What Is So Great about Inpatient Rehabilitation from the Patient Experience Perspective: Qualitative Content Analysis of an Appreciative Inquiry during a Bedside Experience Rounding

BACKGROUND

Positive person-centered attributes of inpatient rehabilitation need to be identified from the patient's perspective to be further developed and sustained.

PURPOSE

To identify which attributes patients openly evoke as being great care experiences, using an open appreciative inquiry during the inpatient rehabilitation stay.

METHODS

Qualitative secondary analysis of appreciative patient comments during a bedside patient experience rounding facilitated by a neutral party was performed. Two independent analysts employed an inductive, summative form of content analysis.

RESULTS

Among 150 patients rounded, 122 provided categorizable appreciative accounts. Over two-thirds of the patients (67.2%) focused on "staff attributes" in their great-experience accounts. Those attributes were mostly interpersonal such as being "attentive & caring-beyond clinical duty" and being "encouraging (but not too hard) & reassuring". These interpersonal staff attributes were reported with words showing deep levels of personal significance or patient appreciation. Beyond staff attributes, the perceived quality of "patient care" (31.1%) and opportunities for "leisure and social activities" (9.0%) were also frequently evoked. Amenities like food or customer service were the least evoked, rarely so as an exclusive attribute (0.8% for each).

CONCLUSIONS

The human(e) factor, especially the interpersonal qualities of staff, emerged as greatly appreciated from the patient experience perspective during inpatient rehabilitation. These experiences help identify which person-centered attributes of care might be further developed and sustained.

Rehabilitation following periacetabular osteotomy for acetabular dysplasia: A qualitative interview study exploring challenges, hopes and expectations among patients in Denmark and Australia

INTRODUCTION

Guidelines have been proposed for post-operative rehabilitation following periacetabular osteotomy (PAO). However, the perspectives of individuals undergoing PAO have not been considered.

AIM

The present study aimed to explore the perceived challenges of everyday life and hopes for and expectations of post-PAO rehabilitation from the perspective of individuals with acetabular dysplasia living in Denmark and Australia.

METHODS

In this qualitative study, we used a hermeneutic phenomenological approach with semi-structured interviews to explore the perspectives of 25 participants (four males), aged 16-43 years, who underwent a PAO. Purposeful sampling was used to provide variations in age and sex. Inclusion criteria were age above 15 years, radiographic evidence of acetabular dysplasia, PAO within the last seven weeks and undergoing post-operative rehabilitation. Inductive content analysis was adopted to code and analyse interviews.

RESULTS

The analysis of the interview transcripts revealed four major themes: different expectations, self-confidence, tailored rehabilitation and aligning expectations. Several subthemes emerged within each theme, and similar patterns with minor variations were identified across countries. However, the financial burden of self-funded surgery and rehabilitation challenged some Australian participants, whereas none of the Danish participants mentioned this challenge.

CONCLUSION

Our findings elucidate the diverse range of hopes and expectations in individuals undergoing PAO, and how these relate to their perceived challenges. In particular, the findings highlight the importance of aligning expectations between individuals and clinicians when designing the rehabilitation.

Implementing Activity-Based Therapy for Spinal Cord Injury Rehabilitation in Canada: Challenges and Proposed Solutions

