The effect of a structured programme to increase patient activity during inpatient stroke rehabilitation: a Phase I cohort study

Lower limb rehabilitation using modified constraint-induced movement therapy and motor relearning program on balance and gait in sub-acute hemiplegic stroke: a comparative study

Background

A stroke is described by the World Health Organization as "a clinical syndrome with rapidly developing symptoms that consist of a focal (or global, in a situation of coma) disruption of cerebral function that lasts more than 24 hours or leads to mortality without a known cause other than a vascular origin". Stroke is the most prevalent cause of impairment and mortality on a global scale. Modified constraint-induced movement therapy (mCIMT) is an approach to therapy for motor disabilities that involves constraining the movements of the nonparetic limb, diligent practice and behaviour modification to extend the time the paretic limb is utilized for daily tasks. The motor relearning program (MRP) method involves many aspects of motor learning theory and is helpful in providing instructions for retraining practical skills (including walking, standing and sitting in balance and transferring abilities). So, the objective of this study is to assess the impact of the MRP and mCIMT on balance and gait in sub-acute hemiplegic stroke patients.

Methods

In this study, each group will consist of 17 people in total. The randomization procedure will be conducted using a computer-generated random number system. For sample distribution, we will use the sequentially numbered opaque sealed envelope technique. Outcome measures will be as follows: Berg balance scale, Dynamic gait index, Trunk impairment scale, Functional reach test, 10 Meter walk test and Fall efficacy test. Each patient will be evaluated prior to and during treatment at baseline and six weeks later.

Conclusions

There is sufficient evidence to derive the conclusion that the functional mobility and balance of stroke victims can be improved with physiotherapy. Therefore, this study will try to seek the comparison of mCIMT (group A) and MRP (group B) in sub-acute stroke subjects and compare the two regimes to determine which one will be superior.

Registration

CTRI ( CTRI/2023/05/052674; 16/05/2023).

A Qualitative Study Exploring Rehabilitant and Informal Caregiver Perspectives of a Challenging Rehabilitation Environment for Geriatric Rehabilitation

There is a trend toward formalization of the rehabilitation process for older rehabilitants in a Challenging Rehabilitation Environment (CRE). This concept involves the comprehensive organization of care, support, and environment in rehabilitation wards. So far, literature about the principles of CRE is scarce. This study aims to explore the opinions of rehabilitants and informal caregivers regarding CRE, through a qualitative study between 2019 and 2020. Three telephone interviews were conducted with informal caregivers, and also 3 focus groups with 15 rehabilitants and 3 informal caregivers, all with recent experience in rehabilitation. Nine themes emerged regarding the rehabilitation process: (1) rehabilitant (attention for resilience, motivation, cognitive and emotional aspects), (2) rehabilitant centered (goal setting, physical and cognitive functioning and coping), (3) informal caregivers (involving and attention for resilience and relation), (4) communication (aligning the rehabilitation process), (5) exercise (increasing intensity by using task-oriented exercise, patient-regulated exercise, and group training), (6) peer support (learning experiences and recognition), (7) daily schedule (influence on the planning and activities outside therapy), (8) nutrition (energy for rehabilitation), and (9) eHealth (makes rehabilitation more challenging and fun). Regarding organizational processes, 4 themes were identified: (1) environmental aspects (single bedrooms, shared room for activities and therapy options on the ward), (2) staff aspects (small team with an emphatic supportive and motivating attitude), (3) organizational aspects (organized in an efficient way), and (4) return home (the discharge process should be well prepared for instance with home visits). Organizing excellent rehabilitation care requires a thorough understanding of the concept of CRE, as it is a complex and comprehensive concept that concerns the whole rehabilitation process. Its effectiveness and efficiency should be researched in prospective studies.

Early Occupational Therapy Intervention in the Hospital Discharge after Stroke

Stroke is the leading cause of acquired disability in adults which is a cerebrovascular disease of great impact in health and social terms, not only due to its prevalence and incidence but also because of its significant consequences in terms of patient dependence and its consequent impact on the patient and family lives. The general objective of this study is to determine whether an early occupational therapy intervention at hospital discharge after suffering a stroke has a positive effect on the functional independence of the patient three months after discharge—the patient’s level of independence being the main focus of this research. Data will be collected on readmissions to hospitals, mortality, returns to work and returns to driving, as well as an economic health analysis. This is a prospective, randomized, controlled clinical trial. The sample size will be made up of 60 patients who suffered a stroke and were discharged from the neurology unit of a second-level hospital in west Malaga (Spain), who were then referred to the rehabilitation service by the joint decision of the neurology and rehabilitation department. The patients and caregivers assigned to the experimental group were included in an early occupational therapy intervention program and compared with a control group that receives usual care.

