The Family Conference as an example of involving the patient's relatives in neurological early rehabilitation

For the patient the social support plays a crucial role when trying to cope with critical life events. Therefore the "Saarland-Heilst?tten" hospitals in Saarbrücken usually integrate the relatives of patients in a minimally conscious state ("apallisches Syndrom") or having a severe brain injury into the therapies during the neurological early rehabilitation. All members of the interdisciplinary working team attend to the relatives of those patients: there are one-to-one meetings with therapists, weekly meetings with groups of relatives, and Family Conferences. This article explains why generally the qualified work with patients' relatives is absolutely necessary, and it illustrates that concept by describing the approach of the Family Conference. Finally the therapeutic possibilities and limitations of Family Conferences in the rehabilitation process are discussed as seen after several years of experience.     

Exploring the content of physiotherapeutic home-based stroke rehabilitation in New Zealand

OBJECTIVE: To address the paucity of information on the content of home interventions for people with stroke by reporting on the practice of physiotherapeutic home-based stroke rehabilitation in New Zealand. DESIGN: Qualitative research methodology comprising a series of semi-structured interviews. SETTING: Community setting in 6 cities in New Zealand. PARTICIPANTS: A purposeful sampling strategy recruited 20 physiotherapists working in home-based stroke rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Participants described patients as being fatigued, frustrated, depressed, and scared once discharged home and said that the primary aim of rehabilitation in the home environment is preparation for life after stroke. Physiotherapists aimed at optimal independent functioning by building patients' confidence, self-responsibility, and problem-solving skills while ensuring patient safety. Participants, illustrating the complexities of stroke rehabilitation, described a wide range of interventions. We identified a number of factors that influenced the practice decisions made by participants. The success of intervention was measured more by the successful attainment of carefully set patient-centered goals than by the use of validated outcome measures. CONCLUSIONS: This study presents a conceptual model or framework for physiotherapy practice for people with stroke living in the community.     

Comparing stroke rehabilitation outcomes between acute inpatient and nonintense home settings

OBJECTIVE: To compare outcomes in stroke survivors who received rehabilitation services in an acute inpatient rehabilitation setting (multidisciplinary rehabilitation team) with outcomes in survivors in a home-based setting (family caregivers, limited team supervision). DESIGN: Randomized clinical trial, with mean follow-up after 60 days. SETTING: Inpatient rehabilitation setting and home-based settings. PATIENTS: Sixty patients (age range, 43-80yr) who had a stroke between 1996 and 1999 and had been referred after medical stabilization, randomly divided into 2 groups: group 1, inpatient rehabilitation; group 2, home-based rehabilitation. INTERVENTIONS: Group 1: therapeutical and neuromuscular exercises with occupational therapy with professional supervision; group 2: conventional exercises with family caregiver and limited professional supervision. MAIN OUTCOME MEASURES: Spasticity was evaluated with the Ashworth Scale, motor status with Brunnstrom's stages, functional status with the FIM instrument, and cognitive status with the Mini-Mental State Examination before and after rehabilitation. RESULTS: Patients rehabilitated in acute inpatient settings had better motor, functional, and cognitive outcomes (p < .05). Spasticity changes did not differ between the groups. CONCLUSION: Intense inpatient rehabilitation services for stroke survivors provide significantly more favorable functional and cognitive outcomes with relatively low complications than did nonintense rehabilitation efforts in home settings.     

Can staff attitudes to team working in stroke care be improved?

BACKGROUND: Teamwork is regarded as the cornerstone of rehabilitation. It is recognized that the skills of a multiprofessional team are required to provide the care and interventions necessary to maximize the patient's potential to recover from his/her stroke. LITERATURE REVIEW: Critical evaluation of team working is lacking in the literature. Indeed, there is no consensus on a precise definition of teamwork or on the best way of implementing it, beyond a general exhortation to members to work to the same therapeutic plan in a cohesive manner. The literature has highlighted many problems in team working, including petty jealousies, ignorance and a perceived loss of autonomy and threat to professional status. AIM: To determine if the use of team co-ordinated approaches to stroke care and rehabilitation would improve staff attitudes to team working. METHOD: A pre-post design was adopted using 'The Team Climate Inventory' to explore attitudes to team working before and after introducing the interventions. Local Research Ethics Committee approval was obtained. RESULTS: Improvements in attitudes towards team working suggest that the introduction of team co-ordinated approaches (integrated care pathways and team notes) did not result in greater team working. LIMITATIONS: The introduction of an integrated care pathway and team notes is based on an assumption that they would enhance team working. CONCLUSIONS: The results suggest that the introduction of team co-ordinated approaches (team notes and care pathways) do not improve attitudes to team working, teams appear to take a long time to establish cohesion and develop shared values.     