Activity-based therapy (ABT) is a therapeutic approach with multiple benefits including promoting neurorecovery and reducing the likelihood of secondary complications in people living with spinal cord injury (SCI). Barriers and facilitators to ABT implementation for SCI rehabilitation have been studied from various perspectives through qualitative research. However, these viewpoints have not been synthesized to identify challenges of and strategies for implementing ABT across the Canadian healthcare system. Thus, the purpose of our study was to examine the current state of ABT in Canadian healthcare settings according to users' perspectives. Our main objectives were to compare barriers and facilitators to ABT implementation across Canadian healthcare settings according to users' perspectives and to identify optimal intervention strategies for ABT delivery across the Canadian healthcare system from acute to community care. We searched Scopus, CINAHL, OvidMedline, and other sources. Eligible articles were qualitative or mixed methods studies exploring ABT for adults with SCI in a Canadian healthcare setting. We analyzed qualitative findings through a thematic synthesis followed by a deductive content analysis. The Mixed Methods Appraisal Tool was used for critical appraisal. Nine articles were included. The thematic synthesis revealed two main themes: (1) factors influencing acceptance and adaptation of ABT across healthcare settings in Canada and (2) proposed solutions. The deductive analysis applied the Behaviour Change Wheel (BCW) to identify limited components of behaviour and appropriate interventions. To address ABT implementation challenges across the Canadian healthcare system, evidence-based interventions should target BCW subcategories of reflective motivation, social opportunity, and physical opportunity.

Identifying central elements of the therapeutic alliance in the setting of telerehabilitation: A qualitative study

INTRODUCTION

Therapeutic alliance is a relevant aspect of healthcare and may influence patient outcomes. So far, little is known about the therapeutic alliance in telerehabilitation.

PURPOSE

To identify and describe central elements of therapeutic alliance in the setting of telerehabilitation and compare it to those in conventional rehabilitation.

METHODS

In this qualitative study, a literature search and in-depth semi-structured interviews with rehabilitation and telerehabilitation experts were conducted from 15.5.-10.8.2020 on elements influencing the therapeutic alliance in rehabilitation and telerehabilitation. Using a combined deductive and inductive approach, qualitative content analysis was used to identify categories and derive central themes.

RESULTS

The elements bond, communication, agreement on goals and tasks and external factors were identified in the literature search and informed the development of the interview guide. Twelve purposively sampled experts from the fields of physiotherapy, occupational therapy, speech and language therapy, psychology, general medicine, sports science and telerehabilitation software development participated in the interviews. We identified three central themes: building effective communication; nurturing a mutual relationship of trust and respect; and agreement on goals and tasks and drivers of motivation.

CONCLUSIONS

In this qualitative study, key elements of therapeutic alliance in rehabilitation confirmed those reported in the literature, with additional elements in telerehabilitation comprising support from others for ensuring physical safety and technical connectedness, caregivers acting as co-therapists and applying professional touch, and promoting patient autonomy and motivation using specific strategies.

Physical Therapist and Patient Perspectives on Mobile Technology to Support Home Exercise Prescription for People With Arthritis: A Qualitative Study

Introduction Mobile applications (apps) for exercise prescription may enhance communication between healthcare providers and patients while addressing common barriers to exercise among people with osteoarthritis. However, little is known about preferences and barriers to the use of mobile apps by physical therapists or people aging with osteoarthritis. Therefore, we aimed to examine physical therapist and patient perspectives on mobile apps to support physical therapist-prescribed home exercise for people with osteoarthritis. Methods Eighteen physical therapists and 17 individuals with a history of physical therapy for osteoarthritis participated in the study. Focus groups (n = 6, three each with physical therapists and patients) were conducted to gather perspectives on three commercially available mobile apps designed for physical therapy exercise prescription. Semi-structured questions assessed feature preferences, ease of use, exercise completion support, clinical feasibility, and potential barriers and facilitators to using the apps. Recordings of the focus groups were transcribed verbatim. The study team iteratively coded transcripts using thematic analysis. Results Perspectives of patients and physical therapists intersected but differed on the mobile apps. All patients preferred video exercise prescription over traditional methods and both patients and therapists predicted challenges and opportunities with mobile communication. Four themes emerged: accountability, data-driven, communication boost, and duality of technology. Facilitators of home exercise through mobile apps included exercise tracking, feedback loop, personalization, and the potential for reduced in-person visits. Barriers included technological challenges, complex interface design, lack of universal applicability, and security concerns. Conclusion Mobile app technology has the potential to support exercise adherence for people with osteoarthritis. However, patients' and therapists' perspectives differ and highlight numerous challenges that limit the universal clinical adoption of this technology. While physical therapists acknowledged the potential to improve the rehabilitation experience with mobile apps, there was concern about reimbursement and time constraints in the current fee-for-service environment.

