The development of the Stroke Physiotherapy Intervention Recording Tool (SPIRIT)

Purpose:?To develop a recording system that describes physiotherapy interventions for the rehabilitation of postural control post-stroke.

Methods:?Design: A draft recording tool was developed using the method described by Edwards et al,¹² involving literature searches and collaboration with senior clinicians. It was piloted with stroke physiotherapists using a cross-sectional survey design to assess validity, utility and completeness. Participants used the recording tool to record five treatment sessions. Feedback regarding the utility and completeness of the system was obtained via short semi-structured interviews. Setting: 11 NHS Trusts. Participants: 35 stroke physiotherapists working in acute and rehabilitation settings recorded the treatment of 120 patients in 590 treatment sessions.

Results:?A double-sided A4 form with a checklist of 79 physiotherapy interventions in 9 categories was produced: the Stroke Physiotherapy Intervention Recording Tool (SPIRIT). The participants found it quick and easy to use and reflective of clinical practice. There were a few missing interventions and some confusion regarding definition of terms. Revisions were to include the omitted interventions and to produce a user's booklet defining the categories and interventions.

Conclusions:?SPIRIT provides a system for recording physiotherapy treatment for stroke patients which reflects current clinical practice in acute and rehabilitation settings.     

Executive dysfunction post-stroke: an insight into the perspectives of physiotherapists

Abstract

Purpose: To gain an understanding of physiotherapy practice in relation to executive dysfunction (ED) post-stroke. Method: Three focus groups were conducted using semi-structured interview schedules to highlight how ED post-stroke was understood by 12 physiotherapists with greater than 1 year of experience working in the area of stroke care. The focus group data were analysed using qualitative data analysis. Results: The themes extracted from the data on physiotherapists’ self-reported knowledge of ED post-stroke were: physiotherapists’ lack of knowledge of ED post-stroke; current physiotherapy practice regarding ED post-stroke; the negative impact of ED on physiotherapy rehabilitation post-stroke and the future learning needs of physiotherapists regarding ED post-stroke. Conclusions: Current results demonstrate that ED has negative implications for physiotherapy rehabilitation post-stroke. Although further interdisciplinary research is warranted, the present results suggest that physiotherapists should be aware of the presence of ED in people post-stroke and develop strategies to minimise the impact of ED on physiotherapy rehabilitation.

• Implications for Rehabilitation

• Physiotherapists report a lack of knowledge of ED post-stroke and a requirement for future learning and training regarding the optimal management of people with ED undergoing physiotherapy rehabilitation post-stroke.

• ED has negative implications for physiotherapy rehabilitation post-stroke and physiotherapists should be aware of the presence of ED in people post-stroke and develop strategies to minimise the impact of ED on physiotherapy rehabilitation.

     

Perceived value of stroke outcome measures across the post-acute care continuum: A qualitative case study

Connecting the continuum of post-acute care stroke services may be important for easing patients' transition between settings and facilitating recovery and community reintegration. The use of outcome measures is suggested as one means of connecting the continuum. The purpose of this qualitative case study is to describe administrators' and physiotherapists' perceived value of an outcomes program across the post-acute care stroke continuum at a rehabilitation hospital. Data were collected through individual interviews and focus groups with 18 participants. Three themes emerged on the value of the outcomes program: 1) enhanced communication; 2) supports clinical decision-making; and 3) value of objective data. These findings lend support for the use of standardized outcome measures by physiotherapists in stroke rehabilitation. Findings from this study may be useful for organizations and physiotherapists who wish to integrate outcome measures into practice.     

The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: A systematic review of available evidence

Purpose.?To develop a clinical practice guideline for the physiotherapy management of patients with stroke as support for the clinical decision-making process, especially with respect to the selection of appropriate interventions, prognostic factors and outcome measures.

Introduction.?Physiotherapists have a high caseload of patients with stroke, so there is a need to identify effective evidence-based physiotherapy procedures. The availability of a guideline that includes information about prognostic factors, interventions, and outcome measures would facilitate clinical decision-making.

Method.?A systematic computerized literature search was performed to identify evidence concerning the use of: (i) prognostic factors related to functional recovery; (ii) physiotherapy interventions in patients with stroke; and (iii) outcome measures to assess patients' progress in functional health. Experts, physiotherapists working in the field of stroke rehabilitation, and a multidisciplinary group of health professionals reviewed the clinical applicability and feasibility of the recommendations for clinical practice and their comments were used to compose the definitive guideline.

