Discharge from physiotherapy following stroke: the management of disappointment

What influences provision of information about recovery on stroke units? A focused ethnographic case study

OBJECTIVE

Patients and carers frequently report dissatisfaction with post-stroke information provision. This study aimed to develop an in-depth understanding of the factors influencing provision of information about recovery in stroke units.

METHODS

Focused ethnographic case-studies in two UK stroke units, including non-participant observations and semi-structured interviews with professionals, patients and carers, and documentary analysis. A Framework approach to analysis was undertaken.

RESULTS

Twenty patients, 17 carers and 47 professionals participated. The unpredictable recovery trajectory led professionals to present prognostic estimates as uncertain possibilities. The need to maintain patients' motivation limited sharing of negative predictions, and generic information over-emphasised the importance of therapy in recovery. A structured multidisciplinary team approach to delivering information improved consistency. Complex clinical reasoning was required to identify and meet patients' needs. Hospital environments and routines restricted opportunities for dialogue, particularly with carers.

CONCLUSIONS

The process of providing information about post-stroke recovery is complex, requiring enhanced clinical reasoning and communication. The challenges faced by professionals are numerous and if not addressed can result in suboptimal provision.

PRACTICE IMPLICATIONS

Professionals should develop a co-ordinated multidisciplinary approach to information provision; and engage in dialogue to ensure a tailored approach to identifying and meeting patients' and carers' information needs.

Facilitators and Barriers to Implementing High-Intensity Gait Training in Inpatient Stroke Rehabilitation: A Mixed-Methods Study

(1) Background: High-intensity gait training (HIT) is a recommended intervention that improves walking function (e.g., speed and distance) in individuals who are undergoing stroke rehabilitation. This study explored clinicians' perceived barriers and facilitators to implementing HIT utilizing a mixed-methods approach comprising a survey and exploratory qualitative research. (2) Methods: Clinicians (n = 13) who were implementing HIT at three facilities participated. We collected and analyzed data using the consolidated framework for implementation research. Three focus groups were recorded and transcribed, and data were coded and thematically categorized. (3) Results: Survey results identified that the facilitators with a strong impact on implementation were access to knowledge/resources and intervention knowledge/beliefs. The only agreed-upon barrier with a strong impact was lack of tension for change. The focus groups resulted in 87 quotes that were coded into 27 constructs. Frequently cited outer setting facilitators were cosmopolitanism and peer pressure, and the only barrier was related to the patient needs. Innovation characteristics that were facilitators included relative advantage and design quality and packaging, and complexity was a barrier. Inner setting facilitators included networks and communication, learning climate, leadership engagement, and readiness for implementation. However, communication, leadership engagement, and available resources were also barriers. Regarding characteristics of individuals, knowledge and beliefs were both barriers and facilitators. In the implementation process domain, common facilitators were formally appointed implementation leaders and innovation participants. Barriers in this domain were related to the patients. (4) Conclusions: Clinicians identified many barriers and facilitators to implementing HIT that often varied between facilities. Further research is warranted to deepen our understanding of clinicians' experiences with HIT implementation.

Downward adjustment of rehabilitation goals may facilitate post-stroke arm motor recovery

Objective: Patients starting with physical rehabilitation often hold unrealistically high expectations for their recovery. Because of a lower-than-expected rate of recovery, such unrealistic goals have been linked to adverse effects on mental health. Additionally, overtraining due to overly ambitious goals can lead to suboptimal recovery. We investigated the effectiveness of adjusting rehabilitation goals to a more realistic level as a strategy to select appropriate exercise intensity and achieve better recovery outcomes. Design: Patients with arm paralysis from recent stroke were recruited and went through 6-8 weeks of telerehabilitation and in-clinic rehabilitation programme conducted at 11 US sites (N = 124). Main Outcome Measures: Adjustment of recovery goal was assessed in two timepoints during the rehabilitation programme and arm motor function was assessed before and after the clinical trial. Results: Greater use of goal adjustment strategies predicted better recovery of arm motor function, independent from therapy compliance. This pattern was observed only when the choice of exercises is patient-regulated rather than directed by a physical therapist. Conclusion: Benefits from goal adjustment were more pronounced among patients who entered the programme with poorer motor functions, suggesting that goal adjustment is the most beneficial when goals of complete recovery are most unrealistic.

PREP Plus combined postrehabilitation programme to support upper limb recovery in community-dwelling stroke survivors: protocol for a mixed-methods, cluster-assigned feasibility study

INTRODUCTION

Poor recovery of the upper limb following a stroke has been recognised as a significant problem in the UK. Although there is good evidence that early, intense rehabilitation can lead to upper limb recovery, often this is not maintained, with less than 50% of people regaining the ability to use their upper limb for independent function at 6 months. Upper limb recovery potential is reported for many years poststroke, yet current long-term provision is insufficient.

METHODS AND ANALYSIS

60 participants will be recruited into this feasibility study, with 30 allocated to a Post Rehabilitation Enablement Programme (PREP) alone and 30 allocated to a combined programme, PREP Plus, consisting of PREP and the Graded Repetitive Arm Supplementary Programme (GRASP). We will aim to complete four iterative waves. Within each wave, the intervention design will be refined, based on participant feedback. Within each wave, there will be one cluster unit (one intervention group ;PREP Plus) and one control group ;PREP alone)). A total of five PREP sites within Northern Ireland Health and Social Care Trusts will be used for this study. PREP Plus will have a home exercise component along with exercises logs and a behaviour contract. Qualitative and quantitative measures will evaluate the acceptability and feasibility to determine how feasible it is to embed the intervention into practice, as well as to determine the feasibility of a larger, mixed-methods, randomised controlled trial to assess intervention efficacy. Clinical endpoints will also be explored.

ETHICS AND DISSEMINATION

This study has been approved by the Health and Social Care Research Ethics Committee A, IRAS project ID (278620). Participants will provide informed consent prior to participating in the study. Information outlining the purpose of the study, what data will be collected and how the data will be managed will be provided. Results will be published in peer-reviewed journals and any published data will be available on the university data repository. The project management group will advise on different avenues for dissemination to ensure it reaches appropriate audiences.

TRIAL REGISTRATION NUMBER

NCT05090163.

Understanding the facilitators and barriers of stroke survivors' adherence to recovery-oriented self-practice: a thematic synthesis

PURPOSE

Stroke survivors receive considerable rehabilitation efforts as inpatients, but one-on-one therapy decreases after discharge. The gap between the amount of required therapy and the lack of its availability in this phase of care may be partly overcome by self-practice. However, patient's adherence to prescribed programs is often low. While single studies have examined factors affecting adherence in this specific case, they have not been reviewed and synthesised previously.