Interplay Between Innovation and Intersubjectivity: Therapists Perceptions of Phantom Motor Execution Therapy and Its Effect on Phantom Limb Pain

Purpose

Interpersonal processes, including therapeutic alliance, may modulate the impact of interventions on pain experience. However, the role of interpersonal context on the effects of technology-enhanced interventions remains underexplored. This study elicited therapists' perspectives on how a novel rehabilitative process, involving Phantom Motor Execution (PME), may impact phantom limb pain. The mediating role of therapeutic alliance, and the way PME influenced its formation, was investigated.

Methods

A qualitative descriptive design, using a framework method, was used to explore therapists' (n=11) experiences of delivering PME treatment. Semi-structured online-based interviews were conducted.

Results

A 3-way interaction between therapist, patient, and the PME device was an overarching construct tying four themes together. It formed the context for change in phantom limb experience. The perceived therapeutic effects (theme 1) extended beyond those initially hypothesised and highlighted the mediating role of the key actors and context (theme 2). The therapeutic relationship was perceived as a transformative journey (theme 3), creating an opportunity for communication, collaboration, and bonding. It was seen as a cause and a consequence of therapeutic effects. Future directions, including the role of expertise-informed adaptations and enabling aspects of customised solutions, were indicated (theme 4).

Conclusion

This study pointed to intrapersonal, interpersonal, and contextual factors that should be considered in clinical implementation of novel rehabilitative tools. The results demonstrated that therapists have unique insights and a crucial role in facilitating PME treatment. The study highlighted the need to consider the biopsychosocial model of pain in designing, evaluating, and implementing technology-supported interventions.

Supporting Collaboration in Rehabilitation Trajectories With Information and Communication Technologies: Scoping Review

BACKGROUND

Despite a surge in health information and communication technology (ICT), there is little evidence of lowered cost or increased quality of care. ICT may support patients, health care providers, and other stakeholders through complex rehabilitation trajectories by offering digital platforms for collaboration, shared decision-making, and safe storage of data. Yet, the questions on how ICT can become a useful tool and how the complex intersection between producers and users of ICT should be solved are challenging.

OBJECTIVE

This study aims to review the literature on how ICTs are used to foster collaboration among the patient, the provider, and other stakeholders.

METHODS

This scoping review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. Studies were identified by searching MEDLINE (OVID), Embase (OVID), CINAHL (EBSCOhost), AMED (EBSCOhost), and Scopus. Unpublished studies were extracted from OAIster, Bielefeld Academic Search Engine, ProQuest Dissertations and Theses, NARIC, and Google Scholar. Eligible papers addressed or described a remote dialogue between stakeholders using ICT to address goals and means, provide decision support, or evaluate certain treatment modalities within a rehabilitation context. Due to the rapid development of ICTs, searches included studies published in the period of 2018-2022.

RESULTS

In total, 3206 papers (excluding duplicates) were screened. Three papers met all inclusion criteria. The papers varied in design, key findings, and key challenges. These 3 studies reported outcomes such as improvements in activity performance, participation, frequency of leaving the house, improved self-efficacy, change in patients' perspective on possibilities, and change in professionals' understanding of patients' priorities. However, a misfit between the participants' needs and the technology offered, complexity and lack of availability of the technology, difficulties with implementation and uptake, and lack of flexibility in setup and maintenance reduced the value of ICT for those involved in the studies. The low number of included papers is probably due to the complexity of remote collaboration with ICT.