Results.?Of 9482 relevant articles, 322 were selected. These were screened for methodological quality. Seventy-two recommendations for clinical practice were retrieved from these articles and included in the guideline: Six recommendations concerned the prediction of functional recovery of activities of daily living (ADL), including walking ability and hand/arm use; 65 recommendations concerned the choice of physiotherapy interventions; and 1 recommendation concerned the choice of outcome instrument to use. A core set of seven reliable, responsive, and valid outcome measures was established, to determine impairments and activity limitations in patients with stroke.

Conclusions.?The guideline provides physiotherapists with an evidence-based instrument to assist them in their clinical decision making regarding patients with stroke. As most of the recommendations included in the guideline came from studies of patients in the post acute and chronic phase of stroke, and in general involved patients with less severe and uncomplicated stroke, more needs to be learned about the more complex cases.     

Exploring the decision-making process in the delivery of physiotherapy in a stroke unit

Abstract

Purpose: The aim of this study was to explore the decision-making process in the delivery of physiotherapy in a stroke unit. Methods: A focused ethnographical approach involving semi-structured interviews and observations of clinical practice was used. A purposive sample of seven neurophysiotherapists and four patients participated in semi-structured interviews. From this group, three neurophysiotherapists and four patients were involved in observation of practice. Data from interviews and observations were analysed to generate themes. Results: Three themes were identified: planning the ideal physiotherapy delivery, the reality of physiotherapy delivery and involvement in the decision-making process. Physiotherapists used a variety of clinical reasoning strategies and considered many factors to influence their decision-making in the planning and delivery of physiotherapy post-stroke. These factors included the therapist’s clinical experience, patient’s presentation and response to therapy, prioritisation, organisational constraints and compliance with organisational practice. All physiotherapists highlighted the importance to involve patients in planning and delivering their physiotherapy. However, there were varying levels of patient involvement observed in this process. Conclusions: The study has generated insight into the reality of decision-making in the planning and delivery of physiotherapy post-stroke. Further research involving other stroke units is required to gain a greater understanding of this aspect of physiotherapy.

• Implications for Rehabilitation

• Physiotherapists need to consider multiple patient, therapist and organisational factors when planning and delivering physiotherapy in a stroke unit.

• Physiotherapists should continually reflect upon how they provide physiotherapy, with respect to the duration, frequency and time of day sessions are delivered, in order to guide current and future physiotherapy delivery.

• As patients may demonstrate varying levels of participation in deciding and understanding how physiotherapy is delivered, physiotherapists need to adjust how they engage patients in the decision-making process and manage patient expectations accordingly.

     

Palliative cancer patients in the acute hospital setting – Physiotherapists attitudes and beliefs towards this patient group

Abstract

Background

With advances in medical technology, increasing numbers of patients are ‘living with’ a terminal cancer diagnosis for longer periods; this coupled with changes in government policy is resulting in patients being treated closer to home rather than in specialist centres, bringing acute hospital physiotherapists into increasing contact with this patient group.

Aim

To describe the experience of acute hospital physiotherapists with palliative cancer patients.

Design

Semi-structured interviews analysed utilizing Colaizzi's method of analysis, reported using the COREQ guidelines.

Setting

Acute Hospital in the UK.

Participants

The first 12 physiotherapists who volunteered for the study who met the inclusion criteria.

Results

Two main themes were identified, attitudes and issues, with four sub-themes in attitudes (terminology, physiotherapists perceptions, other professionals perceived attitudes towards physiotherapists, and patients and families perceived attitudes towards physiotherapists'); there were six sub-themes in issues (communication, education, emotions, boundaries, referring onward from the acute setting, and time).

Conclusions and implications for practice

Some physiotherapists understand and apply their skills to improve the quality of life of palliative cancer patients. However, it is suggested that the majority of physiotherapists regard these patients as ‘dying from’ rather than ‘living with’ a terminal cancer diagnosis. Referral protocols and service pathways are lacking. There is an opportunity to improve how the profession promotes itself to other professionals, the public and physiotherapists of the future, to facilitate palliative cancer patients' access to rehabilitation when and where they need it, and to deliver services in line with government policy.     