METHODS

A thematic synthesis of qualitative studies explored factors affecting stroke survivors' adherence to prescribed, recovery-oriented self-practice. Five databases were systematically searched for references: Medline, Psycinfo, CINAHL, Embase, and ASSIA. Quality assessment was undertaken using the CASP tool.

RESULTS

From 1308 references, 68 potential papers were read in full, and 12 were included in the review. An overarching theme was identified as: "Tailoring and personalization rather than standardization." It was informed by the following three analytical themes: "The meaning of 'self' in self-practice," "Identifying self-practice as a team effort," and "Self-practice that is grounded in one's reality."

CONCLUSION

To have a positive effect on adherence to self-practice, clinicians are advised to spend time learning about each individual's life circumstances, so they can tailor proposed exercise programs to patients' personal situations, preferences, and needs.IMPLICATIONS FOR REHABILITATIONThe topic of patient's adherence to self-practice of prescribed exercise is a common concern, often voiced by frustrated rehabilitation health professionals. Bridging the gap between the patient's needs for post-discharge intensive therapy and the inability of healthcare systems to provide it could be filled partly by self-practice.Adherence to self-practice has become even more essential since the COVID 19 pandemic and the decrease in face-to-face delivery of rehabilitation due to social distancing requirements.Adherence to exercise is a broad topic. Reasons for poor adherence differ between patient populations and the exercises they are prescribed. This study focuses on post-discharge stroke survivors' adherence to recovery targeted exercise that could be described as repetitive and less physically demanding movements and functions.Reviewed studies were qualitative and usually included a relatively small number of participants within a specific context. Using thematic synthesis, we combined these small pieces of the puzzle into a larger picture, to produce recommendations that could be drawn on by clinicians to improve self-practice adherence.

Making Best Use of Home-Based Rehabilitation Robots

Large-scale clinical trials have shown that rehabilitation robots are as affective as conventional therapy, but the cost-effectiveness is preventing their uptake. This study investigated whether a low-cost rehabilitation robot could be deployed in a home setting for rehabilitation of people recovering from stroke (n = 16) and whether clinical outcome measures correlated well with kinematic measures gathered by the robot. The results support the feasibility of patients independently using the robot with improvement in both clinical measures and kinematic data. We recommend using kinematic data early in an intervention to detect improvement while using a robotic device. The kinematic measures in the assessment task (hits/minute and normalised jerk) adequately pick up changes within a four-week period, thus allowing the rehabilitation regime to be adapted to suit the user’s needs. Estimating the long-term clinical benefit must be explored in future research.

The role of goal adjustment during rehabilitation from stroke

We investigated motivational regulation involving adjustment of recovery goals in post-stroke rehabilitation via standard in-clinic physiotherapy and in-home telerehabilitation (TR). We used a secondary dataset collected at 11 US sites as part of a clinical trial using video games and game control pads designed to induce certain arm movements required for recovery (n = 124; M_age  = 61.44, SD = 13.30). Participants were randomly assigned to either the TR or in-clinic condition and underwent 36 therapy sessions, reporting on their activity-inherent enjoyment for 6-8 weeks. Compared with the in-clinic patients and TR patients with high game performance, TR patients with lower game performance reported lower activity-inherent enjoyment, which is an important motivational resource for successful recovery. The results suggest that these differences occur because TR patients become discouraged by low game score feedback, which may have signaled a poor prospect for recovery. However, the results also suggest that low game performers who successfully adjusted their recovery goals were resilient to the impact of low game score feedback on their motivational resources and satisfaction with therapy. The findings suggest that goal adjustment may be particularly beneficial when patients are discouraged by feedback indicating suboptimal recovery prospects.

Goal attainment, adjustment and disengagement in the first year after stroke: A qualitative study

Understanding stroke survivor responses to attainable and unattainable goals is important so that rehabilitation staff can optimally support ongoing recovery and adaption. In this qualitative study, we aimed to investigate (i) stroke survivor's experiences of goal attainment, adjustment and disengagement in the first year after stroke and (ii) whether the Goal setting and Action Planning (G-AP) framework supported different pathways to goal attainment. In-depth interviews were conducted with eighteen stroke survivors' to explore their experiences and views. Interview data were transcribed verbatim and analysed using a Framework approach to examine themes within and between participants. Stroke survivors reported that attaining personal goals enabled them to resume important activities, reclaim a sense of self and enhance emotional wellbeing. Experiences of goal-related setbacks and failure facilitated understanding and acceptance of limitations and informed adjustment of, or disengagement from, unattainable goals. Use of the G-AP framework supported stroke survivors to (i) identify personal goals, (ii) initiate and sustain goal pursuit, (iii) gauge progress and (iv) make informed decisions about continued goal pursuit, adjustment or disengagement. Stroke survivor recovery involves attainment of original and adjusted or alternative goals. The G-AP framework can support these different pathways to goal attainment.

Experiences and views of receiving and delivering information about recovery in acquired neurological conditions: a systematic review of qualitative literature

OBJECTIVE

To review and synthesise qualitative literature relating to the views, perceptions and experiences of patients with acquired neurological conditions and their caregivers about the process of receiving information about recovery; as well as the views and experiences of healthcare professionals involved in delivering this information.

DESIGN

Systematic review of qualitative studies.

DATA SOURCES

MEDLINE, Embase, AMED, CINAHL, PsycINFO, Web of Science and the Cochrane library were searched from their inception to July 2019.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data from the included studies and assessed quality using an established tool. Thematic synthesis was used to synthesise the findings of included studies.

RESULTS

Searches yielded 9105 titles, with 145 retained for full-text screening. Twenty-eight studies (30 papers) from eight countries were included. Inductive analysis resulted in 11 descriptive themes, from which 5 analytical themes were generated: the right information at the right time; managing expectations; it's not what you say, it's how you say it; learning how to talk about recovery and manage emotions; the context of uncertainty.

CONCLUSIONS

Our findings highlight the inherent challenges in talking about recovery in an emotional context, where breaking bad news is a key feature. Future interventions should focus on preparing staff to meet patients' and families' information needs, as well as ensuring they have the skills to discuss potential recovery and break bad news compassionately and share the uncertain trajectory characteristic of acquired neurological conditions. An agreed team-based approach to talking about recovery is recommended to ensure consistency and improve the experiences of patients and their families.