Rehabilitation in the home versus the hospital: The importance of context

Purpose: Stroke rehabilitation has received increased attention in the past decade. Recent trials with new alternatives such as home-based rehabilitation services are being conducted. The purpose of the study was to explore differences between a therapy session with a stroke patient in two different contexts, i.e. in the patient's home and in the hospital.

Methods: The research design was a qualitative case study. Three data collection methods were used; participant observations of therapy sessions in two different contexts, semi-structured interviews and documents.

Results: The data were examined and coded for common categories. Analysis of the data looking for similarities and differences in behaviour of two therapists and their patients during therapy sessions in the hospital and in the home was performed. The observations revealed that there was clearly a difference in behaviour; a different role-set used by the two therapists when working in the patient's home versus in the hospital. The major difference in patient behaviour was that the patient, observed in his home, took the initiative and expressed his goals, which was not the case with the patients observed in the hospital. The findings were confirmed in the interviews and the documents.

Conclusion: It is suggested that the context is a key component to be considered in the rehabilitation process of stroke patients.     

Comparing the experience of outpatient therapy in home and day hospital settings after traumatic brain injury: patient,significant other and therapist perspectives

Purpose.?To explore how therapy in a home and day hospital setting impacts on rehabilitation processes and outcomes from the perspective of the patients, their significant others and their treating occupational therapists.

Method.?Fourteen participants with severe traumatic brain injury received a one-to-one, goal-directed, client-centred outpatient occupational therapy programme (a) in their home for 6 weeks and (b) in a day hospital clinic for 6 weeks. The experience of rehabilitation in both settings was explored using semi-structured interviews with the participants, their significant others and their treating occupational therapists.

Results.?Participants and their significant others described the two environments as disparate with home-based therapy perceived as more relaxing, normal, satisfying and effective. The approach to therapy at home was commonly described as ‘real-life’ whereas the therapy approach in day hospital was characterised as ‘simulation of real life tasks’ and ‘remedial exercises’. Participants' experience of therapy relationships at home was characterised as ‘friendship’, in which the therapist was a ‘visitor’, whereas in the hospital, participants were characterised as ‘patients’ and therapists as ‘bosses’ and ‘teachers’.

Conclusion.?The experience of home-based therapy was perceived as more convenient, positive and preferred by patients and their family members. Therapists described more therapeutic benefits and the ability to work more effectively on activity and participation level goals in the client's real-life environment.     

Health care and social welfare costs in home-based and hospital-based rehabilitation after stroke

During the 1990s most western European and Organization of Economic Cooperation and Development (OECD) countries experienced financial difficulties and were forced to cut back on or restrain health care expenditures. Home rehabilitation has received attention in recent years because of its potential for cost containment. Often forgotten, however, is the redistribution of costs from one caregiver to another. The aim of this study was to analyse whether a redistribution of costs occurs between health care providers (the County councils) and social welfare providers (the municipalities) in a comparison of home-based rehabilitation and hospital-based rehabilitation after stroke. The study population included 123 patients, 53 in the home-based rehabilitation group and 68 in the hospital-based rehabilitation group. The patients were followed up at 6 and 12 months after onset of stroke. Resource use over a 12-month period included acute hospital care, in-hospital rehabilitation, home rehabilitation and use of home-help service as well as nursing home living. The hospital-based rehabilitation group had significantly fewer hospitalization days after a decision was made about rehabilitation at the acute care ward and consequently the cost for the acute care period was significantly lower. The cost for the rehabilitation period was significantly lower in the home-based rehabilitation group. However, the cost for home help service was significantly higher in the home-based rehabilitation group. The total costs for the care episode did not differ between the two groups. The main finding of this study is that there seems to occur a redistribution of costs between health care providers and social welfare providers in home rehabilitation after stroke in a group of patients with mixed degree of impairment.     

Understanding nursing practice in stroke units: a Q-methodological study

Abstract

Purpose: Nurses represent the largest professional group working with stroke-survivors, but there is limited evidence regarding nurses’ involvement in post-stroke rehabilitation. The purpose of this study was to identify and explore the perspectives of nurses and other multidisciplinary stroke team members on nurses’ practice in stroke rehabilitation. Method: Q-methodological study with 63 multidisciplinary stroke unit team members and semi-structured interviews with 27 stroke unit team members. Results: Irrespective of their professional backgrounds, participants shared the view that nurses can make an active contribution to stroke rehabilitation and integrate rehabilitation principles in routine practice. Training in stroke rehabilitation skills was viewed as fundamental to effective stroke care, but nurses do not routinely receive such training. The view that integrating rehabilitation techniques can only occur when nursing staffing levels were high was rejected. There was also little support for the view that nurses are uniquely placed to co-ordinate care, or that nurses have an independent rehabilitation role. Conclusions: The contribution that nurses with stroke rehabilitation skills can make to effective stroke care was understood. However, realising the potential of nurses as full partners in stroke rehabilitation is unlikely to occur without introduction of structured competency-based multidisciplinary training in rehabilitation skills.

