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.     

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.     

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.     

Learning to eat after radiation therapy for throat cancer

Purpose: The initial purpose was to find more expedient ways for learning to eat for personal rehabilitation. The secondary purposes were to inform other radiation therapy patients and to inform clinicians and therapists involved in rehabilitation of throat cancer patients.

Method: This is an account of personal experiences of the author who is a throat cancer survivor. This rehabilitation engineer, and his social worker wife, systematically sought and found more effective ways for learning to eat again.

Results: More effective approaches for discovering, preparing, presenting and consuming food by recovering throat cancer patients were identified.

Conclusion: The rehabilitation process for patients with radiation damage to the throat can be enhanced through simple methods and dedicated efforts of the patients themselves.     

Recovery from unilateral neglect after right-hemisphere stroke

Purpose: To show the recovery process for different forms of unilateral neglect (UN)—including personal neglect and neglect of far space—in relationship to impairment, disability, cognition and mood.

Method: Patients were tested at 2 - 4 weeks, at 6 months and at 1 year. We used the Behaviour Inattention Test and a test for personal neglect. We also used the NIH Stroke Scale, the Functional Independence Measure (FIM), the Mini-Mental State Evaluation and the Geriatric Depression Scale.

Results: Peripersonal neglect diminishes within 6 months, but complete recovery occurred in only 13%. The prognosis for personal neglect and neglect of far space is better, with a recovery ratio at 6 months of 52% and 46%, respective. The correlations between UN and FIM are high. A few patients deteriorate in the absence of recurrent stroke.

Conclusions: For clinical purposes, it is practical to postpone UN evaluation until a couple of weeks after a stroke. Many of the patients who then have UN are likely to retain their UN, although many will improve. Patients with UN should receive special attention in the rehabilitation phase, as well as at discharge. One explanation of the worsening of UN seen in some patients, may be continuing cerebral atherosclerosis.     

Consequences of stroke, arthritis and chronic pain--are there important similarities?

Purpose: This study aimed to explore the applicability of a previously derived model of what mattered most to people with arthritis across a number of different disabling conditions.

Method: A qualitative study using interviews with 30 participants from three out-patient groups (rheumatoid arthritis, stroke and chronic pain) was conducted. Participants were asked to identify and discuss the most important consequences of living with their condition. Narratives were explored for similarities and differences within and across conditions.

Results: While diagnostically related differences were clearly evident, particularly in categories within the Intrinsic, Extrinsic and Future Issues themes, a marked level of similarity in view was apparent in two themes, Taking Charge and Perceptions of Normality.

Conclusions: The study identified a shared perspective about a number of issues, but also detailed where there were differences. We suggest explicit consideration of the themes highlighted in this research, and a deeper understanding of the inter-relatedness of seemingly separate issues will help health professionals and researchers re-think ways of working with people who have disabling conditions, and identify different factors to address in measuring the success of rehabilitation.     

Long-term outcomes after moderate to severe traumatic brain injury

Objective: This research examined the long-term outcomes of rehabilitation patients with moderate to severe traumatic brain injury (TBI).

Design: Retrospective cohort study.

Setting and subjects: We examined consecutive records of persons with moderate to severe traumatic brain injury who were discharged from a large rehabilitation hospital in Pennsylvania from 1973 to 1989. We interviewed consenting participants (n = 306) up to 24 years post-injury.

Main outcome measures: Self-rated health, activity limitations, employment, living arrangements, marital status, Community Integration Questionnaire, and use of rehabilitation services.

Results: Participants were most limited in activities such as managing money and shopping. Twenty-nine per cent of our participants were working full time. There were significant relationships between activity limitations and residual cognitive impairment at follow-up. Self-rated health was correlated with most instrumental activities of daily living.

Conclusion: Our findings document health and function in a large post acute TBI population and implications for rehabilitation are discussed.     

Issues for selection of outcome measures in stroke rehabilitation: ICF Body Functions

Purpose: To evaluate the psychometric and administrative properties of outcome measures assigned to the ICF Body Functions category, and commonly used in stroke rehabilitation research.