Theorising rehabilitation: Actors and parameters shaping normality, liminality and depersonalisation in a UK hospital

Sociological concern for rehabilitation remains limited. This paper aims to contribute to rehabilitation theory. It examines two units of a specialist rehabilitation hospital in the UK (amputee and neurological services) by focusing on the key actors involved - families, patients, staff - and the parameters shaping their relationships. The findings extend previous theoretical understandings of rehabilitation in three themes: normality, liminality and depersonalisation. We argue, first: normality is constantly negotiated amongst the different actors. This complicates existing works' critique of rehabilitation as reproducing the ideology of normality. Second, discourses produced during acute care shape the inpatient rehabilitation experience. This calls attention to the pre-rehabilitation phase and complicates existing works' emphasis on the transition from inpatient stay to the time of discharge. Finally, inpatient rehabilitation is notable in rendering the adverse effects of depersonalisation apparent. It combines the bureaucracy of a regular hospital ward, with institutionalising aspects of long-term care. These findings have a potential to enhance practice as well as knowledge. We call for a deeper sociological attention, combining theory-building with empirical data for a better understanding of inpatient rehabilitation.

Expectations of individuals with neurological conditions from rehabilitation: A mixed-method study of needs

Background

Knowledge of the specific expectations of patients with neurological conditions (NCs) from rehabilitation helps in setting attainable goals. Such expectations may vary from situation to situation. There are no studies investigating rehabilitation expectations amongst individuals with NCs in Nigeria.

Objectives

The aim of our study was to explore the rehabilitation expectations of individuals with NCs.

Method

This convergent mixed-methods study comprised a cross-sectional survey of 105 individuals with NCs and two sessions of Focus Group Discussions (FGDS) amongst eight individuals with NCs. The modified Needs Assessment Questionnaire was used to assess rehabilitation needs as a proxy for rehabilitation expectations, whilst disability was assessed using the World Health Organization Disability Assessment Schedule 2.0. Quantitative data were summarised using descriptive statistics and analysed using inferential statistics at p < 0.05. Thematic analysis was conducted on the qualitative data.

Results

Sixty-one (58.1%) stroke survivors, 33 (31.4%) individuals with spinal cord injury (SCI) and 11 (10.5%) with traumatic brain injury (TBI) aged 46.48 ± 15.91 were surveyed. The need for social/recreational activity was the most expressed need (100%) amongst the participants. Mobility was reported as an important need constituting a barrier to enjoying life by 93 (88.6%) participants. Individuals with SCI expressed the greatest needs compared with the other two groups. Needs were significantly correlated with severity of disability (p < 0.05). Four overarching themes (physical health, financial, healthcare services/rehabilitation and emotional/social) representing major areas of needs emerged from the FGD data.

Conclusion

Individuals with NCs in Nigeria have specified expectations of rehabilitation. Disability was a major driver of these expectations, irrespective of NC subtype.

Clinical implications

Rehabilitation programmes for individuals with NCs should target expressed needs or expectations of each patient cohort and minimise disabilities associated with these conditions.

Telerehabilitation After Stroke Using Readily Available Technology: A Randomized Controlled Trial

Background

The number of people living with stroke has increased demand for rehabilitation. A potential solution is telerehabilitation for health care delivery to promote self-management. One such approach is the Augmented Community Telerehabilitation Intervention (ACTIV). This structured 6-month program uses limited face-to-face sessions, telephone contact, and text messages to augment stroke rehabilitation.

Objective

To investigate whether ACTIV improved physical function compared with usual care.

Methods

This 2-arm, parallel randomized controlled trial was conducted in 4 New Zealand centers. Inclusion criteria were patients with first-ever stroke, age >20 years, and discharged home. A blinded assessor completed outcome measurement in participants’ homes at baseline, postintervention, and 6 months postintervention. Stratified block randomization occurred after baseline assessment, with participants allocated to ACTIV or usual care control.

Results

A total of 95 people were recruited (ACTIV: n = 47; control: n = 48). Postintervention intention-to-treat analysis found a nonsignificant difference between the groups in scores (4·51; P = .07) for physical function (measured by the physical subcomponent of the Stroke Impact Scale). The planned per-protocol analysis (ACTIV: n = 43; control: n = 48) found a significant difference in physical function between the groups (5·28; P = .04). Improvements in physical function were not maintained at the 12-month follow-up.

Conclusions

ACTIV was not effective in improving physical function in the ACTIV group compared with the usual care group. The per-protocol analysis raises the possibility that for those who receive more than 50% of the intervention, ACTIV may be effective in preventing deterioration or even improving physical function in people with stroke, in the period immediately following discharge from hospital.

Recovery after stroke: perspectives of young stroke survivors in Taiwan

PURPOSE

To learn about the experiences of stroke recovery among young stroke survivors in Taiwan and to elucidate the beliefs, goals, and facilitators of and barriers to their recovery.

METHODS

A qualitative approach was used for data collection, and data were obtained from five focus groups consisting of stroke survivors aged 20-64 years (n = 25). Data were transcribed verbatim and analyzed thematically by two independent coders using NVivo version 10.

RESULTS

"Returning to prestroke status" was a common belief of recovery for stroke survivors; their goals of recovery changed overtime from regaining physical functions, independent living, and participating in work and leisure activities to maintaining functions or returning to normality. Their perceived personal and environmental facilitators of recovery included positive attitude, family and friends, and rehabilitation, whereas barriers to recovery included psychological factors, social stigma, and physical environment.

CONCLUSION

These findings provide useful insights for rehabilitation clinicians to develop culturally tailored interventions to improve poststroke recovery outcomes in young stroke survivors.Implications for rehabilitationRehabilitation clinicians should understand stroke survivors' beliefs and goals of recovery to provide tailored services.Optimizing the goal-setting process and patient-provider communication may help clinicians and survivors examine and adjust their expectations toward recovery during rehabilitation.Interventions will be needed to address personal and environmental supports and barriers, such as motivation, psychological factors, social support, and the physical environment to help survivors achieve their recovery goals.

The role of hope for health professionals in rehabilitation: A qualitative study on unfavorable prognosis communication

BACKGROUND

The communication of prognosis represents an ethical and clinical challenge in medical practice due to the inherent uncertain character of prognostic projections. The literature has stressed that the mode of communicating prognoses has an impact on patients' hope, which is considered to play a major role in adapting to illness and disability. In light of this, this study aims to explore health professionals' (HPs) perceptions of the role of hope in rehabilitation and to examine if and how they use strategies to maintain hope when discussing prognostic information with patients.

METHODS

Eleven qualitative semi-structured interviews with a purposive sample of HPs were conducted at two rehabilitation clinics in the Canton of Ticino, Switzerland. The interviews were analyzed using thematic analysis.