CONCLUSIONS

ICT has the potential to facilitate communication among stakeholders in the complex and collaborative context of rehabilitation trajectories. This scoping review indicates that there is a paucity of research considering remote ICT-supported collaboration in health care and rehabilitation trajectories. Furthermore, current ICT builds on eHealth literacy, which may differ among stakeholders, and the lack of sufficient eHealth literacy and ICT knowledge creates barriers for access to health care and rehabilitation. Lastly, the aim and results of this review are probably most relevant in high-income countries.

Motivation in Aphasia Treatment: Self-Determination Theory Applied to the FOURC Model

PURPOSE

Although the importance of motivation to successful rehabilitation is frequently acknowledged in the aphasia literature, little evidence-based guidance has been provided on how to support it. The purpose of this tutorial is to introduce a well-validated theory of motivation, self-determination theory (SDT); explain its role as the foundation for the FOURC model of collaborative goal setting and treatment planning; and explain how it may be applied during rehabilitation to support the motivation of people with aphasia.

METHOD

We provide an overview of SDT, explore the link between motivation and psychological wellness, and discuss how psychological needs are addressed in SDT and the FOURC model. Concrete examples from aphasia therapy are used to illustrate main concepts.

CONCLUSIONS

SDT offers tangible guidance for supporting motivation and wellness. SDT-based practices support positive forms of motivation, which is one of the targets of FOURC. An understanding of SDT's theoretical foundation will help clinicians maximize the impact of collaborative goal setting and aphasia therapy more generally.

Clients and professionals elicit long-term care preferences by using 'What matters to me': A process evaluation in the Netherlands

BACKGROUND

'What matters to me' is a five-category preference elicitation tool to assist clients and professionals in choosing long-term care. This study aimed to evaluate the use of and experiences with this tool.

METHODS

A mixed-method process evaluation was applied. Participants were 71 clients or relatives, and 12 professionals. They were all involved in decision-making on long-term care. Data collection comprised online user activity logs (N = 71), questionnaires (N = 38) and interviews (N = 20). Descriptive statistics was used for quantitative data, and a thematic analysis for qualitative data.

RESULTS

Sixty-nine per cent of participants completed one or more categories in an average time of 6.9 (±0.03) minutes. The tool was rated 6.63 (±0.88) of 7 in the Post-Study System Usability Questionnaire (PSSUQ). Ninety-five per cent experienced the tool as useful in practice. Suggestions for improvement included a separate version for relatives and a non-digital version. Although professionals thought the potentially extended consultation time could be problematic, all participants would recommend the tool to others.

CONCLUSION

'What matters to me' seems useful to assist clients and professionals with preference elicitation in long-term care. Evaluation of the impact on consultations between clients and professionals by using 'What matters to me' is needed.

State-Level Sexism and Gender Disparities in Health Care Access and Quality in the United States

In this investigation, we examined the associations between state-level structural sexism-a multidimensional index of gender inequities across economic, political, and cultural domains of the gender system-and health care access and quality among women and men in the United States. We linked administrative data gauging state-level gender gaps in pay, employment, poverty, political representation, and policy protections to individual-level data on health care availability, affordability, and quality from the national Consumer Survey of Health Care Access (2014-2019; N = 24,250). Results show that higher state-level sexism is associated with greater inability to access needed health care and more barriers to affording care for women but not for men. Furthermore, contrary to our hypothesis, women residing in states with higher state-level sexism report better quality of care than women in states with lower levels of sexism. These findings implicate state-level sexism in perpetuating gender disparities in health care.

A qualitative study on promoting reablement among older people living at home in Norway: opportunities and constraints

BACKGROUND

Healthcare services that traditionally have been provided in long-term care institutions in Norway are increasingly being delivered at home to a growing population of older people with chronic conditions and functional limitations. Fostering reablement among older people is therefore important if they are to live safety at home for as long as possible. This study examines how healthcare professionals and managers (staff) in Norwegian municipalities promote reablement among community-dwelling older people.

