Scoping review of resources for integrating evidence-based supported employment into spinal cord injury rehabilitation

Purpose: Individual placement and support (IPS), an evidence-based supported employment (SE) program, has helped Veterans with spinal cord injury (SCI) receiving care in the Veterans Health Administration to obtain work. To facilitate integration of IPS into SCI rehabilitation, resources are needed. A scoping review was conducted to identify tools and resources suitable for providers of SCI care.

Methods: Applying a modified version of Arksey and O’Malley’s framework, a scoping review of literature on SE tools or resources was conducted. The original review focused on resources published between 2002 and 2015 and available in English. Prior to publication an updated review through 2017 was conducted.

Results: From 1822 tools and resources identified in the initial review, 24 met criteria for inclusion and were evaluated by an advisory panel of experts, who selected 16 tools that addressed five topics: IPS in SCI (n?=?2) orientation to SCI (n?=?3); IPS SE (n?=?7), job accommodations (n?=?2), and benefits planning (n?=?2). The updated review yielded no tools or resources that met inclusion criteria.

Conclusion: Despite few resources to guide implementation of IPS in SCI, 16 essential resources were identified that, combined into a toolkit, may facilitate translation of IPS in SCI from research to clinical care.

• Implications for rehabilitation

• The toolkit consists of 16 essential resources and is currently available online to all persons involved in spinal cord injury rehabilitation to educate them about this effective means of assisting persons with spinal cord injury to find employment and to facilitate translation of individual placement and support in spinal cord injury from research to clinical care.

• While expert-informed, the toolkit is being field tested with both clinical and vocational providers to facilitate the adoption of individual placement and support by spinal cord injury rehabilitation programs. The revised version will be made available online.

     

Investigating employment following spinal cord injury: outcomes,methods, and population demographics

Purpose: The purpose of this review was to synthesize the literature about spinal cord injury and employment, focusing on sample demographics, indicators of employment outcome, and the methods used. The review included literature from the previous decade; 2006–2017.

Methods: A systematic quantitative literature review methodology was utilized, wherein papers’ characteristics were extracted and categorized in a database according to their topics, employment outcome indicators, populations, locations, and methods. Frequency tables were generated and cross-tabulated to yield conclusions about the outcomes of the studies and the methods and samples used to yield these outcomes.

Results: The review highlighted three key themes; the emergence of broader employment outcome measures that go beyond employment rate; a lack of consistency in the reporting of sample characteristics such as time since injury or ethnicity; and the relative lack of research focusing on people with newly acquired spinal cord injury.

Conclusions: The literature review identified a number of limitations in the existing research including the lack of standardized reporting of employment outcomes and a need for increased consistency in reporting sample characteristics. In addition, there are gaps in the research about people with newly acquired spinal cord injury, particularly regarding the timing of interventions.

• Implications for Rehabilitation

• Spinal cord injury has the potential to disrupt a person’s career across their lifespan.

• Employment rate is the gold standard for evaluating employment outcomes.

• Broader measures of employment, including job retention and hours worked, have potential in evaluating and improving the quality of employment outcomes for this population.

• Further research with people with newly acquired spinal cord injuries would better support the provision of vocational rehabilitation services earlier in a person’s rehabilitation, potentially preserving jobs.

     

Returning to work after spinal cord injury: exploring young adults' early expectations and experience

Purpose.?The study sought to explore experience and expectations about paid work among young adults on sick leave after spinal cord injury (SCI).

Method.?Eight participants with traumatic SCI, who were 20–34 years of age, and had not yet returned to work 1–5 years post-injury, were interviewed. Selection was made with purposive sampling. Data were analysed using a constant comparative method.

Results.?Four main themes emerged as relevant: ‘finding your way to an everyday life where work is possible’, ‘at the crossroads, expectations of work through education’, ‘expectations of paid work as part of a desired future life’ and ‘expectations of finding a solution within oneself or with help from others’. The findings reveal high expectations of work ability but at the same time difficulties to plan for return to work and lack of support in this process.

Conclusions.?The participants represent a vulnerable group in vocational rehabilitation due to their young age and recent injury. Without formal training or suitable work experience, they need tailored work support as part of their general rehabilitation.     