Method: Critical review and synthesis of measurement properties for five commonly reported instruments in the stroke rehabilitation literature. Each instrument was rated using the eight evaluation criteria proposed by the UK Health Technology Assessment (HTA) programme. The instruments were also assessed for the rigour with which their reliability, validity and responsiveness were reported in the published literature.

Results: The reporting of specific measurement qualities for outcome instruments was relatively consistent across measures located within the same general ICF category. Far less information was available on the responsiveness of measures, compared with reliability and validity. The best available instruments were associated with the following body functions: cognitive impairment, depression and motor recovery.

Conclusions: The reader is encouraged to examine carefully the nature and scope of outcome measurement used in reporting the strength of evidence for improved body functions in stroke rehabilitation since there is significant diversity. However there appears to be good consensus about what are the most important indicators of successful rehabilitation outcome in each domain of body function.     

Physiotherapy group treatment for patients with fibromyalgia--an embodied learning process

Purpose: To study how patients with fibromyalgia (FM) experienced physiotherapy group treatment comprising pool exercise and education.

Method: Nineteen patients with FM were interviewed and the transcribed interviews were analysed using a phenomenological life-world approach. The participants' mean age was 45 years and their mean symptom duration was 10 years.

Results: Physiotherapy group treatment was experienced as an embodied learning process, comprising the themes: positive experience of body, sharing experiences of living with FM and creating new patterns of acting. The positive experience of body comprised the following categories: experiencing relaxation, experiencing physical capacity, acknowledging limitations and changing the pattern of activity. Sharing experiences comprised the following categories: not being alone and sharing joy. Three patterns of participation were identified: reciprocity, distancing and remaining outside. Creating new patterns comprised the following categories; calming down, creating a new relationship to self, creating a new relationship to social roles and creating new patterns for managing pain.

Conclusions: The study indicates that physiotherapy group treatment was experienced as an embodied learning process. Positive experiences of body were intertwined with a new relationship to self and objects in the world. Interactions between the co-participants promoted the process of creating new patterns of thinking and acting in the social world.     

Physiotherapy practice in stroke rehabilitation: a survey

Objective : This survey aimed to provide an expert consensus view of the theoretical beliefs underlying physiotherapy practice in stroke rehabilitation the United Kingdom.

Method : Questionnaires (with sections related to: therapist background, physiotherapy management, theoretical beliefs and gait re-education strategies used) were posted to all senior level physiotherapists working in stroke care ( n =1022).

Results : The majority of respondents had more than 10 years experience overall, and at least 5 years experience in stroke care. The Bobath concept was the preferred approach ( n =67%) followed by an 'eclectic' approach ( n =31%). This survey identified four theoretical themes underlying current practice in neurological physiotherapy: the promotion of normal movement, the control of tone, the promotion of function, and the recovery of movement with optimization of compensation.

Conclusions : A consensus was obtained on 16 theoretical beliefs; however the evidence base underlying these beliefs remains sparse. Many of these beliefs require further debate within the physiotherapy profession such as the amount of time spent on preparation for function, the automatic translation of movement into function, carry over outside therapy, and the way in which tasks should be practised.     

The value of the Rehabilitation Activities Profile (RAP) as a quality sub-system in rehabilitation medicine

Purpose: To determine whether interdisciplinary team care, using the Rehabilitation Activities Profile (RAP) as a team tool, results in a better rehabilitation outcome.

Method: A multilevel prospective cohort study, with a controlled before and after design. Eighteen rehabilitation teams in eight rehabilitation centres in the Netherlands and Belgium participated. Based on the level of implementation of the RAP, we compared three study groups. Consecutive adult patients (n = 933) with stroke, amputation of the lower limb, spinal cord injury, multiple sclerosis, or other neuromuscular disorders, were followed during inpatient or outpatient rehabilitation. Main outcome measures were Barthel Index, RAP-CPM (sum score of the domains communication, personal care and mobility), Nottingham Health Profile (NHP), length of rehabilitation (LOR) and discharge destination (home vs elsewhere).