RESULTS

The HPs perceive hope in rehabilitation as a double-edged sword. Three main strategies were identified to maintain hope while avoiding false hope: 1) giving space for self-evaluation; 2) tailoring the communication of prognostic information; and 3) supporting the patient in dealing with the prognosis. These strategies are particularly suitable when HPs consider that patients might not be ready to accept the prognosis, due to their expectations for recovery.

CONCLUSIONS

The strategies identified here support a person-centered approach to the communication of prognosis and are in line with existing protocols for the communication of unfavorable medical information. The findings emphasize the need for strengthening communication and inter-professional collaboration skills of rehabilitation HPs.

The Presence and Persistence of Unrealistic Expectations in Patients Undergoing Nerve Surgery

BACKGROUND

Unrealistic expectations of the outcomes of peripheral nerve surgery reduce patient satisfaction. Most clinicians can recall patients with unrealistic expectations despite verbal preoperative education.

OBJECTIVE

To assess patients’ baseline level of understanding regarding nerve surgery and appropriate expectations. Additionally, we tested the effect of a written, preoperative educational handout on the patients’ retention of knowledge.

METHODS

This cross-sectional survey recruited patients scheduled to undergo peripheral nerve surgery at a single institution in 2016 to 2017. During the preoperative visit, a specialized nurse practitioner reviewed perioperative protocols, risks and benefits of the surgery, and postoperative care. Patients immediately completed a survey to assess their preoperative understanding of the verbally reviewed information. During the same visit, an additional written handout was given to patients in a randomized fashion. At their first postoperative visit, all patients completed the survey again.

RESULTS

A total of 60 patients (mean age 52 yr) were enrolled of which 62% were male. Immediately following verbal instruction, 31% of patients had erroneous (unrealistic) expectations regarding pain, 30% had erroneous expectations regarding postoperative motor outcome, and 41% had erroneous expectations regarding the timing of postoperative recovery. There was no significant difference between patients who received the written handout vs those who did not, on retesting in the postoperative period.

CONCLUSION

Patients undergoing peripheral nerve procedures demonstrated a high baseline level of unrealistic expectations despite standard in-person verbal counseling by specialty providers. A written handout did not have clear benefit in the retention of preoperative surgical teaching. Further investigation into more effective preoperative patient counseling is needed.

The implications of the Canadian Stroke Best Practice Recommendations for design and allocation of rehabilitation after hospital discharge: a problematization

Introduction: Implementation of the Canadian Stroke Best Practice Recommendations has improved inpatient rehabilitation. As attention is turned to the design and allocation of rehabilitation after hospitalization, examination of their implications for post-discharge rehabilitation could help optimize service planningMethods: Critical discourse analysis modeled on Alvesson and Sandberg's method of problematization was conducted to determine how the Canadian Stroke Best Practice Recommendations envision and shape post-discharge rehabilitation, and identify any tensions and potential ways to resolve them.Results: Within the Canadian Stroke Best Practice Recommendations post-discharge rehabilitation is implicitly viewed as a continuation of inpatient rehabilitation. Rehabilitation is largely envisioned as a set of biomedical procedures aimed at normalization through correction of impairment. There is potential tension between this implicit goal and the explicit goal of providing patient and family-centered care and promoting reengagement in valued activities and roles.Conclusion: An alternate vision of post-discharge rehabilitation could help resolve this tension. Post-discharge rehabilitation could be envisioned as a self-management intervention. Rather than primarily an expert-driven process of measuring impairment and applying procedures aimed at normalization, rehabilitation would be considered facilitation of self-management with the goal of reengaging in forms of participation that comprise a satisfying life.Implications for RehabilitationImplicit assumptions within best practice guidelines powerfully influence recommendations. These ideas are difficult to examine because they seem self-evident.Implicit assumptions in the Canadian Stroke Best Practice Guidelines envision post-discharge stroke rehabilitation as an expert-driven, impairment-focused biomedical procedure.This biomedical image makes it difficult to provide care that meets the guideline's explicit goals of client- and family-centeredness.Reimagining post-discharge stroke rehabilitation as a chronic self-care management intervention aimed at developing a satisfying life after stroke could improve patient care.

Illness perceptions of stroke survivors: Predictors and changes over time - A 1 year follow-up study

OBJECTIVE

To describe the illness perceptions (IP) of stroke patients in the first year post stroke; to identify patient clusters with comparable IP trajectories and determine their associations with health.

METHODS

This prospective study included consecutive stroke patients after medical rehabilitation. Three and 12 months post stroke they completed the Brief Illness Perception Questionnaire (B-IPQ) and questionnaires on physical and mental health. All eight IP and their changes over time were described. Clusters of patients with comparable IP trajectories were constructed by k-means clustering, with subsequent comparison of patient characteristics. Multivariable logistic regression analyses were conducted to determine the association between IP clusters and 12-month mental health.

RESULTS

Hundred-and-eighty-four patients were included (men n = 107 [58.2%]; mean age 61.1 [SD 12.7] years). At 3 months, the scores of the IP coherence (mean 3.0, SD 2.3) and treatment control (mean 3.2, SD 2.5) were lowest (best), and consequences (mean 6.1, SD 2.8) and anticipated timeline (mean 6.0, SD 2.7) were highest (worst). At 12 months, the timeline and treatment control scores had significantly worsened. Three clusters of the trajectories of IP were identified, and designated as 'favourable', 'average', and 'unfavourable'. The unfavourable cluster was significantly associated with worse physical and mental health at 3 months (unadjusted) and depressive symptoms at 12 months.

CONCLUSION

Stroke patients' IP partly changed between 3 and 12 months post stroke. Patients with an unfavourable IP trajectory had a higher chance of depressive symptoms at 12 months. Illness perceptions could be considered as an additional target of treatment.

User perspective on receiving adaptive equipment after stroke: A mixed-methods study

BACKGROUND.

Adaptive equipment (AE) is frequently provided during stroke rehabilitation by occupational therapists.

PURPOSE.

This study aimed to identify the AE that people typically use after a stroke and the outcomes achieved as a result, and to explore people's experiences obtaining and using AE, to inform both practice and policy in this field.

METHOD.

A mixed-methods study, involving a postal questionnaire and interviews, used descriptive statistics and grounded theory to analyze the quantitative and qualitative data, respectively.

FINDINGS.

Questionnaire data ( n = 258) revealed mobility AE was issued most frequently, with increased safety as the primary reported outcome. Interview data ( n = 15) indicated relationships with health professionals and the hospital environment shaped early AE selection and use. Once home, making sense of AE and community participation were more influential.

IMPLICATIONS.