The effect of two physiotherapy approaches on physical and cognitive functions and independent coping at home in stroke rehabilitation. A preliminary follow-up study

Purpose. Activating physiotherapy was used to support the principle of post stroke functional recovery as a learning process which requires both cognitive and physical actions. The purpose of the present preliminary study was to examine the influence of activating physiotherapy on stroke patients' cognitive and physical functions and independent living at home compared with traditional treatment over a 12-month follow-up.

Methods. The 40 patients who received activating physiotherapy were compared with 40 patients receiving traditional therapy. Patients' physical functional capacity was measured one week and 12 months post stroke with the Barthel Index (BI), 10-m gait speed, the Postural Control and Balance for Stroke (PCBS) test, walking distances and patients' abilities to cope without outside help. Cognitive capacity was measured with specific neuropsychological tests: language, visuospatial functions, visual inattention and memory.

Results. Physical functional capacity improved significantly (p = 0.001) in both groups at the 12-month follow-up, but no significant differences were found between groups. However, the patients in the activating therapy group coped better without outside help (p = 0.042) and covered longer distances outdoors (p = 0.012). At follow-up all the measured cognitive functions had improved significantly in the activating therapy group and the change in memory in the same group differed significantly from that in the traditional therapy group (p < 0.001), where no significant improvement was observed.

Conclusions. Activating therapy advanced stroke patients' cognitive and physical functional recovery and supported their return to independent life at home more than did traditional physiotherapy. In this respect activating therapy seems to have a beneficial influence on long-term stroke rehabilitation.     

Physiotherapists' clinical reasoning about patients with non-specific low back pain,as described by the International Classification of Functioning,Disability and Health

Purpose.?To explore and describe what physiotherapists experience they need to know about patients with non-specific low back pain (NSLBP) to make decisions about intervention.

Method.?Four focus groups containing a total of 21 physiotherapists were carried out in Sweden. Interviews were transcribed and qualitative content analysis performed. The manifest content was coded and categorised, and a theme emerged. Extracted symptoms and signs were linked to ICF codes.

Result.?Physiotherapists' clinical reasoning represented a broad view on low back pain (LBP) including codes from all ICF components. The participants argued for individualisation of intervention to a specific patient's problems. A theme of case complexity emerged, involving three levels: easy case, characterised by impairment in body function with close relation to specific body structures; complex case, characterised by impairments in body function, particular mental functions, activity limitations and participation restrictions, particular management of activity level and very complex case, characterised by impairments in body function, activity limitations and participation restrictions, and contextual factors, with help-seeking behaviour as a particular feature.

Conclusion.?The physiotherapists' clinical reasoning reflected a broad view on patients with NSLBP, with variations related to case complexity. The use of ICF codes contributed to understanding that the physiotherapists applied a broad perspective on NSLBP as a health condition as well as to knowledge about how physiotherapists' understand patients with NSLBP. Physiotherapists' use of the ICF in clinical practice might facilitate identification and assessment of specific patient's back pain problem as they occur in daily life and therefore be helpful in rehabilitation planning. Findings might also have an educational value.     

Falls among stroke survivors: an online survey on perceptions and approaches among physiotherapists in Flanders

Objective.?To describe physiotherapists' perceptions of fall risk and appropriate fall prevention interventions in rehabilitating stroke patients.

Method.?A web-based survey addressed to physiotherapy units on a stroke unit, general neurology department or rehabilitation ward/centre in Flanders.

Results.?Hospital response rate was 66.3%. Sixty-five physiotherapy units were taken into account. About 84.6% recognised falls among stroke patients as an essential problem and 73.8% thought falls interfered with the outcome. About 56.9% agreed with the need of a standardised fall assessment at the beginning of the treatment and only 36.9% reported that on their department stroke patients are screened on risk of falling. The most used fall risk assessments are: Berg Balance scale and Tinetti-test. The most popular fall prevention measures are: specific exercises for balance, gait and functional abilities (100%), informative education (92.3%) and adapting or intensifying the treatment after a fall (81.5%).

Conclusions.?Physiotherapy units acknowledge falls as an essential threat, implying a need for risk screening and prevention. However, results reveal that perception of the necessity of such screening is lower and that the performance is even less. This discrepancy underlines the necessity of guidelines and education of therapists working with stroke patients.     

