Do clinical guidelines guide clinical practice in stroke rehabilitation? An international survey of health professionals

Navigating the acute to post-acute transition with patients: a first characterization of medical student knowledge gaps in rehabilitation and post-acute care

PURPOSE

Clinical rehabilitation and post-acute care (PAC) learning experiences are not uniformly required within medical school core curricula in the United States or internationally. This study aims to characterize what medical students might know/need to know to support patients in the transition from acute hospitalization to post-acute rehabilitation settings.

MATERIALS/METHODS

The medical student cohort completing required clinical rotations in a United States quaternary care hospital system was provided a voluntary survey prompting reflection on experiences discharging patients to rehabilitation/PAC and related learning needs. Data were analyzed using descriptive statistics and qualitative grounded theory.

RESULTS

Response rate was 72% (39/54). All respondents reported at least one gap in rehabilitation/PAC knowledge, falling into 8 themes: daily experience of rehabilitation/PAC; determination of eligibility/screening processes; distinctions among levels of rehabilitation/PAC; insurance coverage/equity; rehabilitation/PAC clinical practice environment; post-rehabilitation/PAC discharge support; medical capabilities within PAC settings; developing rehabilitation goals.

CONCLUSIONS

Despite caring for patients discharged to post-acute rehabilitation settings, medical students lack essential knowledge about the process of rehabilitation and recovery, including patient eligibility for and service availability across PAC settings. Explicit rehabilitation/PAC education for medical students could enhance their ability to counsel and advocate for patients with disability and rehabilitation needs through care transitions.Implications for rehabilitationMedical students lack knowledge about rehabilitation and post-acute care that is important for helping patients navigate the acute to post-acute transition.Dedicated rehabilitation/post-acute care education could prepare trainees for counseling and advocating for patients during care transitions.Knowledge gaps identified in this study could inform development of curricular interventions to address medical student learning needs.

Classification and Quantification of Physical Therapy Interventions across Multiple Neurological Disorders: An Italian Multicenter Network

Despite their relevance in neurorehabilitation, physical therapy (PT) goals and interventions are poorly described, compromising a proper understanding of PT effectiveness in everyday clinical practice. Thus, this paper aims to describe the prevalence of PT goals and interventions in people with neurological disorders, along with the participants' clinical features, setting characteristics of the clinical units involved, and PT impact on outcome measures. A multicenter longitudinal observational study involving hospitals and rehabilitation centers across Italy has been conducted. We recruited people with stroke (n = 119), multiple sclerosis (n = 48), and Parkinson's disease (n = 35) who underwent the PT sessions foreseen by the National Healthcare System. Clinical outcomes were administered before and after the intervention, and for each participant the physical therapists completed a semi-structured interview to report the goals and interventions of the PT sessions. Results showed that the most relevant PT goals were related to the ICF activities with "walking" showing the highest prevalence. The most used interventions aimed at improving walking performance, followed by those aimed at improving organ/body system functioning, while interventions targeting the cognitive-affective and educational aspects have been poorly considered. Considering PT effectiveness, 83 participants experienced a clinically significant improvement in the outcome measures assessing gait and balance functions.

Challenges in applying evidence-based practice in stroke rehabilitation: a qualitative description of health professional experience in low, middle, and high-income countries

Purpose: Evidence-based practice (EBP) is considered central to ethical, effective service delivery in rehabilitation, and the implementation of the World Health Organisation's Rehabilitation Strategy 2030. This study aimed to explore and compare the experiences of health professionals regarding the application of EBP for stroke rehabilitation in each participant's region and country, which provided perspectives from low, middle, and high-income countries.Methods and materials: Interviews were conducted with 12 experienced rehabilitation professionals from 12 different countries (5 high-income, 2 upper-middle income, 3 lower-middle income, and 2 low-income countries) and interpreted using qualitative descriptive analysis.Results: Nine factors influencing evidence-based stroke rehabilitation were: 1) the complexity of rehabilitation research; 2) the (ir)relevance of research to local context; 3) lack of time for EBP; 4) minimal training in EBP; 5) changing health professional behaviours; 6) poor access to resources for developing EBP; 7) influence of culture, patients, and families; 8) language barriers; and 9) lack of access to research evidence. Economic constraints contributed to many challenges; but not all challenges related to the country's economic classification.Conclusion: A global approach is needed to share knowledge about EBP, especially scientific evidence and innovative thinking about its application to clinical practice. Implications for rehabilitationRehabilitation professional groups should contribute to a global network to improve informal knowledge sharing and training around evidence-based practice.Support for training in evidence-based practice and its application needs to be developed and accessible in all countries, including low and middle-income countries.It is imperative that policymakers prioritise practical, evidence-based solutions for rehabilitation research in low and middle-income countries that can be effectively implemented within local settings.There must be solutions and increased accessibility of journal articles for those working in low and middle-income countries including those whose first language is not English.