Therapeutic relationships and reflection time are critical to maximize AE use after stroke. Policy and related funding for AE need to prioritize community participation.

Patients' outcome expectations and their fulfilment in multidisciplinary stroke rehabilitation

BACKGROUND

Patients' expectations of the outcomes of rehabilitation may influence the outcomes and satisfaction with treatment.

OBJECTIVES

For stroke patients in multidisciplinary rehabilitation, we aimed to explore patients' outcome expectations and their fulfilment as well as determinants.

METHODS

The Stroke Cohort Outcomes of REhabilitation (SCORE) study included consecutive stroke patients admitted to an inpatient rehabilitation facility after hospitalisation. Outcome expectations were assessed at the start of rehabilitation (admission) by using the three-item Expectancy scale (sum score range 3-27) of the Credibility/Expectancy Questionnaire (CEQ). After rehabilitation, patients answered the same questions formulated in the past tense to assess fulfilment of expectations. Baseline patient characteristics were recorded and health-related quality of life (EQ-5D) was measured at baseline and after rehabilitation. The number of patients with expectations unfulfilled or fulfilled or exceeded was computed by subtracting the admission and discharge CEQ Expectancy scores. Multivariable regression analysis was used to determine the factors associated with outcome expectations and their fulfilment, estimating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

We included 165 patients (96 males [58.2%], mean (SD) age 60.2 years [12.7]) who completed the CEQ Expectancy instrument at admission (median score 21.6, interquartile range [IQR] 17.0-24.0); 79 completed it both at admission (median score 20.6, IQR 16.6-24.4) and follow-up (median score 20.0, IQR 16.4-22.8). For 40 (50.6%) patients, expectations of therapy were fulfilled or exceeded. No patient characteristic at admission was associated with baseline CEQ Expectancy score. Odds of expectation fulfilment were associated with low expectations at admission (OR 0.70, 95% CI 0.60-0.83) and improved EQ-5D score (OR 1.35, 95% CI 1.04-0.75).

CONCLUSIONS

In half of the stroke patients in multidisciplinary rehabilitation, expectations were fulfilled or exceeded, most likely in patients with low expectations at admission and with improved health-related quality of life. More research into the role of health professionals regarding the measurement, shaping and management of outcome expectations is needed.

Affordable stroke therapy in high-, low- and middle-income countries: From Theradrive to Rehab CARES, a compact robot gym

Affordable technology-assisted stroke rehabilitation approaches can improve access to rehabilitation for low-resource environments characterized by the limited availability of rehabilitation experts and poor rehabilitation infrastructure. This paper describes the evolution of an approach to the implementation of affordable, technology-assisted stroke rehabilitation which relies on low-cost mechatronic/robot devices integrated with off-the-shelf or custom games. Important lessons learned from the evolution and use of Theradrive in the USA and in Mexico are briefly described. We present how a stronger and more compact version of the Theradrive is leveraged in the development of a new low-cost, all-in-one robot gym with four exercise stations for upper and lower limb therapy called Rehab Community-based Affordable Robot Exercise System (Rehab C.A.R.E.S). Three of the exercise stations are designed to accommodate versions of the 1 DOF haptic Theradrive with different custom handles or off-the-shelf commercial motion machine. The fourth station leverages a unique configuration of Wii-boards. Overall, results from testing versions of Theradrive in USA and Mexico in a robot gym suggest that the resulting presentation of the Rehab C.A.R.E.S robot gym can be deployed as an affordable computer/robot-assisted solution for stroke rehabilitation in developed and developing countries.

Training in positivity for stroke? A qualitative study of acceptability of use of Positive Mental Training (PosMT) as a tool to assist stroke survivors with post-stroke psychological problems and in coping with rehabilitation

BACKGROUND

Post-stroke psychological problems predict poor recovery, while positive affect enables patients to focus on rehabilitation and may improve functional outcomes. Positive Mental Training (PosMT), a guided self-help audio shows promise as a tool in promoting positivity, optimism and resilience.

OBJECTIVE

To assess acceptability of training in positivity with PosMT for prevention and management of post-stroke psychological problems and to help with coping with rehabilitation.

METHODS

A modified PosMT tool consisted of 12 audio tracks each lasting 18 minutes, one listened to every day for a week. Survivors and carers were asked to listen for 4 weeks, but could volunteer to listen for more. Interviews took place about experiences of the tool after 4 and 12 weeks.

SUBJECTS

10 stroke survivors and 5 carers from Stroke Support Groups in the UK.

RESULTS

Three stroke survivors did not engage with the tool. The remainder reported positive physical and psychological benefits including improved relaxation, better sleep and reduced anxiety after four weeks. Survivors who completed the programme gained a positive outlook on the future, increased motivation, confidence and ability to cope with rehabilitation. No adverse effects were reported.

CONCLUSIONS

The PosMT shows potential as a tool for coping with rehabilitation and overcoming post-stroke psychological problems including anxiety and depression.

How is rehabilitation with and without an integrated self-management approach perceived by UK community-dwelling stroke survivors? A qualitative process evaluation to explore implementation and contextual variations

OBJECTIVE

Self-management programmes could support long-term needs after stroke and using methods integrated into rehabilitation is one option. To explore theoretical assumptions and possible mechanisms of implementation a process evaluation was delivered alongside a cluster trial which has demonstrated feasibility of an integrated self-management programme (Bridges SMP) in community-dwelling stroke survivors. This paper aims to show the extent to which experiences from stroke survivors receiving rehabilitation in control (usual care) and intervention (integrated self-management) sites reflected the differences in rehabilitation received and whether their understandings aligned with the self-management approach employed.

DESIGN

Semistructured qualitative interviews carried out as part of a process evaluation analysed thematically.

SETTING

Study was based in South London; all interviews were carried out in participants' home setting.

PARTICIPANTS

22 stroke participants recruited; 12 from integrated self-management sites and 10 from usual care sites.

RESULTS

All participants revealed shared appreciation of knowledge and support from therapists but subtle differences emerged between sites in respect to perceptions about responsibility, control and how previous experiences were used. Accounts depicted a variance regarding who had structured and planned their rehabilitation, with greater flexibility about content and involvement perceived by participants from the integrated self-management sites. They also provided accounts and experiences which aligned with principles of the intervention, such as self-discovery and problem-solving.

CONCLUSIONS

The findings reflect our theoretical assumptions and possible mechanisms of implementation that rehabilitation with a focus on supporting self-management is reflected in accounts and understandings of stroke survivors. Taken together with our previous research this justifies evaluating the effectiveness of Bridges SMP in a larger sample to further contribute to an understanding of the functioning of the intervention, implementation, contextual factors and mechanisms of impact.

