focus more fully on the patient’s goals.
Patients should be informed about the aim of every step of the goal-setting process in order to increase their awareness and involvement.
Training physiotherapists to use a patient-specific method for goal setting is crucial for a correct application.
Design: A qualitative methodology with semi-structured focus group interviews was employed.
Setting: General practice setting in Denmark.
Subjects: Thirty-one GPs from two Danish regions between 38 and 68 years of age participated in seven focus group interviews.
Results: Although understood to involve broad life conditions such as present and future being and identity, connectedness to a society and to other people, the existential dimension was primarily reported integrated in connection with life-threatening diseases and death. Furthermore, integration of the existential dimension was characterized as unsystematic and intuitive. Communication about religious or spiritual questions was mostly avoided by GPs due to shyness and perceived lack of expertise. GPs also reported infrequent referrals of patients to chaplains.
Conclusion: GPs integrate issues related to the existential dimension in implicit and non-standardized ways and are hindered by cultural barriers. As a way to enhance a practice culture in which GPs pay more explicit attention to the patients’ multidimensional concerns, opportunities for professional development could be offered (courses or seminars) that focus on mutual sharing of existential reflections, ideas and communication competencies.
- Key points
Although integration of the existential dimension is recommended for patient care in general practice, little is known about GPs’ understanding and integration of this dimension in the GP–patient encounter.
The existential dimension is understood to involve broad and universal life conditions having no explicit reference to spiritual or religious aspects.
The integration of the existential dimension is delimited to patient cases where life-threatening diseases, life crises and unexplainable patient symptoms occur. Integration of the existential dimension happens in unsystematic and intuitive ways.
Cultural barriers such as shyness and lack of existential self-awareness seem to hinder GPs in communicating about issues related to the existential dimension. Educational initiatives might be needed in order to lessen barriers and enhance a more natural integration of communication about existential issues.