Methods: A scoping review was conducted, beginning with a systematic search of relevant databases using key search terms. Studies with a focus on the role of the working alliance in shaping rehabilitation outcomes, and factors influencing perceptions of the working alliance were included and key information extracted.
Results: A total of 10 quantitative studies met inclusion criteria. In most studies, ratings of the working alliance were compared with other process variables or outcome measures. The working alliance was linked to positive activity and participation outcomes, including return to work, school, and driving. Client related factors such as age, level of education and approach to rehabilitation tasks were associated with client and therapist perceptions of the working alliance.
Conclusions: The working alliance emerged as a complex process that interacts with many factors and processes at play in the rehabilitation environment. Notwithstanding the limitations of the research base, findings indicate that enhancement of the working alliance may indeed influence rehabilitation outcomes. Allowing time for the development of the working alliance, and consideration of factors such as therapist skill, may support therapists to strengthen their alliances in ABI rehabilitation.
- Implications for Rehabilitation
Allowing time for the development of the working alliance has the potential to enhance the alliance and thereby influence rehabilitation outcomes.
Factors such as the client’s age and level of education may influence the strength of the working alliance, and hence, awareness of these factors may assist clinicians in maintaining strong alliances with all clients.
A strong working alliance is possible in the presence of client cognitive impairment, however, the skill of the therapist may be important in managing the potential impact of cognitive impairment on the working alliance.
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: A concurrent mixed-method design was employed. Four patients participated in the combined therapist- and self-delivered HBR program for 5 months. The perceived health outcomes were quantitatively assessed at baseline, after the therapist-delivered intervention period, and at 1 and 3 months after the self-delivered intervention period. Then, in-depth individual interviews were conducted to explore the facilitators and barriers to rehabilitation.
Results: The perceived health of patients who were fully or partially engaged in society was increased during the therapist-delivered intervention period, and maintained the increased level during the self-delivered intervention period, whereas that of patients who were rarely or not engaged dropped again to lower than the baseline. These results were caused by differentiated facilitators and barriers to rehabilitation depending on the level of social engagement.
Conclusions: Applying tailored strategies to patients with differing levels of social engagement is recommended to further optimize the local relevance of the HBR program.
- Implications for rehabilitation
A community-based participatory research approach can provide an opportunity to enhance local relevance through community-academic partnerships, in developing a home-based rehabilitation (HBR) program for the people with disabilities.
For community therapists, enhancing the local relevance of the HBR program, applying tailored strategies to patients with differing levels of social engagement is recommended because the perceived health of the HBR program can be different owing to differing perceived facilitators and barriers to rehabilitation, depending on the level of social engagement.
For patients with rare or no engagement in society, satisfying their need for interaction with the therapists and helping them cope with their wrong belief about the possibility of their recovery is important to encourage behavioral change and perceived physical improvements.
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: A total of 90 participants were enrolled in a longitudinal study and completed measures at four time points over 15 months.
Results: Participants reported increases in all variables, and in general these changes were maintained at six weeks post-rehabilitation and at 15 months post-baseline. As well, the SDT Model of Health Behavior provided adequate fit to the data.
Conclusions: These results underscore the importance of health care practitioners’ providing support for their patients’ autonomy, competence, and relatedness to improve well-being, physical activity, and RTW in the context of vocational rehabilitation.
- Implications for Rehabilitation
Vocational rehabilitation that emphasizes physical activity is associated with increases in patients’ well-being, physical activity, and return to work (RTW).
It is important for health care practitioners to provide support for their patients’ autonomy, competence, and relatedness in the context of vocational rehabilitation, as doing so is associated with increases in patients’ autonomous motivation, perceived competence, and psychosocial outcomes.
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.
Methodology: Semistructured interviews were carried out with participants with chronic stroke (>6 months). The participants took part in 16 tai chi sessions over 8 weeks. Interviews were conducted in person using an interview guide based on the theory of planned behavior (TPB), and a thematic analysis was conducted.
Results: Eight interviews were carried out with participants at various stages of motor recovery. Participants perceived a number of physical, functional, and psychological benefits. They found tai chi to be a global exercise, including both physical and mental aspects, and suggested that it can be included as part of rehabilitation for stroke patients. Many participants expressed a desire to continue practicing tai chi after completion of the study because it exceeded their expectations, among other reasons.
Conclusion: This study can serve to guide future tai chi interventions and research on tai chi for rehabilitation in terms of the characteristics of the intervention and the various areas to assess in order to measure the overall benefits.
- IMPLICATIONS FOR REHABILITATION
Tai chi was perceived as a good way of integrating various skills learned during rehabilitation.
Despite having different functional abilities, all the participants noted various physical, functional, and psychological benefits from participating in the tai chi sessions.
Tai chi seems to be a form of exercise that stroke patients would perform more long-term since all the participants in this study expressed the desire to continue practicing tai chi.
Method: A cross-sectional study was conducted on 43 blind participants and 42 sighted participants. The participants performed auditory computerized tests assessing selective, sustained and divided attention, attentional switching, and working memory.
Results: Two-way analysis of variance revealed significant visual status effect and age effect on most of the variables studied. No interaction was found between visual status and age effects.
Conclusions: These results suggest that the trajectories of cognitive age-related change are similar in blind people and in sighted people. This study has implications for rehabilitation, such as cognitive intervention.
- Implications for Rehabilitation
Blind people show improved attentional capacities compared to sighted people, even in old blind people.
Old blind people have lower performances than younger blind people in tests assessing selective, sustained and divided attention, and working memory.