METHODS

Face-to-face, semi-structured interviews lasting between 21 and 89 min were conducted between November 2018 and March 2019 with healthcare managers (N = 8) and professionals (N = 8 focus groups with 2-5 participants) in six municipalities in Norway. All interviews were audio-recorded, transcribed, and thematically coded inductively and analyzed with the aid of NVivo 12 software.

RESULTS

Overall, healthcare staff in this study used several strategies to promote reablement, including: carrying out assessments to evaluate older people's functional status and needs (including for safe home environments), and to identify older people's wishes and priorities with regard to reablement training. Staff designed care plans informed by the needs assessments, and worked with older people on reablement training at a suitable pace. They promoted among older people and staff (within and across care-units) the principle of 'showing/doing with' versus 'doing for' the older person so as to not enable disablement. Additionally, they supported older people in the safe and responsible use of welfare technology and equipment. Even so, staff also reported constraints to their efforts to foster reablement, such as: heavy workload, high turnover, insufficient training in reablement care, and poor collaboration across care-units.

CONCLUSION

Older people may be supported to live safely at home by meeting them as individuals with agency, identifying and tailoring services to their needs and wishes, and encouraging their functional abilities by 'showing/doing with' versus 'doing for them' when possible. The healthcare professionals and managers in this study were positive towards reablement care. However, meeting the resource demands of reablement care is a key challenge.

Occupational Therapy Interventions to Address Depressive and Anxiety Symptoms in the Physical Disability Inpatient Rehabilitation Setting: A Systematic Review

IMPORTANCE

Depressive and anxiety symptoms across physical disability inpatient rehabilitation (IPR) patient groups are well documented and negatively affect functional recovery. The strategies within the occupational therapy scope of practice to address these symptoms in IPR are unclear.

OBJECTIVE

To determine what interventions within the occupational therapy scope of practice have been used to address depressive and anxiety symptoms in IPR and to determine intervention efficacy.

DATA SOURCES

Nine databases for all publication years were searched (PubMed, Scopus, Embase, Web of Science, PsycINFO, Cochrane Library, AgeLine, OTseeker, and CINAHL). Study Selection and Data Collection: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for abstracting data and assessing quality. Included articles were peer reviewed, based in the United States, in English, controlled clinical trials or randomized controlled trials, in the IPR setting, and within the occupational therapy scope of practice. Two reviewers independently screened articles, with disagreements resolved by consensus.

FINDINGS

Five of 8,082 articles met inclusion criteria. Diagnoses included stroke (n = 1), traumatic brain injury (n = 1), spinal cord injury (n = 1), and musculoskeletal conditions (n = 2). Results are discussed among four categories: study design and outcome variables, intervention type, intervention intensity, and intervention efficacy.

CONCLUSIONS AND RELEVANCE

Limited, moderate-quality evidence exists within the occupational therapy scope of practice for addressing depressive and anxiety symptoms in the physical disability IPR setting. Interventions primarily included cognitive and behavioral strategies. Further research among diverse patient populations is needed to support occupational therapy practitioners in facilitating client participation and functioning. What This Article Adds: This systematic review provides an evaluation of the evidence within the occupational therapy scope of practice to address depressive and anxiety symptoms within the physical disability IPR setting. This research can support occupational therapy practitioners to comprehensively address physical and mental health for participation in IPR.

The hand therapist's role in the prevention and management of upper extemity injuries in the modern mass production industrial setting

BACKGROUND

This case study presents the role of an onsite hand therapist (Certified Hand Therapist, Occupational Therapist, Physical Therapist) in an industrial setting and the services that can be provided in this comprehensive care model. Onsite hand therapists can impact on Occupational Safety and Health Administration (OSHA) first aid programs and can provide state of the art treatment for the injured worker in both a direct and indirect capacity.

PURPOSE

The purpose of this case study article is to review the many potential services the hand therapist can offer to facilitate the return-to-work of injured employees and provide employers with a proactive case management and state-of-the-art ergonomic prevention, improving profit margins and facilitating safe work environments.