Perceived barriers and facilitators to implementing research findings in the Irish practice setting

Background. Studies have consistently demonstrated that nurses are increasingly recognizing the role research has to play in their daily practice. Despite this recognition the actual application of research findings in the practice setting is still poor. To date, the barriers to implementing research findings in the Republic of Ireland's practice setting have not been explored empirically. This study sought to address this gap. Aims. The aims of this study were to ascertain what Registered Nurses practising in the Republic of Ireland perceive as barriers to the implementation of research findings in the practice setting and to explore what they perceive would facilitate them in using research findings in their daily practice. Design. Cross‐sectional survey. Methods. A non‐probability strategy was employed with all Registered Nurses who commenced a nursing‐focused academic course accredited by the University of Dublin, Trinity College, between September 2001 and February 2002 invited to participate. The ethical rights of the participants in terms of anonymity, privacy and informed consent were assured through a number of mechanisms. Data were collected via the Barriers scale. Findings. Eight of the top 10 ranked barriers were organization centred. The top barrier was a perception of insufficient authority to instigate change in the practice setting. The perceived key facilitators to implementing research findings included protected time for retrieval and evaluation of research findings, instrumental support from management, informed supportive personnel in the practice settings and accessible educational opportunities to augment critical reading skills. Relevance to clinical practice. The Irish Government is committed to provide the people of Ireland with an evidence‐based health service. From a nursing perspective the findings of this study indicate that a number of strategies have to be introduced or enhanced in the practice settings before this commitment can be realized.     

Working after a stroke: Survivors' experiences and perceptions of barriers to and facilitators of the return to paid employment

Purpose. This paper examines respondents' relationship with work following a stroke and explores their experiences including the perceived barriers to and facilitators of a return to employment.

Method. Our qualitative study explored the experiences and recovery of 43 individuals under 60 years who had survived a stroke. Participants, who had experienced a first stroke less than three months before and who could engage in in-depth interviews, were recruited through three stroke services in South East England. Each participant was invited to take part in four interviews over an 18-month period and to complete a diary for one week each month during this period.

Results. At the time of their stroke a minority of our sample (12, 28% of the original sample) were not actively involved in the labour market and did not return to the work during the period that they were involved in the study. Of the 31 participants working at the time of the stroke, 13 had not returned to work during the period that they were involved in the study, six returned to work after three months and nine returned in under three months and in some cases virtually immediately after their stroke. The participants in our study all valued work and felt that working, especially in paid employment, was more desirable than not working. The participants who were not working at the time of their stroke or who had not returned to work during the period of the study also endorsed these views. However they felt that there were a variety of barriers and practical problems that prevented them working and in some cases had adjusted to a life without paid employment. Participants' relationship with work was influenced by barriers and facilitators. The positive valuations of work were modified by the specific context of stroke, for some participants work was a cause of stress and therefore potentially risky, for others it was a way of demonstrating recovery from stroke. The value and meaning varied between participants and this variation was related to past experience and biography. Participants who wanted to work indicated that their ability to work was influenced by the nature and extent of their residual disabilities. A small group of participants had such severe residual disabilities that managing everyday life was a challenge and that working was not a realistic prospect unless their situation changed radically. The remaining participants all reported residual disabilities. The extent to which these disabilities formed a barrier to work depended on an additional range of factors that acted as either barriers or facilitator to return to work. A flexible working environment and supportive social networks were cited as facilitators of return to paid employment.

Conclusion. Participants in our study viewed return to work as an important indicator of recovery following a stroke. Individuals who had not returned to work felt that paid employment was desirable but they could not overcome the barriers. Individuals who returned to work recognized the barriers but had found ways of managing them.     

Motivational interviewing: a novel intervention for translating rehabilitation research into practice

Purpose: Despite recent advances in rehabilitation research, moving evidence into clinical practice remains a challenge. This article explores a novel approach to knowledge translation (KT) – motivational interviewing (MI). MI is a style of communication that is typically used to facilitate health related behavior change in patients. Here we explore its potential use as a KT intervention aimed at clinicians. Methods: Commentary. Relevant literature on MI and KT is summarized and discussed by considering how MI could be used in a KT strategy aimed at rehabilitation clinicians. Results: Clinician motivation and readiness to change are key issues influencing implementation of evidence-based practice. We provide an argument suggesting that clinicians’ readiness to change clinical practices can potentially be enhanced through MI. The MI conceptual framework, principles, and strategies, typically used in patients, are discussed here in a novel context – enhancing clinician change in practice. Conclusions: MI is an effective intervention when the goal is to motivate individuals to change a current behavior. We suggest that MI is an evidence-based intervention that has been proven to be effective with patients and warrants study as a promising KT intervention.

Implications for Rehabilitation

• Despite recent advances in rehabilitation research, moving evidence into practice remains a challenge.

• Clinician motivation is one key issue influencing the implementation of evidence-based practice.

• Clinician motivation to implement evidence-based practice can potentially be enhanced through an approach called motivational interviewing (MI).