Early discharge to therapy-based rehabilitation at home in patients with stroke: a systematic review

Abstract

Early discharge and home rehabilitation (EDHR) for stroke patients seems logical as an alternative to rehabilitation in stroke units, as these patients often show impaired ability to perform activities of daily living. The objective of this review is to present the effects of EDHR for stroke patients on health, quality of life and costs, and to describe the physiotherapy provided. Seventeen randomised controlled trials were included, assessed with the PEDro scale and rated using Sackett's rules of scientific evidence. The results showed that EDHR can reduce the length of time spent in hospital. It might improve basic activities of daily living, but is more likely to improve patients' instrumental activities of daily living and quality of life. The context is a core issue for the physiotherapy intervention. Early discharge and home rehabilitation seems to be cost-effective if rehabilitation at home is provided by a multidisciplinary team from a hospital. It is important to consider patients' coping capacities and possible strain on caregivers as contributing factors to the efficacy of EDHR.     

Implementing one standardized rehabilitation protocol following autologous chondrocyte implantation or microfracture in the knee results in comparable physical therapy management

Objective: The major aim of the study was (1) to compare the physiotherapy management in patients treated with autologous chondrocyte implantation (ACI) versus microfracture (MF) at the knee using a standardized rehabilitation protocol; and (2) to investigate the effect of activities in low-load conditions after surgery on the functional recovery was explored. Design: 95 physiotherapists received a standardized rehabilitation protocol that was used in a randomized controlled trial. A secondary analysis on patients' outcome was studied in a cohort design. Outcome measures: An electronic report form including 18 physiotherapy variables was used to compare physiotherapy management. Patients' functional outcome was assessed using the KOOS (Knee Injury Osteoarthritis Outcome Score) and the pooled symmetry index (SI) based on one strength and three hop tests. Both subjective and objective outcomes were evaluated pre-surgery, and at 1 and 2 years post-surgery. Results: 65 physiotherapists adhered very consistently to the protocol during the first 3 months and showed a similar preference and timing for the physiotherapy modalities in both treatment groups. Patients with high amount of low-load activities (LLA+, n=21) post-surgery performed significantly better compared to patients with low amount of LLA (LLA?, n=17). At 24 months the mean pooled SI of LLA+ cohort was 92.4 compared to 78.2 for LLA? cohort (95% confidence interval [CI] 1.8 to 26.2). Conclusion: Overall, the compliance post-surgery with the rehabilitation protocol was excellent and the applied rehabilitation was comparable in both treatment groups. A high amount of low-load activities post-surgery appears beneficial for the objective functional outcome.     

Adaptation of the person centered therapeutic relationship patient version (PCTR-PT) to a version for physiotherapists (PCTR-PHYS) and evaluation of its psychometric properties

Background and Purpose

The therapeutic relationship is a central component for developing person-centered care within physiotherapy services. However, it is necessary to understand how this relationship is perceived by both parties involved. The Person Centered Therapeutic Relationship-Patient scale (PCTR-PT) was constructed to identify patients' perceptions. No instruments are currently available to correlate patients' and physiotherapists' perceptions of the therapeutic relationship. This study sought to adapt the PCTR-PT to develop a version for physiotherapists, the Person Centered Therapeutic Relationship Scale for Physiotherapists (PCTR-PHYS) and to determine its psychometric properties.

Methods

A three-stage study was performed: (1) item generation, (2) pretesting of the questionnaire, (3) analysis of psychometric properties. Factor validity and psychometric properties were analyzed by confirmatory factor analysis (CFA). Convergent validity was calculated. Internal consistency was verified using the Cronbach's alpha coefficient. The intraclass correlation coefficient (ICC) was used to examine temporal stability.

Results

Thirty-three physiotherapists participated in two rounds of cognitive interviews and 343 participated in the analysis of psychometric properties. The CFA confirmed the four-structure model. Reliability of the tool was confirmed by Cronbach's alpha (α = 0.863) for all four dimensions, as all were above 0.70, ranging from 0.704 (relational bond) and 0.898 (therapeutic communication). Test-retest was performed with 2-week intervals, indicating an appropriate stability for the scale (ICC = 0.908).

Discussion

The Person Centered Therapeutic Relationship Scale for Physiotherapists is a useful, valid and applicable instrument to evaluate the person-centered therapeutic relationship during physiotherapy interventions. It will enable the comparison of patients' and physiotherapists' perceptions. To provide person-centered care in physiotherapy services, there is a clear need to incorporate specific resources into clinical practice to evaluate the quality of the therapeutic relationship from the perspective of both the persons being treated and the professionals providing care.     