Effectiveness of Rehabilitation Nursing versus Usual Therapist-Led Treatment in Patients with Acute Ischemic Stroke: A Randomized Non-Inferiority Trial

Purpose

To determine the effectiveness of rehabilitation nursing program interventions in patients with acute ischemic stroke.

Patients and Methods

An assessment-blinded randomized controlled trial was conducted at a tertiary referral hospital in China. Eligible patients were stratified according to their weighted corticospinal tract lesion load and then randomly assigned to an experimental group (n = 121) or a control group (n = 103). The experimental group received rehabilitation nursing from well-trained, qualified nurses (30 minutes per session, two sessions per day for seven consecutive days). The control group received therapist-led rehabilitation with the same timing and frequency. Comparative analysis of the primary outcomes was performed to determine non-inferiority with a predetermined non-inferiority margin. The primary outcomes were the Motor Assessment Scale, Fugl-Meyer Assessment, and the Action Research Arm Test assessed at baseline and after seven days of treatment. The secondary outcomes were the modified Barthel Index, the National Institutes of Health Stroke Scale, and the modified Rankin Scale, evaluated before and after the intervention and at 4 and 12 weeks of follow-up.

Results

Two hundred participants completed the trial. In both groups, all outcomes improved significantly after seven days and at follow-ups. The rehabilitation nursing program was non-inferior to therapist-led treatment with lower 95% confidence limits beyond the margins for primary outcomes (P < 0.001).

Conclusion

Both treatments had comparable effects; however, no definite conclusion could be drawn. Adequately powered studies are required.

A quality improvement project targeting physical, cognitive and social activity levels in inpatient rehabilitation

Background/aims

People undergoing inpatient rehabilitation largely spend their day by the bedside, inactive and alone. Increasing patients' physical, cognitive and social activity levels may improve rehabilitation outcomes for both the individual and the service. The aim of this study was to trial an activity programME that aimed to increase inpatient physical, cognitive and social activity levels, provided within existing resources whilE maintaining or increasing patient satisfaction.

Methods

A mixed-methods approach was used to develop and evaluate a multi-component activity programme for patients undergoing inpatient rehabilitation.

Results

Patient activity across the unit did not change but the amount of time spent alone during a weekday was significantly reduced. Patient satisfaction levels remained high. Each new therapy group was well received by patients and the volunteers who supported implementation. Novel programmes included table tennis coaching and independent gym access for selected inpatients, which were well used and not resource intensive. Therapist prescription of independent practice programmes remained low. Broader initiatives such as patient education folders require revision and further investment to succeed.

Conclusions

It is possible to change and evaluate multiple therapy services concurrently. The absence of change in overall activity levels demonstrates a need to establish the most successful components, harness support from the organisation to address some of the physical/environmental barriers and expand smaller programmes, and invest more time to consolidate the whole-of-service changes required to push the rehabilitation service in the direction of greater patient activity and ownership. Clinicians should pursue, implement, evaluate and revise novel programmes to engage their patient population.

Association between Functional Independence Measure and mortality in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis: A single-center observational study

OBJECTIVES

Previous studies have identified several predictors of mortality in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). However, functional dependence as a predictor of mortality has never been reported. In this study, we investigated whether Functional Independence Measure (FIM) was associated with mortality in AAV patients.

METHODS

We analyzed 52 adults with biopsy-proven AAV in Teine Keijinkai Medical Center between January 2000 and March 2019. Adjusted Cox regression analyses were conducted to evaluate the association between three FIM-based groups and all-cause mortality. Estimates were calculated as hazard ratios with 95% confidence intervals (95% CIs).

RESULTS

During a median follow-up of 2.3 years (interquartile range, 0.7-4.6 years), death occurred in 15 patients (29%). Compared to the highest-FIM group (91-126 points), the adjusted hazard ratios for the intermediate- (55-90 points) and lowest-FIM (18-54 points) groups were 3.59 (95% CIs, 0.40-32.0) and 15.7 (95% CIs, 2.07-119) for all-cause mortality, respectively. In addition, the lower-FIM groups were associated with higher mortality (p=.0179).

CONCLUSION

This study suggested that the FIM score is a predictor of all-cause mortality in AAV patients. Future studies will have to investigate whether FIM assessment leads to better outcomes.

Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study

Background

Therapy is key to effective stroke care, but many patients receive little.

Objectives

To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.

Design

Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.

Setting

Stroke services in England, Wales and Northern Ireland.

Participants

A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.

Results

Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.

Limitations

Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.

Conclusions

Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.