TRIAL REGISTRATION NUMBER

ISRCTN42534180; Post-results.

Effectiveness of Medical Rehabilitation on Return-to-Work Depends on the Interplay of Occupation Characteristics and Disease

Introduction Work disability causes high costs for economy, organizations, and employees. However, medical rehabilitation does not always enable employees to return to their old jobs. In the present study, we investigated how disease classification and work characteristics interact in predicting the success of medical rehabilitation in terms of one's ability to return to a former job. Methods To this end, we matched 2009 patient data from the German Statutory Pension Insurance agency with job characteristics data from the Occupational Information Network (O*NET) 17.0 database. We used a multilevel approach and a sample of N = 72,029, nested in 194 occupational groups. Results We found that workers are less likely to reenter a former job if mental illnesses coincide with emotionally demanding labor and if musculoskeletal diseases coincide with extreme environmental conditions. We did not find different effects between occupational groups for other types of diseases (circulatory system, neoplasms, injuries, others). Conclusion Thus, the contextual overlap of disease and occupational characteristics notably lowers the chances of a successful return-to-work. These findings should be taken into account by physicians when attempting to set realistic goals for rehabilitation in collaboration with the patient and the funding agency.

Toward an evidence-based patient-provider communication in rehabilitation: linking communication elements to better rehabilitation outcomes

Background:

There is a growing interest in linking aspects of patient-provider communication to rehabilitation outcomes. However, the field lacks a conceptual understanding on: (a) ‘how’ rehabilitation outcomes can be improved by communication; and (b) through ‘which’ elements in particular. This article elaborates on the conceptual developments toward informing further practice and research.

Methods:

Existing models of communication in healthcare were adapted to rehabilitation, and its outcomes through a comprehensive literature review.

Results:

After depicting mediating mechanisms and variables (e.g. therapeutic engagement, adjustment toward disability), this article presents the ‘4 Rehab Communication Elements’ deemed likely to underpin rehabilitation outcomes. The four elements are: (a) knowing the person and building a supportive relationship; (b) effective information exchange and education; (c) shared goal-setting and action planning; and (d) fostering a more positive, yet realistic, cognitive and self-reframing.

Discussion:

This article describes an unprecedented, outcomes-oriented approach toward the design of rehabilitation communication, which has resulted in the development of a new intervention model: the ‘4 Rehab Communication Elements’. Further trials are needed to evaluate the impact of this whole intervention model on rehabilitation outcomes.

The complexities of 'otherness': reflections on embodiment of a young White British woman engaged in cross-generation research involving older people in Indonesia

If interviews are to be considered embodied experiences, than the potential influence of the embodied researcher must be explored. A focus on specific attributes such as age or ethnicity belies the complex and negotiated space that both researcher and participant inhabit simultaneously. Drawing on empirical research with stroke survivors in an ethnically mixed area of Indonesia, this paper highlights the importance of considering embodiment as a specific methodological concern. Three specific interactions are described and analysed, illustrating the active nature of the embodied researcher in narrative production and development. The intersectionality of embodied features is evident, alongside their fluctuating influence in time and place. These interactions draw attention to the need to consider the researcher within the interview process and the subsequent analysis and presentation of narrative findings. The paper concludes with a reinforcement of the importance of ongoing and meaningful reflexivity in research, a need to consider the researcher as the other participant, and specifically a call to engage with and present the dynamic nature of embodiment.

Three different points of view in stroke rehabilitation: patient, caregiver, and physiotherapist

BACKGROUND

The similarities or differences of the three some (physiotherapists, patients, and caregivers) thought about the process of stroke rehabilitation can play a key role in the success of rehabilitation.

OBJECTIVE

The aim of this qualitative study was to investigate the perspectives of the three some, with regard to the two themes of the study: (1) What are the problems faced by the patients after stroke?; and (2) What does recovery after stroke mean to you?

METHODS

The qualitative questions and possible answers were prepared by four physiotherapists. The answers were matched to International Classification of Functioning (ICF) components. Seventy patients who were having treatment as in-patient rehabilitation centers, their caregivers, and physiotherapists were invited to the study. After the questions were asked and the possible response choices were presented, subjects were asked to prioritize these response choices.

RESULTS

One hundred and fifty-nine subjects, including 53 patients, 53 caregivers, and 53 physiotherapists, were included to the study. When the theme 1 were examined, we found that the patients' first priority was functional abilities (ICF: body function and structure) such as using the hands and feet while the caregivers and physiotherapists prioritized self-care problems (ICF: activity and participation). The most common response to the theme 2 was "being in same health condition before the disease" (ICF: activity and participation) among the patients and caregivers and "being able to move arm and leg on the affected side" (body function and structure) among the physiotherapists.

CONCLUSION

As a conclusion, problems faced by the patients, caregivers, and physiotherapists were perceived under the same ICF domain and that caregivers' and physiotherapists' priorities were the same.

Postacute rehabilitation quality of care: toward a shared conceptual framework

There is substantial interest in mechanisms for measuring, reporting, and improving the quality of health care, including postacute care (PAC) and rehabilitation. Unfortunately, current activities generally are either too narrow or too poorly specified to reflect PAC rehabilitation quality of care. In part, this is caused by a lack of a shared conceptual understanding of what construes quality of care in PAC rehabilitation. This article presents the PAC-rehab quality framework: an evidence-based conceptual framework articulating elements specifically pertaining to PAC rehabilitation quality of care. The widely recognized Donabedian structure, process, and outcomes (SPO) model furnished the underlying structure for the PAC-rehab quality framework, and the International Classification of Functioning, Disability and Health (ICF) framed the functional outcomes. A comprehensive literature review provided the evidence base to specify elements within the SPO model and ICF-derived framework. A set of macrolevel-outcomes (functional performance, quality of life of patient and caregivers, consumers' experience, place of discharge, health care utilization) were defined for PAC rehabilitation and then related to their (1) immediate and intermediate outcomes, (2) underpinning care processes, (3) supportive team functioning and improvement processes, and (4) underlying care structures. The role of environmental factors and centrality of patients in the framework are explicated as well. Finally, we discuss why outcomes may best measure and reflect the quality of PAC rehabilitation. The PAC-rehab quality framework provides a conceptually sound, evidence-based framework appropriate for quality of care activities across the PAC rehabilitation continuum.