STUDY DESIGN

A Case Study design demonstrating the diverse and positive impact of hand therapy on the mass production industrial setting.

METHODS

Novel to this approach is a description of outcome instruments (QuickDASH) administered in a periodic manner to understand the trajectory of change in patient-level disability throughout the rehabilitation process. The Optimal Screening for Prediction of Referral and Outcome (OSPRO-YF) is utilized to help predict the functional outcome for the injured worker. Case studies on common upper extremity pathologies will be discussed, demonstrating the benefits of onsite hand therapy with enhanced treatment and case management.

RESULTS

The utilization of the QuickDASH and the OSPRO-YF creates a process to determine the progression of injured workers in therapy, the trajectory of change in patient-level disability and to observe when changes occurred. An example of the periodic assessment approach is described in a case study to identify when the most significant change occurred and creating a mechanism to determine if patients were progressing as expected.

CONCLUSIONS

Inherent in this case study process is a fluidity in which the therapist can monitor patient progress and adjust the rehabilitation process that benefits both the patient and the industrial setting. A hierarchical functional level system is presented to describe an appropriate intervention strategy to coincide with a patient's progression of wound healing which can be provided by a hand therapist with specialized knowledge.

What matters most: a qualitative study of person-centered physiotherapy practice in community rehabilitation

BACKGROUND

Person-centered approaches to care require physiotherapists to engage in trying to understand the full range of biomedical, psychological, and social factors that people bring to the consultation, along with the client's individual responses to those factors. If, however, the main issues of importance to people are not openly declared and discussed they cannot be addressed. This is likely to result in people receiving interventions that clinicians think they need, rather than care based on their expressed needs and preferences.

OBJECTIVE

To understand people's abilities to express the issues of importance to them within a consultation and clinicians' abilities to acknowledge and address those issues.

DESIGN

A qualitative study using an interpretive phenomenological approach.

METHODS

Eight clients were interviewed before they met their physiotherapist, the initial consultation with their physiotherapist was recorded, and both were interviewed separately afterward.

ANALYSIS

The clients frequently do not raise their emotions or feelings as issues of importance, and physiotherapists generally struggle to elicit, or identify as important, such matters. How these were presented to the clinician and subsequently addressed varied. We formulated three themes: 1) managing complex situations; 2) establishing a person-centered agenda; and 3) addressing emotional issues.

CONCLUSIONS

Community physiotherapists may aim for a more person-centered approach; however, their habits, practices and behaviors remain within a culturally entrenched, clinician-centric, biomedical model.

Benefits of emotion-based training for the rehabilitation of stroke patients: A scoping review

BACKGROUND

The application of emotional stimuli is beneficial when practicing tasks that must be learned.

OBJECTIVE

This scoping review examined related literature to identify the applicability of emotion-based training for therapeutic activities.

METHOD

All relevant literature published as of April 1, 2020 in four prominent databases was searched (CINAHL, Embase, PubMed, and PsycINFO) using the five-stage review framework proposed by Arksey and O'Malley.

RESULTS

After sophisticated searches and exclusions, ten publications were included for further review. Our results revealed three types of emotion-based stimulation methods that can influence therapeutic effects on stroke patients. However, the research did not compare the difference between the pros, cons, and effectiveness of each type of sensory stimulation.

CONCLUSION

Rehabilitation specialists are encouraged to obtain a broad understanding of therapeutic situations and their possible impacts on a given environment.