Conquering the inner couch potato: precommitment is an effective strategy to enhance motivation for effortful actions

Letting effort-free gratification derail us from effort-requiring goals is one reason why we fail to realize health-relevant intentions like 'exercise regularly'. We tested the effectiveness of the self-control strategy precommitment in such effort-related conflicts, using a novel laboratory choice paradigm, where participants could precommit to an effort-requiring large reward by pre-eliminating an effort-free small reward from their choice set. Our participants used precommitment frequently and effectively, such that they reached effort-requiring large rewards more often. Using computational modelling and Bayesian model comparisons, we assessed whether participants employed precommitment to avoid anticipated willpower failures (i.e. as a self-regulatory measure) or to maximize their motivation to choose the effort-requiring option (i.e. as a self-motivational measure). Observed choices and precommitment decisions were consistent with the motivation maximization hypothesis, but not the willpower hypothesis. Our findings show that offering precommitment is effective in helping individuals optimize their motivation and choice behaviour and thereby achieve effort-requiring goals, and strongly encourage application of precommitment schemes in exercise and rehabilitation interventions. This article is part of the theme issue 'Risk taking and impulsive behaviour: fundamental discoveries, theoretical perspectives and clinical implications'.

Challenging rehabilitation environment for older patients

Introduction

After hospitalization, 11% of the older patients are referred to rehabilitation facilities. Nowadays, there is a trend to formalize the rehabilitation process for these patients in a Challenging Rehabilitation Environment (CRE). This concept involves the comprehensive organization of care, support and the environment on a rehabilitation ward. However, since literature on the principles of CRE is scarce, this review aimed to explore and describe the principles of CRE.

Methods

A search was made in PubMed for relevant literature concerning CRE. Then, articles were hand searched for relevant keywords (ie, task-oriented training, therapy intensity, patient-led therapy, group training), references were identified, and topics categorized.

Results

After evaluating 51 articles, 7 main topics of CRE were identified: 1) Therapy time; ie, the level of (physical) activity; the intensity of therapy and activity is related to rehabilitation outcomes, 2) group training; used to increase practice time and can be used to achieve multiple goals (eg, activities of daily living, mobility), 3) patient-regulated exercise; increases the level of self-management and practice time, 4) family participation; may lead to increased practice time and have a positive effect on rehabilitation outcomes, 5) task-oriented training; in addition to therapy, nurses can stimulate rehabilitants to perform meaningful tasks that improve functional outcomes, 6) enriched environment; this challenges rehabilitants to be active in social and physical activities, and 7) team dynamics; shared goals during rehabilitation and good communication in a transdisciplinary team improve the quality of rehabilitation.

Discussion

This is the first description of CRE based on literature; however, the included studies discussed rehabilitation mainly after stroke and for few other diagnostic groups.

Conclusion

Seven main topics related to CRE were identified that may help patients to improve their rehabilitation outcomes. Further research on the concept and effectivity of CRE is necessary.

Pedometers alone do not increase mobility in inpatient rehabilitation: a randomized controlled trial

OBJECTIVE

To test if pedometers, as a motivational tool, could affect mobility outcomes in inpatient rehabilitation.

DESIGN

Randomized controlled clinical trial.

SETTING

Subacute hospital rehabilitation unit in Australia.

PARTICIPANTS

A total of 78 participants with reduced mobility and clinician-determined capacity to improve.

INTERVENTIONS

Both groups received usual care. For the intervention group, a pedometer was worn on the hip with the step count visible to participant and recorded daily on an exercise log. For the control group, a pedometer fixed shut was worn on the hip and they recorded estimated distances walked on an exercise log.

MAIN MEASURES

Primary outcome was functional mobility - De Morton Mobility Index. Secondary outcome measures were walking velocity, functional independence measure, time spent upright and daily step count.

RESULTS

Significant improvements over time (P < 0.001) in functional mobility, comfortable walking velocity and functional independence measure were not influenced by the intervention. The daily average upright time (hours) in the first week of intervention was different (P = 0.004) between the intervention group (median, interquartile range (IQR): 1.67, 1.77) compared to the control group (median, IQR: 1.12, 0.82).

CONCLUSION

Pedometers as a motivational tool without targets do not improve functional mobility in this population. Pedometers may improve daily upright time in this setting.

Does feedback on daily activity level from a Smart watch during inpatient stroke rehabilitation increase physical activity levels? Study protocol for a randomized controlled trial

Background

Practicing activities improves recovery after stroke, but many people in hospital do little activity. Feedback on activity using an accelerometer is a potential method to increase activity in hospital inpatients. This study’s goal is to investigate the effect of feedback, enabled by a Smart watch, on daily physical activity levels during inpatient stroke rehabilitation and the short-term effects on simple functional activities, primarily mobility.