• Implications for Rehabilitation

• Multidisciplinary rehabilitation in stroke units is a cornerstone of effective stroke care.

• Views of stroke unit team members on nurses’ involvement in rehabilitation have not been reported previously.

• Nurses can routinely incorporate rehabilitation principles in their care.

• Specialist competency-based stroke rehabilitation training needs to be provided for nurses as well as for allied health professionals.

     

社区脑卒中患者康复现状与指导需求调查

目的:深入了解社区脑卒中患者的康复现状和指导需求。方法:选取北京市某社区脑卒中恢复期患者110例,采用自行设计的问卷,对患者康复现状和指导需求进行调查。结果:110例患者中有89例患者选择在家进行康复锻炼,7例患者在社区卫生服务中心接受康复治疗,18例患者在康复专业机构接受康复治疗,9例患者得到过专业人员上门指导,6例患者进行过家庭环境的改造,9例患者有日常生活辅助器具并了解其使用方法。患者对专业人员上门指导的需求排在首位。结论:目前社区脑卒中患者的康复地点以家庭为主,应进一步加强脑卒中康复专业队伍建设,根据患者需求丰富康复指导内容,增加社区入户指导工作的力度。     

Experiences of nurses working in a stroke rehabilitation unit

Title. Experiences of nurses working in a stroke rehabilitation unit. Aim. This paper is a report of a study to explore the perceptions, beliefs and feelings of a group of nurses who provided care to individuals admitted to a stroke rehabilitation unit. Background. Following a stroke, survivors should ideally be referred to multidisciplinary inpatient rehabilitation programmes, which attain better outcomes compared to the care provided on general medical wards. However, to achieve these outcomes, team members must work closely together. Communication problems have been reported in these teams, and other members may consider that nurses do not practise functional activities with patients. Methods. An interpretive phenomenological approach was adopted. Eight nurses in one Canadian stroke rehabilitation unit were interviewed during 2004–2005 about their experiences of providing care to stroke survivors. Findings. The nurses enjoyed giving this type of care, feeling that their role was pivotal to the rehabilitation process. At times, they found it difficult to let patients struggle to complete their activities of daily living. The nurses felt that lack of resources, including time, contributed to stroke survivors being short-changed in their rehabilitation nursing care. Despite holding strong views that others devalued their role within the stroke team, the nurses retained positive attitudes. Conclusion. Stroke teams need to recognize the constraints nurses experience in fulfilling their stroke rehabilitation role in order to foster the collegial support that could contribute to a more interactive and respectful work environment. They also need to consider ways to increase the job satisfaction of nurses working in stroke rehabilitation settings.     

社区脑卒中患者居家状况调查

目的：了解社区脑卒中患者居家状况，提出相应的脑卒中患者家庭康复的对策，为开展社区服务工作提供依据。方法：选定包头市6个社区中218例脑卒中患者及其主要照顾者进行人户问卷调查。结果：被调查的患者有多种功能障碍；负性情绪存在较为普遍；多数患者未行康复训练和其家庭未根据患者的具体情况对家庭设施进行相应改造。结论：脑卒中患者的居家状况存在问题较多，亟待得到合适的整体家庭康复服务。     

社区脑卒中患者康复现状和指导需求调查

目的:深入了解社区脑卒中患者的康复现状和指导需求。方法:选取北京市某社区脑卒中恢复期患者110例,采用自行设计的问卷,对患者康复现状和指导需求进行调查。结果:110例患者中有89例选择在家进行康复锻炼,7例在社区卫生服务中心接受康复治疗,18例在康复专业机构接受康复治疗。9例患者得到过专业人员上门指导,6例患者进行过家庭环境的改造,9例患者有日常生活辅助器具并了解其使用方法。患者对专业人员上门指导的需求排在首位。结论:目前社区脑卒中患者的康复地点以居家为主,应进一步加强脑卒中康复队伍建设,根据患者需求丰富康复指导内容,增加社区入户指导力度。     

Reported use of technology in stroke rehabilitation by physical and occupational therapists

Purpose: With the patient care experience being a healthcare priority, it is concerning that patients with stroke reported boredom and a desire for greater fostering of autonomy, when evaluating their rehabilitation experience. Technology has the potential to reduce these shortcomings by engaging patients through entertainment and objective feedback. Providing objective feedback has resulted in improved outcomes and may assist the patient in learning how to self-manage rehabilitation. Our goal was to examine the extent to which physical and occupational therapists use technology in clinical stroke rehabilitation home exercise programs.