"Selling" chronic pain: physiotherapists' lived experiences of communicating the diagnosis of chronic nonspecific lower back pain to their patients

Introduction: Chronic nonspecific lower back pain (CNSLBP) is a common musculoskeletal condition which can be a source of significant distress and disability for patients. Approaches to managing CNSLBP have been explored in healthcare literature, as has the importance of communication in physiotherapy practice. However, no previous studies have explored clinicians' experiences of communicating their understanding of this diagnosis to their patients.Methods: A qualitative research design, using hermeneutic phenomenological methodology, was employed. Five participants were purposively recruited for the research and data collected via semi-structured interviews. Interpretative phenomenological analysis (IPA) methods were used to analyze the data. Emergent, super-ordinate and master themes were developed to help convey the qualitative significant meanings of the lived-through experiences.Findings: Three master themes were identified, with each comprising two sub-themes. These were: 1) Patient-centeredness (1a. Understanding the patient; and 1b. emotional awareness and adaptability); 2) Getting patients "on board" (2a. the "selling" process; and 2b. paternalism and the clinician's perspective); and 3) Dealing with conflict and uncertainty (3a. fear of interpersonal conflict; and 3b. personal doubts and uncertainty).Conclusions: Personal conflicts were identified between clinicians' descriptions of their wishes to "sell" their own perspectives to patients while simultaneously wanting to demonstrate a patient-focused approach and avoid the interpersonal conflicts which arose from clashes with patients' beliefs. Building a good initial rapport, showing empathy and adapting approaches in response to perceptions of patients' reactions were perceived as strategies to help mitigate the risks of failed communication, but this was something for which participants felt unprepared by their prior training.

Scoping review of the person-centered literature in adult physical rehabilitation

PURPOSE

To describe the amount, range, and key characteristics (e.g., publication years, methods, topics) of the person-centered rehabilitation literature in adults with physical impairments.

METHOD

Following the published scoping review protocol, papers were identified through: three major databases, snowball searches and expert consultation. Two independent reviewers have identified English-language papers on adult person-centered rehabilitation according to six pre-defined inclusion categories - theoretical, quantitative and qualitive research papers are included; and then have extracted their key characteristics (e.g., aims, methods, participants). Descriptive statistics, regression and content analyses were used to synthesize the results.

RESULTS

Of 5912 deduplicated records initially screened, 170 papers were included: 136 empirical, including 13 systematic reviews. Empirical papers had data from 15264 clients and 4098 providers, in total. Yearly publications grew significantly from 2009 to 2018 (r² = 0.71; b = 1.98: p < 0.01). Publications were unevenly distributed by countries (e.g., United States' publications per population was 44 times lower than New Zealand's). Most papers focused in more than one profession, setting-type or health conditions. Finally, many empirical papers (n = 67) studied implementation of person-centered rehabilitation approaches, including its effect.

CONCLUSION

This scoping review synthesizes key characteristics and publication trends in the person-centered rehabilitation literature on adults with physical impairments, a growing but unchartered territory thus far. This large and diverse body of literature can ground further person-centered rehabilitation practices and research, including toward building a transdisciplinary, trans-service model of person-centered rehabilitation.Implications for rehabilitationThe person-centered rehabilitation literature on adults with physical impairments, especially the empirical one, has been growing significantly over time, despite inequitably distributed per countries.Rehabilitation stakeholders, including practitioners, have a growing amount of literature in which they can rely for the operationalization and implementation of person-centered rehabilitation approaches into routine practice.Based on our work, person-centered rehabilitation emerges as a practice requirement that cuts across professional and other rehabilitation silos.

Ideal and reality; Community healthcare professionals' experiences of user-involvement in reablement