Methods/design

A randomized controlled trial will be undertaken within the stroke rehabilitation wards of the Second Affiliated hospital of Anhui University of Traditional Chinese Medicine, Hefei, China. The study participants will be stroke survivors who meet inclusion criteria for the study, primarily: able to participate, no more than 4 months after stroke and walking independently before stroke. Participants will all receive standard local rehabilitation and will be randomly assigned either to receive regular feedback about activity levels, relative to a daily goal tailored by the smart watch over five time periods throughout a working day, or to no feedback, but still wearing the Smart watch. The intervention will last up to 3 weeks, ending sooner if discharged. The data to be collected in all participants include measures of daily activity (Smart watch measure); mobility (Rivermead Mobility Index and 10-metre walking time); independence in personal care (Barthel Activities of Daily Living (ADL) Index); overall activities (the World Health Organization (WHO) Disability Assessment Scale, 12-item version); and quality of life (the Euro-Qol 5L5D). Data will be collected by assessors blinded to allocation of the intervention at baseline, 3 weeks or at discharge (whichever is the sooner); and a reduced data set will be collected at 12 weeks by telephone interview. The primary outcome will be change in daily accelerometer activity scores. Secondary outcomes are compliance and adherence to wearing the watch, and changes in mobility, independence in personal care activities, and health-related quality of life.

Discussion

This project is being implemented in a large city hospital with limited resources and limited research experience. There has been a pilot feasibility study using the Smart watch, which highlighted some areas needing change and these are incorporated in this protocol.

Trial registration

ClinicalTrials.gov, NCT02587585. Registered on 30 September 2015. Chinese Clinical Trial Registry, ChiCTR-IOR-15007179. Registered on 8 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2476-z) contains supplementary material, which is available to authorized users.

Rehabilitation - a new approach. Part two: the underlying theories

This editorial considers how healthcare systems should approach the problems associated with ongoing, persistent symptoms and limitations on a person's ability to undertake activities. It starts from the premise, established in the first editorial, that the current reliance on the biomedical model of health and illness is no longer 'fit for purpose', and is one major cause of current difficulties within the health service. Among other problems, it may lead to the marginalisation of rehabilitation services, especially when resources are limited. This editorial describes and then highlights the implications of the holistic, biopsychosocial model of illness. It also outlines the rehabilitation process, demonstrating its similarity to the process used by medical services, with the primary difference being the centre of attention: disease for medical service, disability for rehabilitation services. The model of rehabilitation emphasises: the importance of being patient-centred and goal-directed in rehabilitation; the need for liaison by the team and learning by the patient; and that the patient needs to be encouraged and enabled to practice wanted activities.

Having an impact, making a difference: the Editor's review of the first 30 years

OBJECTIVES

To review publications in Clinical Rehabilitation over the last 30 years, discerning the original goals and whether they were met, and describing major trends over the 30 years.

METHODS

Personal review, backed up by data from 'most read' articles and 'most cited' articles, from yearly lists of all controlled trials published in the journal and other sources.

RESULTS

The original goals included making rehabilitation better understood both within and outside the speciality, and more scientific. The first goal is probably not achieved, but the scientific standard of publication is much higher and it routinely recommends the use of guidelines appropriate to the publication. The journal has established a pre-eminent position in publishing randomized controlled trials, systematic reviews and articles on goal-setting. It has developed a series describing rehabilitation interventions. It aims to increase consideration of the theoretical basis of rehabilitation practices. We would like to think its impact has increased - but we cannot prove that!

CONCLUSION

The journal has established some credentials as being a source of clinically relevant evidence and guidance across the whole field of rehabilitation and across most disabling conditions.

Family's presence associated with increased physical activity in patients with acute stroke: an observational study

BACKGROUND

Inherent differences in organization of stroke care and rehabilitation practices in various settings influence the activity levels of patients in the hospital. The majority of published studies have been carried out in developed countries such as the United States, United Kingdom, Australia, Switzerland and Belgium; however, data from developing countries are scarce.

OBJECTIVE

To measure the amount and nature of physical activity of patients admitted to medical wards of Indian hospitals and to assess the association between family presence and the patient and between the patient's functional status and their physical activity level.

METHOD

This is an observational behavioral mapping study. A trained physical therapist recorded the patients' (N=47) physical activity level through direct observation in the ward using a predetermined observation scheme.