• Motivational interviewing is an evidence-based intervention that has proven to be effective in promoting behavioral change in patients, and warrants study in terms of its potential as a KT intervention.

     

Perspectives and experiences of nurses as facilitators within a Practice Development program

Background

Health services are challenged to change and adapt to meet the changing needs of the populations they serve. To support this, the ‘Essentials of Care’ Practice Development program was developed in Australia. Local facilitators play a key role in its delivery and achievements.

Return to work following spinal cord injury: a review

Purpose. To review literature on return to work (RTW) and employment in persons with spinal cord injury (SCI), and present employment rates, factors influencing employment, and interventions aimed at helping people with SCI to obtain and sustain productive work.

Methods. A systematic review for 2000 – 2006 was carried out in PubMed/Medline, AMED, (ISI) Web of Science, EMBASE, CINAHL, PsycInfo and Sociological abstracts database. The keywords ‘spinal cord injuries’, ‘spinal cord disorder’, ‘spinal cord lesion’ or ‘spinal cord disease’ were cross-indexed with ‘employment’, ‘return to work’, ‘occupation’ or ‘vocational’.

Results. Out of approximately 270 hits, 110 references were used, plus 13 more found elsewhere. Among individuals with SCI working at the time of injury 21 – 67% returned to work after injury. RTW was higher in persons injured at a younger age, had less severe injuries and higher functional independence. Employment rate improved with time after SCI. Persons with SCI employed ranged from 11.5% to 74%. Individuals who sustained SCI during childhood or adolescence had higher adult employment rates. Most common reported barriers to employment were problems with transportation, health and physical limitations, lack of work experience, education or training, physical or architectural barriers, discrimination by employers, and loss of benefits. Individuals with SCI discontinue working at younger age.

Conclusions. This review confirmed low employment rates after SCI. Future research should explore interventions aimed at helping people with SCI to obtain and sustain productive work.     

Return to work following spinal cord injury: a review

Purpose. To review literature on return to work (RTW) and employment in persons with spinal cord injury (SCI), and present employment rates, factors influencing employment, and interventions aimed at helping people with SCI to obtain and sustain productive work.

Methods. A systematic review for 2000 - 2006 was carried out in PubMed/Medline, AMED, (ISI) Web of Science, EMBASE, CINAHL, PsycInfo and Sociological abstracts database. The keywords 'spinal cord injuries', 'spinal cord disorder', 'spinal cord lesion' or 'spinal cord disease' were cross-indexed with 'employment', 'return to work', 'occupation' or 'vocational'.

Results. Out of approximately 270 hits, 110 references were used, plus 13 more found elsewhere. Among individuals with SCI working at the time of injury 21 - 67% returned to work after injury. RTW was higher in persons injured at a younger age, had less severe injuries and higher functional independence. Employment rate improved with time after SCI. Persons with SCI employed ranged from 11.5% to 74%. Individuals who sustained SCI during childhood or adolescence had higher adult employment rates. Most common reported barriers to employment were problems with transportation, health and physical limitations, lack of work experience, education or training, physical or architectural barriers, discrimination by employers, and loss of benefits. Individuals with SCI discontinue working at younger age.

Conclusions. This review confirmed low employment rates after SCI. Future research should explore interventions aimed at helping people with SCI to obtain and sustain productive work.     

Satisfaction and perceptions of long-term manual wheelchair users with a spinal cord injury upon completion of a locomotor training program with an overground robotic exoskeleton

Aim: The main objectives of this study were to quantify clients’ satisfaction and perception upon completion of a locomotor training program with an overground robotic exoskeleton.

Methods: A group of 14 wheelchair users with a spinal cord injury, who finished a 6–8-week locomotor training program with the robotic exoskeleton (18 training sessions), were invited to complete a web-based electronic questionnaire. This questionnaire encompassed 41 statements organized around seven key domains: overall satisfaction related to the training program, satisfaction related to the overground robotic exoskeleton, satisfaction related to the program attributes, perceived learnability, perceived health benefits and risks and perceived motivation to engage in physical activity. Each statement was rated using a visual analogue scale ranging from “0?=?totally disagree” to “100?=?completely agree”.

Results: Overall, respondents unanimously considered themselves satisfied with the locomotor training program with the robotic exoskeleton (95.7?±?0.7%) and provided positive feedback about the robotic exoskeleton itself (82.3?±?6.9%), the attributes of the locomotor training program (84.5?±?6.9%) and their ability to learn to perform sit–stand transfers and walk with the robotic exoskeleton (79.6?±?17%). Respondents perceived some health benefits (67.9?±?16.7%) and have reported no fear of developing secondary complications or of potential risk for themselves linked to the use of the robotic exoskeleton (16.7?±?8.2%). At the end of the program, respondents felt motivated to engage in a regular physical activity program (91.3?±?0.1%).

