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.
Materials and methods: Observational data on group climate and individual participation were triangulated with qualitative data from focus group interviews on the participants’ experiences with transdiagnostic groups.
Results: The study included 222 participants receiving a temporary work disability benefit. Self-reported chronic pain (75%), chronic fatigue (79%), and mental distress (62%) were prevalent and the majority reported overlapping conditions (78%). Program completion among participants was high (96%). Those completing participated actively (95%) in the program. Overall group climate was stable with moderately high engagement. Participants with clinically confirmed mental disorders (22%) showed similar outcomes. Self-reported problems with “working in a group” prior to rehabilitation were not associated with how participants experienced group climate. Qualitative data supported the findings of positive participant experiences with transdiagnostic group settings.
Conclusions: Transdiagnostic groups showed high participation rates, moderately high group engagement across symptom profiles and positive participant experiences. Implementing transdiagnostic occupational rehabilitation in groups mixing participants with chronic pain, chronic fatigue and common mental disorders was feasible and acceptable to participants.
- Implications for rehabilitation
Most research has been done on disorder-specific occupational rehabilitation programs, but emerging evidence supports a more generic approach.
Transdiagnostic therapies, such as Acceptance and Commitment Therapy (ACT), have shown promising results for both somatic and mental disorders.
The feasibility of implementing transdiagnostic rehabilitation groups, their acceptability to participants and the demand for such groups has not been established.
This study indicates that it is feasible to introduce a novel transdiagnostic group-based occupational rehabilitation program for mixed groups of sick-listed participants with chronic pain, chronic fatigue and/or common mental disorders.
Materials and methods: A qualitative study using semi-structured interviews with 10 specialist physiotherapists in vestibular rehabilitation in three university teaching hospitals in England. Data were analyzed using thematic analysis.
Results: Four themes were identified: (i) The therapeutic relationship, (ii) Adapting assessment and treatment, (iii) Psychological intervention and support, and (iv) Physiotherapists’ education and training. Physiotherapists reported using a range of behavioral and cognitive techniques and adapting their therapeutic approach by placing greater emphasis on education, building trust and pacing treatment. Physiotherapists highlighted the need for more specialist psychological support for patients during vestibular rehabilitation and tailored training and guidance on addressing anxiety within vestibular rehabilitation.
Conclusions: Physiotherapists working in vestibular rehabilitation consider managing aspects of anxiety within their scope of practice and describe taking a psychosocial therapeutic approach. There is limited access to expert psychological support for patients with anxiety within vestibular rehabilitation.
- Implications for rehabilitation
Anxiety is strongly associated with vestibular disorders and it is common for these patients to be managed by physiotherapists in vestibular rehabilitation.
Vestibular rehabilitation services could improve access to psychological expertise through dedicated psychological input, more effective signposting and referral pathways, and better access to inter-professional support from psychologists and/or CBT practitioners in managing more complex patients.
Physiotherapists requested tailored training and guidance to enhance their ability to manage patients with anxiety more effectively in vestibular rehabilitation.
Method: Twenty-two participants including 16 rehabilitation clinicians and 6 persons living with a disability participated in four nominal group sessions. Participants were questioned on current or potential rehabilitation strategies carried out to enhance participation in shopping malls for persons living with a disability. Discussions were audio-recorded and qualitative content analysis was conducted.
Results: Participants mentioned strategies that were either carried out by the clinician, or in collaboration with other parties. The latter type of strategies was either carried out with the collaboration of the client, the interdisciplinary team, the relatives, or community organizations.
Conclusions: Rehabilitation clinicians have a role to play in preparing persons living with a disability to resume activities in a shopping mall. Additionally, therapeutic interventions in community settings may enhance the participation of rehabilitation clients in their everyday activities.
- Implications for rehabilitation
Many strategies are currently used in rehabilitation to prepare persons living with a disability to resume shopping activities.