Group-based circuit training to improve mobility after stroke: a cross-sectional survey of German and Austrian physical therapists in outpatient settings

BACKGROUND

A contextual transferability analysis identified group-based circuit training (GCT) as an optimal intervention in German and Austrian outpatient physical therapy to improve mobility post-stroke. GCT incorporates task-oriented, high-repetitive, balance, aerobic and strength training and allows for increased therapy time without increasing personnel.

OBJECTIVE

To determine the extent to which German and Austrian physical therapists (PTs) use GCT and its components in the outpatient treatment of stroke-related mobility deficits and to identify factors associated with using GCT components.

METHODS

A cross-sectional online survey was conducted. Data were analyzed descriptively and using ordinal regression.

RESULTS

Ninety-three PTs participated. None reported using GCT moderately to frequently (4- 10/10 patients). The percentage of PTs reporting frequent use (7- 10/10 patients) of task-oriented, balance, strength, aerobic, and high-repetitive training was 45.2%, 43.0%, 26.9%, 19.4%, and 8.6%, respectively. Teaching or supervising students, time for evidence-based practice activities at work, and working in Austria was associated with using GCT components frequently.

CONCLUSION

German and Austrian PTs do not yet use GCT in outpatient physical therapy for stroke. Almost half of PTs, however, employ task-oriented training as recommended across guidelines. A detailed, theory-driven and country-specific evaluation of barriers to GCT uptake is necessary to inform implementation.

Current physical therapy practice and implementation factors regarding the evidence-based 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline in Germany: a cross-sectional online survey

BACKGROUND

Evaluation of the current physical therapy practice for German stroke rehabilitation with respect to the 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline recommendations and the associated implementation factors.

METHODS

A descriptive cross-sectional study employing an online survey was performed among German physical therapists in 2019. The survey consisted of three sections with open and closed questions: 1) self-reported use of ReMoS recommendations, 2) barriers of guideline use and 3) socio-demographic characteristics. The benchmark level for guideline adherent physical therapy was set at > 80%.

RESULTS

Data from 170 questionnaires were eligible for analysis. Participants' mean age was 41.6 years, 69.4% were female, while 60.1% had no academic degree. The ReMoS guideline was unknown to 52.9% of the responders. Out of all the 46 ReMoS guideline recommendations, only 'intensive walking training without a treadmill' was reported to be performed in a guideline adherent manner. Respondents usually denied any personal limitations, such as limited knowledge, or that the ReMoS guideline did not fit their routine practice.

CONCLUSIONS

Among German physical therapists, the ReMoS guideline is not well-known and many interventions are not performed as recommended, illustrating the discrepancies between the ReMoS guideline recommendations and current physical therapy practice. Interventions aimed at overcoming this gap should consider both knowledge of existing barriers and facilitators of guideline usage.

TRIAL REGISTRATION

The study was retrospectively registered to the German Clinical Trials Register ( DRKS00026681 ).

Current practice of physiotherapists in outpatient stroke rehabilitation: a cross-sectional survey in Austria / Arbeitsweise von Physiotherapeut*innen in der ambulanten Schlaganfallrehabilitation: eine Querschnittsumfrage in Österreich

Ziel

Leitlinienbasiertes Arbeiten hat Vorteile für Patient*innen und das Gesundheitssystem. Trotz dieser Vorteile arbeiteten in der Vergangenheit nur ca. 10 % der österreichischen Physiotherapeut*innen leitlinienbasiert. Zur Behandlung von Mobilitätseinschränkungen nach Schlaganfall empfehlen aktuelle, internationale Leitlinien aufgabenorientiertes Training sowie den Einsatz standardisierter Assessments. Das Ziel dieser Studie ist es, die Arbeitsweise von in der ambulanten Schlaganfallversorgung tätigen Physiotherapeut*innen in Österreich bezüglich dieser Leitlinienempfehlungen darzustellen.

Methode

Ein bereits in einer Umfrage in Deutschland verwendeter Fragebogen wurde an den österreichischen Kontext adaptiert. Der Fragebogen beinhaltete ein Fallbeispiel, anhand dessen je drei Untersuchungsmethoden und Behandlungsmaßnahmen genannt und begründet werden sollen. Eingeschlossen wurden Physiotherapeut*innen, die mindestens drei Personen nach Schlaganfall pro Jahr behandeln. Die Datenanalyse erfolgte über eine qualitative Inhaltsanalyse und deskriptive Statistik.