Materials and methods: Surveys were sent via mail, email and online postings to over 500 therapists, 107 responded.

Results: Conventional equipment such as stopwatches are more frequently used compared to newer technology like Wii and Kinect games. Still, less than 25% of therapists’ report using a stopwatch five or more times per week. Notably, feedback to patients is based upon objective data less than 50% of the time by most therapists. At the end of clinical rehabilitation, patients typically receive a written home exercise program and non-technological equipment, like theraband and/or theraputty to continue rehabilitation efforts independently.

Conclusions: The use of technology is not pervasive in the continuum of stroke rehabilitation.

• Implications for Rehabilitation

• The patient care experience is a priority in healthcare, so when patients report feeling bored and desiring greater fostering of autonomy in stroke rehabilitation, it is troubling.

• Research examining the use of technology has shown positive results for improving motor performance and engaging patients through entertainment and use of objective feedback.

• Physical and occupational therapists do not widely use technology in stroke rehabilitation.

• Therapists should consider using technology in stroke rehabilitation to better meet the needs of the patient.

     

Team supervision in multiprofessional teams: team members' descriptions of the effects as highlighted by group interviews

The aim of the study was to describe the effects of team supervision in multiprofessional teams as perceived by team members. The literature describes team supervision as a way to develop collaboration in multiprofessional teams. However, little empirical research into the effects of team supervision is available. A research project was undertaken on five units of a university hospital between 1995 and 1998. Data were collected using group interviews with 62 interviewees and were analysed using qualitative content analysis. Team members' perceptions of the feeling of togetherness varied. Communication had become more open in the teams, but the frankness of expression varied: communication had generally become more tactful, whereas in one of the teams frankness offended some members. Team members had learned to know each other. This had improved mutual understanding, but also increased tension. Teams' working methods had changed. Joint decision making had developed, but conflicts had also emerged. Motivation for work had improved as a result of the awareness of shared problems. However, motivation had been lessened by frustration caused by slow progress in the team. Perceptions of the effects of team supervision in the multiprofessional teams varied by units and teams. The study showed that team supervision is a challenge to supervisors.     

Home-based psychoeducational and mailed information programs for stroke-caregiving dyads post-discharge: a randomized trial

Abstract

Purpose: This randomized trial compared 6- and 12-month outcomes of a home-based psychoeducational program to mailed information provided to 159 survivors of stroke (SS) and their spousal caregivers (CG). Methods: SS (age 50+) and CG were recruited as dyads post-discharge from inpatient rehabilitation. All dyads received mailed information for 12 months. Dyads randomized to the home-based group received an average of 36.7?h of psychoeducation over 6 months. Health status, depression, stress, burden, coping, support, mutuality and function were obtained on all dyads. Repeated measures analysis with linear mixed models was used to compare the groups for change over time in the outcome variables. Results: Both groups demonstrated less depression and stress over time. Compared to the mailed information group, SS in the home-based group demonstrated significantly improved self-reported health and cognitive function; CG demonstrated significantly improved self-reported health and coping strategies. Mutuality and social support decreased in both groups. Conclusions: The home-based intervention was effective in improving self-reported health, coping skills in CG and cognitive functioning in SS. However, the finding that dyads in both groups demonstrated decreased depression and stress suggests that providing repeated doses of relevant, personalized information by mail may result in positive changes.

• Implications for Rehabilitation

• A stroke affects both the stroke survivor and the spousal caregiver, so nurses and therapists should use multicomponent strategies to provide education, support, counseling and linkages to community resources to ease the transition from hospital to home.

• Stroke may have a negative impact on the dyad’s relationship with each other and also on the availability of support people in their lives during the 12 months after hospital discharge. Comprehensive stroke programs should encourage dyads to attend support groups and to seek individual and group counseling, as needed.

• Establishing an ongoing relationship with stroke survivors and their spouses and providing relevant and engaging information by mail can reduce stress and depression over 12 months post-discharge at a minimal cost.

• Nurses and therapists should consider home visits post-discharge to reinforce education and skills taught in the hospital, increase self-reported health in stroke survivors and spousal CG, increase coping skills and to link the couple to community resources.