Focus group insights assist trial design for stroke telerehabilitation: a qualitative study

The objective of the study was to draw on the insights of people with stroke to assist in the development of a telerehabilitation program, using easily accessible technology to deliver an intervention. A qualitative study was conducted with four focus groups of people who were at least 12 months post-stroke and who had completed their rehabilitation. All focus groups were conducted in community facilities and used a semi-structured approach. Fifteen people took part in the focus groups. Three main themes emerged from the data in response to questions about use of technology and important aspects of physiotherapy. The first theme expressed the participants' perspective that the technology really helped with "keeping connected". The second theme indicated "what we need from therapists" in order to gain the most from therapy; and the third theme highlighted aspects of a physiotherapy program they considered important, "what we would like from therapy". The themes helped us gain insight into how participants viewed the use of technology to augment rehabilitation and also what they needed from therapists to make the gains they viewed as important. These themes informed the development of a telerehabilitation program using readily accessible technology.

[Subacute care of stroke-affected patients. Satisfaction and results]

OBJECTIVE

To determine the satisfaction of the stroke inpatients and their caregivers in Rehabilitation Service and to analyze the effectiveness, social risk, and discharge destination.

MATERIAL AND METHOD

Prospective longitudinal cohort multicenter study. An analysis was made of the social risk (Gijón Scale), co-morbidity (Charlson Index), disability (Barthel Index), effectiveness of the rehabilitation treatment, satisfaction (Pound Questionnaire) and discharge destination of 241 patients. An evaluation was also made on 119 caregivers 6 months post-stroke, recording age, family relationship, time care-giving, satisfaction with the information/training, and accessibility to the rehabilitation team.

RESULTS

The patient profile is a 71 year-old male, with low/intermediate social risk, high co-morbidity and total/severe dependence, with 27.1% living alone. Almost all (96.6%) of the patients claimed to be satisfied/very satisfied with the treatment, with satisfaction with the recovery being lower (80.3%). The effectiveness was 32.5 ± 20.4. Home was the discharge destination of 81.7% of the patients.The average age of the caregivers was 58.8 ± 12.3 years, and 73.9% were women. The time dedicated to care-giving was over 6 hours per day in the 62% of the cases. Being satisfied/very satisfied with the received information was recorded by 89.9% of the caregivers.

CONCLUSIONS

Patients admitted for stroke rehabilitation achieve significant functional gain during hospitalization and return to their homes in most cases. The satisfaction with the rehabilitation treatment and received information is high. The training of the caregiver is an aspect that needs improving.

Service users’ views of the assessment process in stroke rehabilitation

Objective:

To investigate the service users’ (stroke survivors and care-givers) experiences and views of the rehabilitation assessment process.

Design:

Qualitative data analysis from three focus groups using a content analysis to identify the major themes.

Setting:

Participants were recruited from stroke support groups and community rehabilitation services in a large UK city.

Subjects:

Seventeen community-dwelling stroke survivors who had completed their rehabilitation within the previous year and six care-givers.

Results:

Five themes emerged: understanding the purpose of the assessment; repetition of assessments; feedback about assessments and progress; format of feedback and barriers to feedback. While all participants reported undergoing assessment, some felt their purpose was not always explained and resented unexplained repetitions of tests. Some participants reported a positive experience, but most wanted more information about their progress and predictions of recovery. They wanted regular, consistent, objective information presented in layman’s terms; verbally and in writing. Some carers reported difficulty accessing information particularly as a result of confidentiality policies. While some participants accepted these short-comings, others considered them due to staff’s disinterest or ineptitude, which undermined their trust in the team.

Conclusions:

Stroke service users require clear information about the purpose of assessments and regular, consistent, objective feedback about their progress using layman’s language both verbally and in writing.

Development and use of a knowledge translation tool: the rehabilitation measures database

Clinical translation of research evidence is a challenge for rehabilitation clinicians. Publicly accessible and free, online educational resources that summarize research evidence can support implementation of research evidence into practice. Several online resources have been developed recently to overcome common knowledge translation barriers. The Rehabilitation Measures Database (RMD) is a free, web-based searchable database of standardized instruments that was designed to support knowledge translation. It helps clinicians select valid and sensitive instruments for screening patients, monitoring progress, and assessing rehabilitation outcomes. The RMD was developed using feedback from focus groups and beta-test participants. Since its launch in 2011, RMD use has grown to an average of 1851 hits per day from 168 countries. As of September 2013, 202 instrument summaries are viewable in the RMD. Most summaries are linked to copies of the instrument or to purchase instructions. A challenge in updating and expanding the RMD is securing the resources to ensure its future. Collaborative relationships with professional associations and graduate programs in the health sciences are critical in sustaining this resource.

What aspects of rehabilitation provision contribute to self-reported met needs for rehabilitation one year after stroke--amount, place, operator or timing?

Background and Objective

To a large extent, people who have suffered a stroke report unmet needs for rehabilitation. The purpose of this study was to explore aspects of rehabilitation provision that potentially contribute to self‐reported met needs for rehabilitation 12 months after stroke with consideration also to severity of stroke.

Methods

The participants (n = 173) received care at the stroke units at the Karolinska University Hospital, Sweden. Using a questionnaire, the dependent variable, self‐reported met needs for rehabilitation, was collected at 12 months after stroke. The independent variables were four aspects of rehabilitation provision based on data retrieved from registers and structured according to four aspects: amount of rehabilitation, service level (day care rehabilitation, primary care rehabilitation and home‐based rehabilitation), operator level (physiotherapist, occupational therapist, speech therapist) and time after stroke onset. Multivariate logistic regression analyses regarding the aspects of rehabilitation were performed for the participants who were divided into three groups based on stroke severity at onset.

Results

Participants with moderate/severe stroke who had seen a physiotherapist at least once during each of the 1st, 2nd and 3rd–4th quarters of the first year (OR 8.36, CI 1.40–49.88 P = 0.020) were more likely to report met rehabilitation needs.

Conclusion

For people with moderate/severe stroke, continuity in rehabilitation (preferably physiotherapy) during the first year after stroke seems to be associated with self‐reported met needs for rehabilitation.

Implementing a framework for goal setting in community based stroke rehabilitation: a process evaluation

BACKGROUND

Goal setting is considered 'best practice' in stroke rehabilitation; however, there is no consensus regarding the key components of goal setting interventions or how they should be optimally delivered in practice. We developed a theory-based goal setting and action planning framework (G-AP) to guide goal setting practice. G-AP has 4 stages: goal negotiation, goal setting, action planning & coping planning and appraisal & feedback. All stages are recorded in a patient-held record. In this study we examined the implementation, acceptability and perceived benefits of G-AP in one community rehabilitation team with people recovering from stroke.

METHODS

G-AP was implemented for 6 months with 23 stroke patients. In-depth interviews with 8 patients and 8 health professionals were analysed thematically to investigate views of its implementation, acceptability and perceived benefits. Case notes of interviewed patients were analysed descriptively to assess the fidelity of G-AP implementation.