Ergebnisse

Dreißig Physiotherapeut*innen füllten den Fragebogen vollständig aus und nannten je 88 Untersuchungsmethoden und Behandlungsmaßnahmen. Die Untersuchungsmethoden wurden zu 34,1 % der Kategorie „standardisierte Assessments“ und zu 65,9 % der Kategorie „physiotherapeutische Basisuntersuchung (nicht standardisiert)“ zugeordnet. Die Behandlungsmaßnahmen wurden zu 30,7 % den „traditionellen Behandlungskonzepten“ Bobath und Propriozeptive Neuromuskuläre Fazilitation zugeordnet. Die häufigste „andere Maßnahme“ war das gerätegestützte Kraft- und Ausdauertraining (22,7 %). Gründe für die Auswahl waren positive Erfahrung, Wissen aus Fortbildungen, Praktikabilität und Vereinbarkeit mit individuellen Zielen der Personen nach Schlaganfall.

Diskussion

Die ambulante physiotherapeutische Versorgung von Personen nach Schlaganfall ist aktuell geprägt von Untersuchungsmethoden und Behandlungsmaßnahmen, die in Leitlinien großteils nicht empfohlen werden. Da die Auswahl u. a. mit Wissen aus Fortbildungen begründet wird, könnten Fortbildungen ein möglicher Ansatzpunkt für die Förderung leitlinienkonformer Physiotherapie sein. Die geringe Teilnehmer*innenzahl limitiert die Aussagekraft der Studie.

Reading and Study Habits of Medical Students on Clerkships and Performance Outcomes: a Multi-institutional Study

PURPOSE

To describe medical students' reading habits and resources used during clinical clerkships, and to assess whether these are associated with performance outcomes.

METHOD

Authors administered a cross-sectional survey to medical students at 3 schools midway through the clerkship year. Closed and open-ended questions focused on resources used to read and learn during the most recent clerkship, time spent and purpose for using these resources, influencers on study habits, and barriers. A multiple regression model was used to predict performance outcomes.

RESULTS

Overall response rate was 53% (158/293). Students spent most of their time studying for clerkship exams and rated question banks and board review books as most useful for exam preparation. Sixty-seven percent used textbooks (including pocket-size). For patient care, online databases and pocket-sized textbooks were rated most useful. The main barrier to reading was time. Eighty percent of students ranked classmates/senior students as most influential regarding recommended resources. Hours spent reading for exams was the only significant predictor of USMLE Step 2 scores related to study habits. The predominant advice offered to future students was to read.

CONCLUSIONS

These findings can help inform students and educational leadership about resources students use, how they use them, and links to performance outcomes, in an effort to guide them on maximizing learning on busy clerkships. With peers being most influential, it is important not only to provide time to help students build strong reading and study habits early, but also to guide them towards reliable resources, so they will recommend useful information to others.

Current practice of physical therapists in outpatient stroke rehabilitation: a cross-sectional survey in Baden-Württemberg and Thuringia / Arbeitsweise von Physiotherapeut*innen in der ambulanten Schlaganfallrehabilitation: eine Querschnittsumfrage in Baden-Württemberg und Thüringen

Objective

Guidelines recommend task-oriented training and the use of standardized assessments to improve stroke-related mobility deficits. However, the German outpatient physical therapy prescription catalogue does not include these recommendations resulting in a possible gap between guideline recommendations and clinical practice. Therefore, the purpose of this study was to describe physical therapy practice patterns of stroke-related mobility deficits in the outpatient setting exemplified by the states Baden-Württemberg and Thuringia.

Methods

Using an online survey, physical therapists treating people with stroke in outpatient settings in Baden-Württemberg and Thuringia were recruited. The questionnaire was developed using a multi-step procedure. Using a case vignette and open-ended questions, preferred evaluation and treatment methods were assessed. Data were analyzed using content analysis and descriptive statistics.

Results

Data from 63 physical therapists were included in the analysis. Answers to the open questions showed a wide range of different citations. Of 186 citations on evaluation methods, 28 (15,1 %) were classified as “standardized assessments”, while 158 citations (84,9 %) were classified as “basic physical therapy evaluation (non-standardized)”. Standardized assessments were cited by 25% of participants. Of 182 citations on treatment methods, 69 (35,2%) were classified as “traditional therapies”. These traditional therapies were cited by 81 % of participants. Task-oriented training was not cited.

Discussion

Despite the small sample size our data confirm the insufficient guideline use in German physical therapy and contribute results on practice patterns in outpatient stroke settings. These results will be used to initiate theory-based implementation strategies aiming to optimize physical therapy for people with stroke.