RESULTS

Participants were found inactive and alone for 19% (inter quartile range [IQR] 12-36%) and 15% (IQR 10-19%) of the time during the day, respectively. They spent 46% (IQR 31-55%) of the time in therapeutic activities and 31% (IQR 22-34%) of the time in non-therapeutic activities. The family was present with patients 50% of the time during the day. Family presence with the patient and the patient's moderate dependence in daily activities are positively associated with their activity levels.

CONCLUSION

Patients with stroke admitted to Indian hospitals spent less time being inactive and alone and more time with family participating in therapeutic activities. The presence of family members with the patients during hospital stay may be a significant resource for encouraging patients to be more active.

Improving practice with integration of patient directed activity during inpatient rehabilitation

BACKGROUND

Early initiation of rehabilitation following stroke promotes better long-term outcomes than delayed onset, emphasizing the importance of inpatient therapy. However, literature indicates that following stroke individuals in inpatient rehabilitation spend the majority of their day in their bedroom and inactive. Consequently, since amount of functional activity is posited to relate to outcomes, the current rehabilitation model needs to be challenged with innovative solutions to maximize recovery.

RATIONALE

In an attempt to promote greater activity and higher doses of therapy during inpatient rehabilitation, we implemented the "Patient Directed Activity Program" to facilitate specific movement and improve outcomes for patients post stroke. Our interdisciplinary activity program was conceptualized on a theoretical model for stroke recovery and principles of experience-dependent neural plasticity.

MAIN FEATURES

The "Patient Directed Activity Program" includes distinct activity stations designed to increase repetition, stimulation, attention, and activity of the affected upper extremities, lower extremities, and trunk. Each task-specific activity was easily graded to achieve moderate- to high-intensity. The activity program prescribed individuals up to three additional 30-minute bouts of activities daily that were to be completed independently, and in addition to standard of care. Clinical application: After implementing this program in our facility for one year as a quality improvement project, the intervention has been delivered as an Institutional Review Board approved randomized controlled trial (Clinical Trial #NCT02446197). Challenges with people and facilities have been overcome, resulting in a feasible program that can be delivered in an inpatient setting. High satisfaction has been reported by patients and clinicians.

Rehabilitation – a new approach. Part four: a new paradigm, and its implications

This editorial proposes changes in healthcare services that should greatly improve the health status of all patients with disability. The main premises are that: rehabilitation usually involves many actions delivered by many people from different organisations over a prolonged period; specific rehabilitation actions cover a wide range of professional activities, with face to face therapy only being one; and the primary patient activity that improves function is practice of personally relevant activities in a safe environment. This editorial argues that: rehabilitation should occur at all times and in all settings, in parallel with medical care in order to maximise recovery and to avoid loss of fitness, skills and confidence associated with rest and being cared for; hospitals and other healthcare settings should adapt the environment to encourage practice of activities at all times; and that measuring rehabilitation, whether in research or for re-imbursement, should not simply consider face-to-face ‘therapy time’ but must include: all the other important activities undertaken by the team; ‘structures’ such as the appropriateness of the environment; and a process measure of the time spent by patients undertaking activities.

Effects of therapeutic positioning on vital parameters in patients with central neurological disorders: a randomised controlled trial

AIMS AND OBJECTIVES

To investigate the effects of positioning on heart rate, breathing frequency and blood pressure in postacute, severely disabled patients with central neurological disorders.

BACKGROUND

Positioning patients is part of the regular nursing routine in the care for severely disabled patients. Positioning can be done in a conventional way or in Lagerung in Neutralstellung (Engl.: positioning in neutral), which has recently been shown to have better effects on the passive range of motion and comfort than conventional positioning. While it is thought that positioning influences vital parameters, so far no study has investigated this for a clinically relevant observation period, and no study has compared different positioning concepts in this respect.

DESIGN

A multicentre, randomised, controlled, single-blind clinical trial.

METHODS

Two hundred and eighteen patients were randomly assigned to positioning in neutral or conventional positioning. For two hours, they were lying in one of five positions (supine, 30° and 90° side lying on the right or left side) according to the respective positioning concept. Heart rate, breathing frequency and blood pressure were measured before and after positioning in a supine lying position (i.e. not positioned according to any concept). It was investigated if the interventions influence vital parameters and whether there are differences between positioning in neutral and conventional positioning, or between the different positions.

RESULTS

In neither of the groups did heart rate, breathing frequency and blood pressure change significantly after the intervention compared to before (p ≤ 0·01).

CONCLUSION

Positioning does not influence heart rate, breathing frequency and blood pressure when patients are lying for a clinically feasible length of two hours.

RELEVANCE TO CLINICAL PRACTICE

This study shows that nurses can apply both positioning concepts according to their patients' preferences or to address problems like pressure sore prevention. There is no risk of influencing basic vital parameters.