Clinicians could implement shopping-oriented rehabilitation strategies with the client and/or with other rehabilitation partners.
Involving clients in activities related to shopping might enhance their participation in shopping malls after rehabilitation.
Rehabilitation clinicians can be facilitators for people living with a disability to reach optimal participation.
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: The literature was searched systematically, including MEDLINE database, EMBASE and PsychINFO, combining variations of the terms stroke, rehabilitation and comorbidities. Results were limited to English language publications. Included studies had a functional outcome.
Results: Twenty relevant articles were identified. Fifteen small prospective or large retrospective studies using global comorbidity scales produced conflicting relationships between comorbidities and rehabilitation outcomes. Five publications addressed specific comorbidities, with three studies finding negative correlation between diabetes and rehabilitation outcomes, although effects diminished with age. In general, there were discrepancies in how comorbidities were identified. Few studies specifically focused on comorbidities and/or rehabilitation outcomes.
Conclusions: There is conflicting evidence regarding the impact of comorbidities on stroke rehabilitation outcomes. However, the presence of more severe diabetes may be associated with worse outcomes. The role of comorbidities in stroke rehabilitation would be best clarified with a large cohort study, with precise comorbidity identification measured against rehabilitation specific outcomes.
- Implications for rehabilitation
Benefit of rehabilitation after stroke in improving functional outcome is well-established.
Many stroke patients have comorbid conditions which can impact rehabilitation participation, leading to less benefit obtained from rehabilitation.
The burden of comorbid conditions may slow rehabilitation progress, which may warrant a longer duration of rehabilitation to obtain required functional gain to be discharged into the community.
Method: The medical history of two HIV-positive patients with PML was reviewed; information on their neurological impairments, rehabilitation treatment and outcome was gathered.
Results: The patients, a 47-year-old married man and a 34-year-old single man, both suffered from dense right hemiplegia and motor aphasia. Their rehabilitation course was delayed and prolonged: they were suitable for intensive multidisciplinary rehabilitation only 8 months or more after the initial presentation. Their treatment in outpatient rehabilitation daycare three times a week, that lasted 7 months on average, resulted in slow and steady functional improvement. At the end of the rehabilitation treatment, both patients were living at home, able to express themselves, and able to walk independently with an assistive device. They remained with moderate disability (modified Rankin scale of 3).
Conclusion: PML patients require prolonged multidisciplinary rehabilitation treatment; however, considerable progress can be achieved.
- Implications for Rehabilitation
Progressive multifocal leukoencephalopathy (PML) is a disabling disease occurring in particular in the context of Human Immunodeficiency Virus (HIV).
Presently a growing number of HIV-positive PML patients eventually survive the disease and remain with severe neurological impairments.
PML patients require prolonged multidisciplinary rehabilitation treatment, and considerable progress can be achieved.
This observational cross-sectional study identifies features and occupational needs of complex inpatients during rehabilitation, focusing on function and ability, regardless of diagnosis.
Method: This study included sixteen adult inpatients with stroke, deemed complex according to Rehabilitation Complexity Scale-Extended, at admission to Rehabilitation ward (from July 2014 to February 2015). Patients with primary psychiatric disorders, language barriers, cognitive or severe communication deficits were excluded. Upon admission, a multidisciplinary team collected data on general health, independence in daily activities (Modified Barthel Index), fatigue (Fatigue Severity Scale), resistance to sitting and ability to perform instrumental activities (Instrumental Activities of Daily Living). The occupational therapist identified occupational needs according to Canadian Occupational Performance Measure.
Results: Inpatients enrolled in this study were dependent in basic ADL, limited in instrumental ADL and easily fatigable. Their occupational needs related to self-care (75%) and, to a lesser extent, productivity (15%) and leisure (10%). According to inpatients, rehabilitation process should firstly address self-care needs, followed by productivity and leisure problems.