Conclusion: This study provides new insights on satisfaction and perceptions of wheelchair users while also confirming the relevance to continue to improve such technologies, and informing the development of future clinical trials.

• Implications for Rehabilitation

• All long-term manual wheelchair users with a spinal cord injury who participated in the study are unanimously satisfied upon completion of a 6–8-week locomotor training program with the robotic exoskeleton and would recommend the program to their peers.

• All long-term manual wheelchair users with a spinal cord injury who participated in the study offered positive feedback about the robotic exoskeleton itself and feel it is easy to learn to perform sit–stand transfers and walk with the robotic exoskeleton.

• All long-term manual wheelchair users with a spinal cord injury who participated in the study predominantly perceived improvements in their overall health status, upper limb strength and endurance as well as in their sleep and psychological well-being upon completion of a 6–8-week locomotor training program with the robotic exoskeleton.

• All long-term manual wheelchair users with a spinal cord injury who participated in the study unanimously felt motivated to engage in a regular physical activity program adapted to their condition and most of them do plan to continue to participate in moderate-to-strenuous physical exercise.

• Additional research on clients’ perspectives, especially satisfaction with the overground exoskeleton and locomotor training program attributes, is needed.

     

Understanding faculty perspectives of supports and barriers to interprofessional collaboration within a clinical scholars program: A qualitative study

AimThis study explores the faculty perspective of an interprofessional clinical scholars program to identify recommendations for strengthening team collaboration between academia and clinical practice.BackgroundInterprofessional evidence-based practice, pairing higher education and clinical practice, is a critical part of nursing education.DesignThis qualitative study consisted of two phases of participant engagement, in both data collection and data analysis.MethodsSpecifically, faculty participated in a focus group discussion followed by a card sort of initial codes.ResultsThe major themes identified are Unifying the Team and Navigating Layers of Challenge, encompassing concepts of teamwork and programmatic context that supported or disrupted interprofessional collaboration. This study affirms the importance of role clarity, connectedness, intentionality and continuity within clinical teams. Moreover, faculty identified barriers to teamwork based on workload, leadership turnover and constraining environmental forces.ConclusionsRecommendations for effective teamwork in an interprofessional setting will strengthen future collaboration between higher education and clinical settings.     

Return to work following traumatic brain injury: Trends and challenges

Purpose. The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

Method. Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW.

Results. The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work.

Conclusion. Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 – 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach – medical and psychosocial – eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.     

Return to work following traumatic brain injury: trends and challenges

Purpose. The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

Method. Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW.

Results. The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work.

Conclusion. Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 - 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach - medical and psychosocial - eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.     

Pilot evaluation of a coping-oriented supportive program for people with spinal cord injury during inpatient rehabilitation

Purpose: To report the feasibility and preliminary effects of a psychosocial care program entitled “coping-oriented supportive program” (COSP) for people with spinal cord injury (SCI) during inpatient rehabilitation.

Methods: This was a pilot test of the COSP using a convenience sample of 22 participants with SCI (11 participants per group) with pre- and post-test, comparison group design. The feasibility, acceptability, and preliminary effects of the COSP were examined.

Results: Nine patients with SCI in the intervention group and 11 in the comparison group who completed five or more sessions of the intervention were included in the data analysis. The COSP was feasible with high levels of recruitment, retention and protocol adherence. Good acceptability was suggested by the participants’ feedback on the intervention program. The intervention group had a statistically significant greater improvement in self-efficacy (z?=?–1.978, p?=?0.048), life enjoyment and satisfaction (z?=?–2.801, p?=?0.005), and satisfaction of social support (z?=?–2.298, p?=?0.022) at post-test, when compared to the comparison group. Whereas, no significant improvement was found for coping.

Conclusions: Our findings support the feasibility and acceptability of the COSP, and suggest that this intervention is a promising psychosocial care program to enhance people’s life satisfaction and well-being as well as the satisfaction of social support after SCI. Further testing of this program with a larger-sized and diverse sample of people with SCI is needed.

• Implications for Rehabilitation

• The Chinese culturally-sensitive psychosocial care program (coping-oriented supportive program) is feasible, and has the potential to enhance people’s self-efficacy in coping with spinal cord injury, and improve their psychosocial well-being and life satisfaction.

• The conventional inpatient spinal cord injury rehabilitation services could be improved by providing this “first-line” psychosocial care program in line with the current medical rehabilitation service.