RESULTS

G-AP was mostly implemented according to protocol with deviations noted at the planning and appraisal and feedback stages. Each stage was felt to make a useful contribution to the overall process; however, in practice, goal negotiation and goal setting merged into one stage and the appraisal and feedback stage included an explicit decision making component. Only two issues were raised regarding G-APs acceptability: (i) health professionals were concerned about the impact of goal non-attainment on patient's well-being (patients did not share their concerns), and (ii) some patients and health professionals found the patient-held record unhelpful. G-AP was felt to have a positive impact on patient goal attainment and professional goal setting practice. Collaborative partnerships between health professionals and patients were apparent throughout the process.

CONCLUSIONS

G-AP has been perceived as both beneficial and broadly acceptable in one community rehabilitation team; however, implementation of novel aspects of the framework was inconsistent. The regulatory function of goal non-attainment and the importance of creating flexible partnerships with patients have been highlighted. Further development of the G-AP framework, training package and patient held record is required to address the specific issues highlighted by this process evaluation. Further evaluation of G-AP is required across diverse community rehabilitation settings.

Telerehabilitation to improve outcomes for people with stroke: study protocol for a randomised controlled trial

BACKGROUND

In New Zealand, around 45,000 people live with stroke and many studies have reported that benefits gained during initial rehabilitation are not sustained. Evidence indicates that participation in physical interventions can prevent the functional decline that frequently occurs after discharge from acute care facilities. However, on-going stroke services provision following discharge from acute care is often related to non-medical factors such as availability of resources and geographical location. Currently most people receive no treatment beyond three months post stroke. The study aims to determine if the Augmented Community Telerehabilitation Intervention (ACTIV) results in better physical function for people with stroke than usual care, as measured by the Stroke Impact Scale, physical subcomponent.

METHODS/DESIGN

This study will use a multi-site, two-arm, assessor blinded, parallel randomised controlled trial design. People will be eligible if they have had their first ever stroke, are over 20 and have some physical impairment in either arm or leg, or both. Following discharge from formal physiotherapy services (inpatient, outpatient or community), participants will be randomised into ACTIV or usual care. ACTIV uses readily available technology, telephone and mobile phones, combined with face-to-face visits from a physiotherapist over a six-month period, to help people with stroke resume activities they enjoyed before the stroke. The impact of stroke on physical function and quality of life will be assessed, measures of cost will be collected and a discrete choice survey will be used to measure preferences for rehabilitation options. These outcomes will be collected at baseline, six months and 12 months. In-depth interviews will be used to explore the experiences of people participating in the intervention arm of the study.

DISCUSSION

The lack of on-going rehabilitation for people with stroke diminishes the chance of their best possible outcome and may contribute to a functional decline following discharge from formal rehabilitation. Best practice guidelines recommend a prolonged period of rehabilitation, however this is expensive and therefore not undertaken in most publicly funded centres. An effective, cost-effective, and preference-sensitive therapy using basic technology to assist programme delivery may improve patient autonomy as they leave formal rehabilitation and return home.

TRIAL REGISTRATION

ACTRN12612000464864.

Inpatient Course and Length of Hospital Stay in Patients with Brain Disorders in South Korea: A Population-based Registry Study

OBJECTIVE

To describe inpatient course and length of hospital stay (LOS) for people who sustain brain disorders nationwide.

METHOD

We interviewed 1,903 randomly selected community-dwelling patients registered as 'disabled by brain disorders' in 28 regions of South Korea.

RESULTS

Seventy-seven percent were initially admitted to a Western medicine hospital, and 18% were admitted to a traditional Oriental medicine hospital. Forty-three percent were admitted to two or more hospitals. Mean LOS was 192 days. Most patients stayed in one hospital for more than 4 weeks. The transfer rate to other hospitals was 30-40%. Repeated admissions and increased LOS were related to younger onset age, higher education, non-family caregiver employment, smaller families, and more severe disability.

CONCLUSION

Korean patients with brain disorders showed significantly prolonged LOS and repeated admissions. Factors increasing burden of care influenced LOS significantly.

'It burdens me': the impact of stroke in central Aceh, Indonesia

The complex primary and secondary consequences of stroke have often been equated with the concept of biographical disruption, although a number of mediating factors have been identified. However, the research to date is almost exclusively based in western contexts, despite the fact that stroke is increasing most rapidly in low-income and middle-income countries. This research explores the experience of stroke in the rural community of central Aceh, Indonesia. The participants included 11 stroke survivors and 18 carers, with data collected through in-depth interviews and photographic facilitated interviews, supported with participant observation over a nine month period. The participants discussed and illustrated the disruptive result of their stroke, but for most, their ability to maintain religious duties and contribute to their family resulted in a form of biographical continuity. Their strategies and challenges are discussed alongside the implications for care in this context.

Unfulfilled rehabilitation needs and dissatisfaction with care 12 months after a stroke: an explorative observational study

Background

People who have suffered a stroke commonly report unfulfilled need for rehabilitation. Using a model of patient satisfaction, we examined characteristics in individuals that at 3 months after stroke predicted, or at 12 months were associated with unmet need for rehabilitation or dissatisfaction with health care services at 12 months after stroke.

Methods

The participants (n = 175) received care at the stroke units at the Karolinska University Hospital, Sweden. The dependent variables “unfulfilled needs for rehabilitation” and “dissatisfaction with care” were collected using a questionnaire. Stroke severity, domains of the Stroke Impact Scale (SIS), the Sense of Coherence scale (SOC) and socio demographic factors were used as independent variables in four logistic regression analyses.

Results

Unfulfilled needs for rehabilitation at 12 months were predicted by strength (SIS) (odds ratio (OR) 7.05) at three months, and associated with hand function (SIS) (OR 4.38) and poor self-rated recovery (SIS) (OR 2.46) at 12 months. Dissatisfaction with care was predicted by SOC (OR 4.18) and participation (SIS) (OR 3.78), and associated with SOC (OR 3.63) and strength (SIS) (OR 3.08).

Conclusions

Thirty-three percent of the participants reported unmet needs for rehabilitation and fourteen percent were dissatisfied with the care received. In order to attend to rehabilitation needs when they arise, rehabilitation services may need to be more flexible in terms of when rehabilitation is provided. Long term services with scheduled re-assessments and with more emphasis on understanding the experiences of both the patients and their social networks might better be able to provide services that attend to patients’ needs and aid peoples’ reorientation; this would apply particularly to those with poor coping capacity.