Cognitive approaches to rehabilitation may help people who are blind to deal with age-related cognitive decline and its effects on everyday functioning.
A high level of cognitive stimulation, provided by a cognitive training or a developed social participation, might reduce the age-related effects in people who are blind.
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.
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.
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.
Methods: Semi-structured interviews, subject to general inductive analysis with 20 Clinicians’ working in three UK based stroke rehabilitation teams (one in-patient ward and two community based rehabilitation teams).
Results: There were three key themes that impacted on the patients active involvement in setting goals for rehabilitation after stroke: Patient barriers to goal setting (knowledge of the patient and family, who is the patient and the stroke’s impact); How we work as a team (the role of the patient in setting goals, the effect of clinician attributes on goal setting); and How systems impact goal setting (goal-setting practice, home versus hospital, and professional/funder expectations of clinicians’).
Conclusions: Goal setting served a range of different, sometimes conflicting, functions within rehabilitation. Clinicians’ identified the integral nature of goals to engage and motivate patients and to provide direction and purpose for rehabilitation. Further, there was an identified need to consider the impact of prioritizing clinician-derived goals at the expense of patient-identified goals. Lastly the reliance on the SMART goal format requires further consideration, both in terms of the proposed benefits and whether they disempower the patient during rehabilitation.
- Implications for rehabilitation
Goal setting is often promoted as a relatively simple, straightforward way to structure interactions with patients
Patient-related factors together with resourcing constraints are significant barriers to patient-centered goal setting, particularly during inpatient rehabilitation
Clinicians need to have pragmatic tools that can be integrated into practice to ensure that goal-setting practice can be maximized for patients with different intrinsic characteristics
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.
Methods: Fourteen healthcare professionals (11 women, 3 men) were individually interviewed about their experiences of starting and working with multimodal pain. Interviews were transcribed and analyzed by qualitative content analysis. This study was part of a larger project, which aimed at evaluating multimodal pain rehabilitation in primary care.
Results: The analysis resulted in six categories. Two categories were about management engagement: putting the focus on rehabilitation and creating appropriate conditions. Three were about professional engagement: importance of driving spirits, creating a program – a process, and good teamwork – not a coincidence. The last category was about professional gain from multimodal rehabilitation (MMR): team work is enriching.
Conclusions: To enable implementation of MMR in primary care, managers on all organizational levels must take responsibility for allowing rehabilitation to be a priority. A driving spirit among the professionals facilitates the start, but the entire team is important when processing a program. Creating good teamwork requires hard work, e.g., negotiations for consensus about rehabilitation, and assumption of responsibility by each team member. Collaboration between professionals was perceived to strengthen and enhance knowledge about the patients.
- Implications for rehabilitation
Much can be gained from conducting multimodal pain rehabilitation in primary care.
Front line managers and those at other organizational levels must prioritize and create appropriate conditions to facilitate multimodal pain rehabilitation in primary care.
Creation of an effective multimodal rehabilitation team requires that each team member takes responsibility, drops the focus on individual rehabilitation, seek member consensus about the content of the rehabilitation, and confer equal worth to each team member.
The process of creating a program can be facilitated, especially at the beginning, if the team is supported by speciality pain clinics or more experienced teams.
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: 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: This article describes a training designed for rehabilitation professionals working in operational multidisciplinary teams. The main objective of this training is to help create a professional environment in which sexual health problems can be discussed, if possible prevented and when needed treated. A pretest–posttest design was used to measure the impact of this educational program given to six teams in the Netherlands.
Results: The results demonstrated that the staff’s knowledge, comfort levels and approach levels significantly increased. Team members were more active concerning sexual health and patient care.
Conclusion: These findings clearly indicate that rehabilitation workers can benefit from a custom fit design team training on sexual health care. Strategically working with the modus operandi of a multidisciplinary team, such as task definition, determining pro- and reactive roles and formal agreements, appears to be of importance in integrating sexual health in the overall care for patients.
- Implications for Rehabilitation
Sexuality and intimacy are important aspects of quality of life and difficult to integrate in rehabilitation treatment.
A multidisciplinary Team Training Sexual Health Care (TTSHC) has been developed with core themes: talking about sex, using a biopsychosocial approach, identifying and understanding sexual health issues, applying the existing expertise of the MDT for sexual health care.
After the TTSHC all the participants of the MDTs show significantly more active behavior concerning sexual health and patient care.
Defining roles and responsibilities in the MDT is important for integrating sexual health care in rehabilitation treatment.
Method: Semi-structured interviews were completed with 18 neurological physiotherapists (2–22 years experience) from SCI centres in the United Kingdom and Ireland. Framed by interpretivism, an inductive thematic analysis was conducted.
Results: Three themes were identified: (1) perceived importance of PA; (2) inconsistent PA promotion efforts; and (3) concern regarding community PA.
Conclusions: This article makes a significant contribution to the literature by identifying that although physiotherapists value PA, active promotion of PA remains largely absent from their practice. To enable physiotherapists to promote and prescribe PA as a structured and integral component of their practice, effective knowledge strategies need designing and implementing at the macro, meso, and micro levels of healthcare.
- Implications for Rehabilitation
Physiotherapists are well placed to promote a physically active lifestyle and are perceived as valued and trusted messengers of physical activity (PA).
The importance of PA for patients with spinal cord injury (SCI) is valued by physiotherapists yet PA promotion is largely absent from their practice.
Physiotherapists lack specific education and training on PA and SCI and hold certain beliefs which restrict their promotion of PA.
Knowledge translation across the macro, meso, and micro levels of healthcare are essential to facilitate effective PA promotion.