     

Development and outcomes of a program to translate the evidence for spinal manipulation into physical therapy practice

Abstract

Objectives:

To describe a program to translate evidence into practice for the use of manipulation with a sub-group of patients with low back pain and report the program's outcomes following implementation. We compared outcomes based on appropriate inclusion in the program and compliance with the evidence being translated.

Methods:

The evidence translation program was based on evidence that patients meeting two criteria (duration of symptoms <16 days, no symptoms distal to knee) were likely to respond to a physical therapy that included manipulation in the first two visits. Implementation addressed potential barriers with referring physicians, physical therapists, and scheduling staff to this evidence. Outcomes for patients in the program were tracked following implementation. Process outcomes were appropriateness of inclusion (met both criteria), compliance with evidence for providing thrust manipulation in the first two visits, and number of physical therapy visits. Clinical outcomes were based on Oswestry scores from the first, interim (after two to three visits), and final visit.

Results:

A total of 577 patients entered the evidence translation program (mean age = 43·0, 56·8% female); 79·5% were appropriate inclusions and 83·0% received manipulation. The use of manipulation was associated with fewer visits (mean difference = 0·54 visits, 95% CI: 0·037, 1·04, P = 0·035), and appropriate inclusion was associated with greater Oswestry change (mean difference at the final visit = 6·6 points, 95% CI: 1·6, 11·6; P = 0·010).

Discussion:

Implementing evidence into practice is difficult; however, barriers can be anticipated and overcome. Tracking the outcomes of an implementation program is critical to evaluating its benefit to patients. Additional research using experimental designs are necessary to evaluate the effectiveness of various treatments implemented in physical therapy practice.     

Within-session responses to high-intensity interval training in spinal cord injury

Aim: Completion of high-intensity interval training (HIIT) increases maximal oxygen uptake and health status, yet its feasibility in persons with spinal cord injury is unknown.

Purpose: To compare changes in cardiorespiratory and metabolic variables between two interval training regimes and moderate intensity exercise.

Method: Nine adults with spinal cord injury (duration?=?6.8?±?6.2?year) initially underwent determination of peak oxygen uptake. During subsequent sessions, they completed moderate intensity exercise, HIIT, or sprint interval training. Oxygen uptake, heart rate, and blood lactate concentration were measured.

Results: Oxygen uptake and heart rate increased (p?p?>?0.05) to moderate intensity exercise. Peak oxygen uptake and heart rate were higher (p?Conclusions: Despite a higher intensity and peak cardiorespiratory strain, all participants preferred interval training versus moderate exercise. Examining long-term efficacy and feasibility of interval training in this population is merited, considering that exercise intensity is recognized as the most important variable factor of exercise programming to optimize maximal oxygen uptake.

• Implications for Rehabilitation

• Spinal cord injury (SCI) reduces locomotion which impairs voluntary physical activity, typically resulting in a reduction in peak oxygen uptake and enhanced chronic disease risk.

• In various able-bodied populations, completion of high-intensity interval training (HIIT) has been consistently reported to improve cardiorespiratory fitness and other health-related outcomes, although its efficacy in persons with SCI is poorly understood.

• Data from this study in 9 men and women with SCI show similar changes in oxygen uptake and heart in response to HIIT compared to a prolonged bout of aerobic exercise, although peak values were higher in response to HIIT.

• Due to the higher peak metabolic strain induced by HIIT as well as universal preference for this modality versus aerobic exercise as reported in this study, further work testing utility of HIIT in this population is merited.

     

'It was hard but you did it': the co-production of 'work' in a clinical setting among spinal cord injured adults and their physical therapists

Purpose. This paper focuses on what takes place during the rehabilitation of spinal cord injured (SCI) adults. It analyses the cardinal rehabilitation task of transforming the compromised, limited and injured corporeal style of newly injured adults (best described phenomenologically as an 'I cannot do' or ' I no longer can') into a new style of embodiment, one in which 'I am newly abled'. This transformation is not a passive, surrendering experience. Rather, as informants repeatedly noted, 'rehabilitation is hard work'. This paper examines that 'work'.

Method. This paper draws from observational and interview data collected over an 18-month period in a metropolitan rehabilitation centre in the Midwestern United States. It presents an exemplar case of a clinical setting, that between a physical therapist and her SCI client.

Results. The interactional and meaning-making nature of clinical encounters are explicated, revealing the collaborative and situational constitution of rehabilitation work.

Conclusions. Experience-near, phenomenologically informed, research is shown to be a valuable way of understanding rehabilitation practices and how they might affect inpatients and staff.