     

A randomized controlled trial to evaluate intensity of community-based rehabilitation provision following stroke or hip fracture in old age

OBJECTIVE: To compare intensive with non-intensive home-based rehabilitation provision following stroke or hip fracture in old age (65 years+). DESIGN: Parallel single-blind randomized control trial. SETTING: Domiciliary provided multidisciplinary rehabilitation. SUBJECTS: One hundred and sixty patients aged 65 or over recently discharged from hospital after suffering a stroke or hip fracture. INTERVENTION: Patients assigned to receive six or more face-to-face contacts or three or less face-to-face contacts from members of a multidisciplinary rehabilitation team. MAIN MEASURES: Patients assessed using the Barthel Index, Therapy Outcome Measure, Euroqol 5D (EQ-5D), Hospital Anxiety and Depression Scale (HADS) and Frenchay Activities Index (FAI) at three months. All follow-up assessments were conducted blind to allocation. RESULTS: Subgroup analysis was conducted on the basis of incident condition (stroke or hip fracture). Significant differences were detected for the stroke subgroup at three months [Therapy Outcome Measure Handicap (median difference 0.5 (P< 0.05)) and EQ-5D (median difference 0.17 (P< 0.05))] and in change at three months [Therapy Outcome Measure (mean difference 0.52 (SD 0.85) 95% CI (0.16, 0.88)) and EQ-5D (mean difference 0.15 (SD 0.25) 95% CI (0.05, 0.26))]. No significant differences were detected between the two arms of the study for the hip fracture subgroup. CONCLUSION: Following stroke older people who receive a more intensive community-based multidisciplinary rehabilitation service may experience short-term benefit in relation to social participation and some aspects of health-related quality of life. A more intensive service after discharge from hospital following a hip fracture is unlikely to result in similar patient benefit.     

Using the ICF to clarify team roles and demonstrate clinical reasoning in stroke rehabilitation

PURPOSE: The International Classification of Functioning, Disability and Health (ICF) is advocated as a tool to structure rehabilitation and a universal language to aid communication, within the multi-disciplinary team (MDT). The ICF may also facilitate clarification of team roles and clinical reasoning for intervention. This article aims to explore both factors in stroke rehabilitation. METHOD: Following a review of the literature, a summary was presented and discussed with clinicians working within stroke rehabilitation, to gather expert opinions. The discussions were informal, being part of service development and on-going education. The clinicians summarised key themes for the potential use of the ICF within clinical practice. RESULTS: Two key themes emerged from the literature and expert opinion for the potential use of the ICF in stroke rehabilitation: (i) to aid communication and structure service provision, (ii) to clarify team roles and aid clinical reasoning. Expert opinion was that clarification of team roles needs to occur at a local level due to the skill mix, particular interests, setting and staffing levels within individual teams. The ICF has the potential to demonstrate/facilitate clinical reasoning, especially when different MDT members are working on the same intervention. CONCLUSION: There is potential for the ICF to be used to clarify team roles and demonstrate clinical reasoning within stroke rehabilitation. Further experiential research is required to substantiate this view.     

Rehabilitation professionals’ perceptions of the use of new visualisation software tools with people with stroke

Purpose: The envisage programme of research was funded to explore and evaluate the use of visualisation software tools using biomechanical data within rehabilitation. Three work packages were developed to evaluate the impact of the tools within stroke rehabilitation. The research presented here aimed at exploring the perceptions of rehabilitation therapists about the use of the visualisation software tools in the context of future randomised controlled trials and stroke rehabilitation practice. Methods: Sixteen therapists working in a range of stroke rehabilitation contexts participated in semi-structured interviews. Interview questions explored their current practice, and the perceived impact of the new visualisation technologies on their workplace environment and practice. Framework analysis was used to analyse the textual data. Results: In general, the stroke therapists were enthusiastic about the potential application of the visualisation software tools. Three themes were identified through qualitative framework analysis: potential uses of the visualisation tools; integration within current service provision; and trial involvement. Conclusions: The study highlights important contextual considerations which may impact significantly on the success of novel technologies in stroke rehabilitation. Normalisation process theory was proposed as a useful process evaluation methodology to optimise both trial evaluation and future service implementation.

• Implications for Rehabilitation

• There is limited research exploring the use of visual software technologies featuring biomechanical data within stroke rehabilitation.

• The perspectives of stroke rehabilitation therapists about the potential of such tools are useful both in terms of planning trial evaluations, and implementation.

• Therapists were generally positive about the contribution of visual software tools in stroke rehabilitation, but highlighted a number of practical constraints which required addressing.

• Normalisation process theory provides a useful process evaluation methodology which can support both trial evaluation and implementation of such novel technologies within stroke rehabilitation.