Conclusions: Despite small sample size, this study described patterns of occupational needs in complex inpatients with stroke. These results will be implemented in client-centered rehabilitation programs to be tested in a phase-two trial. [NCT02173197]
- Implications for Rehabilitation
Priority occupational needs of complex inpatients with stroke during rehabilitation are focused on self-care area.
Productivity and leisure problems also arise in early post-acute phase.
Client-centered rehabilitation programs should firstly address self-care needs and, later on, they should also focus on the recovery of family and social roles.
Method: Review of the literature and expert opinion.
Results: We summarize key theoretical frameworks that guide assessment of pragmatic communication ability, describe the developmental progression of pragmatic skills and expectations for children and adults, provide an overview of pragmatic communication disorders, and discuss current assessment approaches.
Conclusions: An understanding of pragmatic communication disorders may assist all rehabilitation team members, as impairments in this domain may have significant effects on rehabilitation progress and outcomes.
- Implications for Rehabilitation
Pragmatic communication ability is the ability to use language in context, beyond understanding and expressing basic word meanings (semantics) in the correct grammatical forms (syntax). Pragmatic communication deficits have been documented in many of the populations frequently referred for rehabilitation, and can affect both progress during rehabilitation and outcomes from treatment.
A broader understanding of pragmatic communication functions can help team members identify a patient's strengths and limitations, inform treatment planning, and improve communication among healthcare professionals, thereby contributing to improved outcomes for patients and their families.
Method: An uncontrolled pre- and post-assessment design was employed to study the use of unmodified, low-cost, off-the-shelf smartphones combined with Internet-calendars as a compensatory memory strategy in community-dwelling patients with traumatic brain injury. Thirteen participants received a 6-week group-based intervention with pre-, post- and 2-month follow-up-assessments by questionnaires and by daily assessment of target behaviors for 2-week periods.
Results: Participants reported significantly fewer retro- and prospective memory problems on questionnaires after the intervention and at follow-up with large effect sizes. The performance of target behaviors, however, improved insignificantly with moderate effect sizes. There were no changes in quality of life or symptoms of emotional distress.
Conclusions: This study adds to a growing body of evidence that smartphones are a useful compensatory aid in rehabilitation of prospective memory that should routinely be considered in rehabilitation of traumatic brain injury patients.
- Implication for rehabilitation
Smartphones are easy-to-use and accessible assistive technology for compensatory memory rehabilitation to most traumatic brain injury patients.
By using low-cost, off-the-shelf devices, the technology becomes available to a broader range of patients.
By combining smartphones with Internet-based and cross-platform services (e.g., calendars, contacts) the participants are less device-dependent and less vulnerable to data loss.
Smartphones should routinely be considered as compensatory aid in rehabilitation of prospective memory of traumatic brain injured patients.
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: Two focus groups, conducted with 15 rehabilitation professionals from various disciplines and working with people with disabilities of all ages were structured around two topics: (i) The usage of malls for rehabilitation and (ii) Factors that facilitate or limit rehabilitation professionals’ use of the mall as an environment for clinical assessment and/or intervention.
Results: The thematic analysis revealed that shopping malls were used to achieve several rehabilitation goals targeting physical and cognitive skills, psychological health and socialization. This real-life environment is motivating and helps foster independence and normalization. Factors affecting mall use during rehabilitation included personal factors (e.g. clients’ personality and level of readiness) and environmental factors (e.g. clinical context, accessibility of the mall and social attitudes of store owners).
Conclusion: Shopping malls may be a relevant rehabilitation assessment and treatment environment that could contribute to optimizing community integration of people with disabilities.
- Implications for rehabilitation
To ensure successful community reintegration, clients could be trained at some point during their rehabilitation, to perform activities in real-life settings, such as a shopping mall.
Shopping malls appear to enable the attainment of rehabilitation goals targeting a variety of skills.
This real-life environment appears to be motivating and helps foster independence and normalization.
Factors felt to affect mall use during rehabilitation include personal factors (e.g. clients’ personality and level of readiness) and environmental factors (e.g. clinical context, accessibility of the mall and social attitudes of store owners).