Results: Overall results show that scores on the Barthel Index, the RAP-CPM and the NHP improved, on average, by 18.4%, 12.7%, and 6.7%, respectively. However, treatment from a rehabilitation team that uses the RAP was associated with a significantly lower Barthel score, and small, non-significant effects on the RAP-CPM and the NHP. Partial use of the RAP resulted in non-significant, lower scores on these measures. With respect to discharge destination and LOR, there were also no significant differences between the three study groups, with the exception of a shorter outpatient rehabilitation period for the group in which partial use was made of the RAP.

Conclusion: The RAP, at the current level of implementation, does not improve rehabilitation outcome.     

Reliability, validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke

Purpose: The upper limb items of the Motor Assessment Scale (MAS) have been shown to be a sensitive, valid and reliable measure of upper limb function for adults following stroke, however the validity and reliability of summing these items into an independent subscale has not yet been evaluated. The stability, internal consistency and construct validity of the upper limb MAS subscale (UL-MAS) was assessed in this study.

Method: Twenty-seven inpatients following stroke (mean age = 67 years, range = 40 - 80) were sampled from an acute, inpatient rehabilitation setting. Patients were evaluated with 'Upper Arm Function', 'Hand Movements', and 'Advanced Hand Activities' items of the MAS by masked physiotherapists who had received standardized training in administration of the MAS.

Results: All items were explained by one factor on confirmatory factor analysis and correlated significantly with one another and with the composite (summed total) score. Internal consistency analysis produced a Cronbach's alpha of 0.83 which did not benefit from removal of any items.

Conclusions: The acceptable internal consistency score obtained verifies the validity and reliability of using the UL-MAS as an independent scale. This study has also verified the construct validity of the UL-MAS subscale and provides a valuable extension of previous work, which together demonstrates the value of the UL-MAS as a responsive, valid and reliable measure of upper limb function in adults following stroke. The UL-MAS produced a single, composite score that could be interpreted as a total score for upper limb function in this population.     

Women on sickness absence--views of possibilities and obstacles for returning to work. A focus group study

Purpose: The aim was to learn how women on sickness absence due to work related strain perceive and describe their possibilities and obstacles for returning to work.

Method: The focus group method was used. Five groups were conducted and each group met at one occasion. Twenty women participated in total.

Results: Three different themes were found. In 'The process of losing control' the participants describe the process from controlling every day living, to total loss of control of private and working life. The second theme, 'Not finding alternatives', deals with the difficulties of finding an alternative way back to work. 'Mastering life as a whole' contains strategies for regaining control over daily activities and life as a whole. The results show that personal as well as environmental factors have an impact for returning to work.

Conclusions: In this study we have received an understanding of the complex situation of being on sickness absence due to work related strain. We have learned the importance of recognizing the context of the individual and understanding the interplay between the person and the environment. As professionals in rehabilitation we can use this knowledge to create a rehabilitation programme supporting people back to work.     

Religious views of the 'medical' rehabilitation model: a pilot qualitative study

Purpose: To explore the religious beliefs that patients may bring to the rehabilitation process, and the hypothesis that these beliefs may diverge from the medical model of rehabilitation.

Methods: Qualitative semi-structured interviews with representatives of six major religions—Islam, Buddhism, Christianity, Judaism, Sikhism, and Hinduism. Representatives were either health care professionals or religious leaders, all with an interest in how their religion approached health issues.

Results: There were three recurrent themes in the interviews: religious explanations for injury and illness; beliefs about recovery; religious duties of care towards family members. The Buddhist, Sikh, and Hindu interviewees described beliefs about karma—unfortunate events happening due to a person's former deeds. Fatalistic ideas, involving God having control over an individual's recovery, were expressed by the Muslim, Jewish, and Christian interviewees. All interviewees expressed the fundamental importance of a family's religious duty of care towards ill or injured relatives, and all expressed some views that were compatible with the medical model of rehabilitation.

Conclusions: Religious beliefs may both diverge from and resonate with the medical rehabilitation model. Understanding these beliefs may be valuable in facilitating the rehabilitation of diverse religious groups.