Physiotherapy in Afghanistan: an analysis of current challenges

Introduction.?Afghanistan has high levels of disability due to prolonged conflict. An important part of the reconstruction process in Afghanistan is strengthening health service capacity and, within this, rehabilitation services.

Aims:?To identify training needs of, and key issues affecting, Afghan physiotherapists.

Methods.?20 interviews and clinical accompaniment of 15 physiotherapists/physiotherapy assistants (APA) carried out in the second quarter of 2003. Analysis was using a grounded theory approach.

Results.?Five themes emerged: (1) Low professional profile of physiotherapy; (2) Difficult working conditions; (3) Difficulty identifying personal training needs; (4) Difficulty with clinical reasoning at undergraduate level; (5) Variable levels of clinical competence.

Discussion.?Many of the challenges facing Afghan physiotherapists are not unique to Afghanistan but are exacerbated by a lack of government recognition of the profession. War has isolated Afghan physiotherapists from completed professional links and consequently the undergraduate curriculum had not matched developments in other comparable countries. This has contributed to the difficulties therapists' experience with current clinical reasoning and accessing new practice developments. Culture also influences attitudes towards training and has restricted female travel and access to education.

Conclusions.?Core training needs include disability sensitization, reflective practice and clinical reasoning. The physiotherapy curriculum needs updating and links with ongoing research need to be established to keep abreast of new developments.     

Critical Care Functional Rehabilitation Outcome Measure: developing a validated measure

Abstract

Introduction: In 2009, the National Institute for Health and Clinical Excellence (NICE) developed guidelines, which recognized that rehabilitation plays a vital role in recovery from illness and in returning patients to their previous activity levels. NICE recommended the use of valid and reliable “outcome measures” as an evaluation tool. Aim: To develop and evaluate the validity and reliability of a new Critical Care Functional Rehabilitation Outcome Measure (CcFROM). Method: The CcFROM was developed by physiotherapists working within the authors' institution and was based on an evaluation of current measures. Face and content validity were investigated using a questionnaire posted to 21 physiotherapists. Same-day and between-day intra-rater reliability and inter-rater reliability were investigated by three physiotherapists viewing 20 physiotherapy rehabilitation sessions and completing the CcFROM. Data were analysed for relative and absolute reliability. Results: The questionnaire demonstrated very high face validity and moderate content validity. 43% of the physiotherapists also suggested including an upper limb activity. Clinically acceptable same-day and between-day intra-rater reliability was demonstrated with ICCs of 0.985 (CI, 0.968–0.993) and 0.985 (CI, 0.871–0.972), respectively. Inter-rater reliability was recorded with an ICC of 0.906 (CI: 0.816–0.959). Conclusion: This study has shown that the CcFROM is a valid and reliable outcome measure for use in Critical Care.     

To what extent are family members and friends involved in physiotherapy and the delivery of exercises to people with stroke?

Purpose. To examine the views of people with stroke, their ‘family members/friends’ and physiotherapists on the role of the family in physiotherapy and the delivery of exercises following stroke.

Methods. A self-report questionnaire was administered to 100 ‘family members/friends’ and 75 people with stroke. Two focus groups were conducted with 10 expert physiotherapists working in the area of stroke rehabilitation.

Results. Family members of people with stroke are willing to participate in the delivery of unsupervised exercises in the hospital and the home setting (n = 91). Furthermore, this is also acceptable to people with stroke (n = 65) as an adjunct to routine physiotherapy. Physiotherapists highlighted a number of factors that influenced participation in physiotherapy such as; level of interest and motivation of the family (n = 5), availability (n = 3) and importance of education (n = 2). ‘Family members/friends’ identified reasons that would also limit participation such as work commitments (n = 24), lack of confidence (n = 20) and unsuitable treatment times (n = 13). The expert practitioners outlined a number of areas that family involvement can have an impact, such as treatment carry-over, assisting the family unit to cope on discharge and improving handling skills.

Conclusions. Our study identifies an under-utilised role for ‘family members/friends’ in the rehabilitation of people with stroke. Family mediated exercises can maximise the carry-over outside formal physiotherapy giving patients the opportunity for informal practice. This study highlights the need to examine the value of a structured programme of exercises that can be delivered to people with stroke by their ‘family members/friends’.