The shopping mall may be an untapped resource as it appears to be a relevant rehabilitation assessment and treatment environment that could contribute to optimizing community integration of people with disabilities.
Method: A systematic search of peer-reviewed literature from electronic databases; MEDLINE, Scopus, CINAHL and Informit health, was conducted. Papers published between 2004 and 2014 were considered.
Results: Eleven quantitative studies met the inclusion criteria. There was a lack of research addressing SDH and neurological rehabilitation simultaneously. Cardiac and cancer rehabilitation studies reported employment and income, social support, transport, housing and food security as the most frequent SDH factors influencing attendance, sustained adherence and motivation. Given this association, a similar relationship between neurological rehabilitation and SDH is plausible.
Conclusions: Rehabilitation of neurological conditions can be a long and difficult process. To pursue optimal outcomes, an individual’s social circumstances should be considered. Understanding how SDH interact with neurological rehabilitation may enhance service delivery, thus maximizing the possible rehabilitation outcomes for individuals. Future research that considers SDH and rehabilitation of neurological conditions jointly may benefit service providers and those requiring neurological rehabilitation.
- Implications for Rehabilitation
Social determinants of health are important to consider in the rehabilitation of neurological conditions.
Understanding the interplay between the social determinants of health and neurological rehabilitation may enhance the possible outcomes for those requiring rehabilitation.
Increased awareness and capacity of health care professionals involved in neurological rehabilitation may hasten momentum towards decreased health disparities instigated by undesirable social determinants of health.
Method: Alvesson and Sandberg’s method of problematisation was used. We began with a historical overview of stroke rehabilitation, and proceeded through five steps undertaken in an iterative fashion: literature search and selection; data extraction; syntheses across texts; identification of assumptions informing the literature and; generation of alternatives.
Results: Discussion of risk in stroke rehabilitation is largely implicit. However, two prominent conceptualisations of risk underpin both knowledge development and clinical practise: the risk to the individual stroke survivor of remaining dependent in activities of daily living and the risk that the health care system will be overwhelmed by the costs of providing stroke rehabilitation.
Conclusions: Conceptualisation of risk in stroke rehabilitation, while implicit, drives both research and practise in ways that reinforce a focus on impairment and a generic, decontextualised approach to rehabilitation.
- Implications for rehabilitation
Much of stroke rehabilitation practise and research seems to centre implicitly on two risks: risk to the patient of remaining dependent in ADL and risk to the health care system of bankruptcy due to the provision of stroke rehabilitation.
The implicit focus on ADL dependence limits the ability of clinicians and researchers to address other goals supportive of a good life following stroke.
The implicit focus on financial risk to the health care system may limit access to rehabilitation for people who have experienced either milder or more severe stroke.
Viewing individuals affected by stroke as possessing a range of independence and diverse personally valued activities that exist within a network of relations offers wider possibilities for action in rehabilitation.
Method: The participants were two mothers of children with physical disabilities and two physical therapists. Therapists received instruction in the strategies for collaboration including client-centred interview, visualising a preferred future, scaling questions, and family routine and activity matrix. The intervention was implemented during 6-weekly sessions. The 2nd and 5th sessions were videotaped to analyse the interactions between the parent and therapist using Response Class Matrix. Telephone interviews were conducted to explore participants’ experiences.
Results: Therapists were able to implement all strategies following 6 h of instruction. Analysis of the videotapes indicated that mother–therapist interactions were characterised by sharing information and open communication in a mutually supportive manner. Interviews with the mothers and therapists indicated that the therapists engaged the mothers in the intervention process and tailored interventions to child and family needs. The scaling questions were difficult to implement (therapists) and answer (parents).
Conclusion: The findings suggest that the strategies can be used by therapists to promote collaboration and involve parents in setting goals and the intervention process.
- Implications for Rehabilitation
Strategies to promote parent–therapist collaboration include client-centred interview, visualising a preferred future, scaling questions, and family routine and activity matrix.
Therapists with no previous instruction or training on family-centred services successfully implemented the strategies following 6 h of instruction.
Interactions between two parent–physical therapist dyads were characterised by sharing information and open communication in a mutually supportive manner following therapist instruction in strategies for parent–therapist collaboration.
Materials and methods: Surveys were sent via mail, email and online postings to over 500 therapists, 107 responded.
Results: Conventional equipment such as stopwatches are more frequently used compared to newer technology like Wii and Kinect games. Still, less than 25% of therapists’ report using a stopwatch five or more times per week. Notably, feedback to patients is based upon objective data less than 50% of the time by most therapists. At the end of clinical rehabilitation, patients typically receive a written home exercise program and non-technological equipment, like theraband and/or theraputty to continue rehabilitation efforts independently.
Conclusions: The use of technology is not pervasive in the continuum of stroke rehabilitation.
- Implications for Rehabilitation
The patient care experience is a priority in healthcare, so when patients report feeling bored and desiring greater fostering of autonomy in stroke rehabilitation, it is troubling.
Research examining the use of technology has shown positive results for improving motor performance and engaging patients through entertainment and use of objective feedback.
Physical and occupational therapists do not widely use technology in stroke rehabilitation.
Therapists should consider using technology in stroke rehabilitation to better meet the needs of the patient.
Material and method: Qualitative interviews were used to uncover expectations about a multimodal rehabilitation programme offered at the Pain and Rehabilitations Centre, The University Hospital; Linköping, Sweden. Sixteen women and two men (mean age 37 years; standard deviation 10 years) with chronic benign pain participated. The interviews were analysed using qualitative content analyses.
Results: To participate actively in the multimodal pain rehabilitation programme and to learn adequate coping strategies to improve daily life emerged as a main category. It was based on the following four categories comprising expectations about: participating actively in the programme, interacting with the professionals and fellow patients, cognitive effects of the programme and tools for coping, and explicit effects from the programme.
Conclusions: Many patients expressed expectations which may reflect that the information before the programme had started rehabilitation process at the time point for this study. The results could be applied in rehabilitation programmes by acknowledging expectations to interact with professional team members and fellow patients, by early addressing of positive and negative expectations about the future pain and by incorporating and strengthen expectations of learning to cope with pain.
- Implications for Rehabilitation
Patients' expectations to interact with professional team members and fellow patients by participating actively in the pain rehabilitation programme should be acknowledged in each rehabilitation situation.
Patients expressed both positive and negative expectations about their future pain situation and these expectations should be addressed as early as possible in the rehabilitation screening process.
Patients' expectations of learning to cope with pain should be incorporated and strengthened in multimodal pain rehabilitation programmes.
Methods: From 101 articles initially identified, 14 articles met the study criteria. Eleven papers described the effects of carbonation on swallowing in healthy participants whereas three described the impact of carbonation in dysphagic populations. A narrative synthesis of papers was undertaken given the diversity of identified studies.
Results: Synthesis of findings was challenging given the exploratory phase of most research activity with diverse populations described and extensive differences in research methodologies. There is currently weak, but potentially positive evidence to support using carbonation as a compensatory technique in dysphagia rehabilitation.
Conclusion: Despite future potential, existing evidence fails to provide clear direction for the clinical implementation of carbonation. Validation of carbonation use with the dysphagic population requires further research with consistent, controlled methodologies, and larger cohorts of participants to inform potential for dysphagia rehabilitation.
- Implications for Rehabilitation
The use of carbonated liquids has been proposed as a possible sensory enhancement technique which may facilitate changes to swallow physiology.
However to date, there is limited information to direct clinical implementation.
This paper provides a narrative synthesis of existing knowledge and highlights possible limitations of findings reported.
Research to date has used disparate research methodologies in varied populations making synthesis of current findings challenging.