Many welfare states offer reablement, also known as restorative care, as an intervention to promote healthy ageing and support older adults in regaining or maintaining their independence in daily life. Reablement is a time-limited, intensive, multidisciplinary, person-centred and goal-directed rehabilitative intervention. Reablement emanates from the user's goals, thus user-involvement is a key factor. The aim of our study was to explore healthcare professionals' experiences of user-involvement in reablement. The context for the study was an urban municipality in south-eastern Norway where reablement had been implemented into home-care services 1.5 years prior to the study. Eighteen healthcare professionals recruited from home-care services participated in focus groups. The material was analysed using qualitative content analysis. The findings resulted in one main theme: Transforming user-involvement from ideal to reality-a demanding process, and four sub-themes: (a) An ideal of self-determination and co-operation; (b) Diverse ability to commit to what user-involvement requires; (c) Continuous co-creation processes; and (d) Challenged by old traditions. User-involvement is a valued ideal that professionals strive towards when providing healthcare. Two main strategies that professionals use to enable user-involvement were identified here: spending sufficient time and having patience with users during the initial stage of an intervention, and starting an intervention by introducing small tasks that users can master. It was also seen that if the time and arenas for interdisciplinary meetings were lacking, professionals could demonstrate traditional attitudes and practice when faced with limited user-involvement in the intervention. There is a need for follow-up over time at the structural, personal, and cultural levels to develop reablement as an intervention with a strong person-centred approach. The findings of this study have relevance for practice development in several reablement settings.

A novel clinical framework: The use of dispositions in clinical practice. A person centred approach

This paper explores a novel clinical framework that is underpinned by a specific philosophical perspective of causation and its utility in clinical practice. A dispositional theory of causation may overcome challenges that clinicians face in complex clinical presentations including those that are medically unexplained. Dispositionalism identifies causes not as regular events necessitating an effect but rather phenomena, which are highly complex, context-sensitive, and which tend toward an effect. Diagnostic uncertainty and causal explanation are significant challenges in terms of clinical reasoning, communication, and the overall therapeutic outcome. This novel framework aims to facilitate improved collaborative clinical reasoning, enhanced patient-practitioner interaction, and supported treatment planning. The paper uses a real case study of a patient with nonspecific spinal pain to demonstrate the clinical framework as used in clinical practice.

Human resources for health (and rehabilitation): Six Rehab-Workforce Challenges for the century

BACKGROUND

People with disabilities face challenges accessing basic rehabilitation health care. In 2006, the United Nations Convention on the Rights of Persons with Disabilities (CRPD) outlined the global necessity to meet the rehabilitation needs of people with disabilities, but this goal is often challenged by the undersupply and inequitable distribution of rehabilitation workers. While the aggregate study and monitoring of the physical rehabilitation workforce has been mostly ignored by researchers or policy-makers, this paper aims to present the 'challenges and opportunities' for guiding further long-term research and policies on developing the relatively neglected, highly heterogeneous physical rehabilitation workforce.

METHODS

The challenges were identified through a two-phased investigation. Phase 1: critical review of the rehabilitation workforce literature, organized by the availability, accessibility, acceptability and quality (AAAQ) framework. Phase 2: integrate reviewed data into a SWOT framework to identify the strengths and opportunities to be maximized and the weaknesses and threats to be overcome.

RESULTS

The critical review and SWOT analysis have identified the following global situation: (i) needs-based shortages and lack of access to rehabilitation workers, particularly in lower income countries and in rural/remote areas; (ii) deficiencies in the data sources and monitoring structures; and (iii) few exemplary innovations, of both national and international scope, that may help reduce supply-side shortages in underserved areas.

DISCUSSION

Based on the results, we have prioritized the following 'Six Rehab-Workforce Challenges': (1) monitoring supply requirements: accounting for rehabilitation needs and demand; (2) supply data sources: the need for structural improvements; (3) ensuring the study of a whole rehabilitation workforce (i.e. not focused on single professions), including across service levels; (4) staffing underserved locations: the rising of education, attractiveness and tele-service; (5) adapt policy options to different contexts (e.g. rural vs urban), even within a country; and (6) develop international solutions, within an interdependent world.

CONCLUSIONS

Concrete examples of feasible local, global and research action toward meeting the Six Rehab-Workforce Challenges are provided. Altogether, these may help advance a policy and research agenda for ensuring that an adequate rehabilitation workforce can meet the current and future rehabilitation health needs.

Behavioral self-management strategies for practice and exercise should be included in neurologic rehabilitation trials and care

PURPOSE OF REVIEW

Rehabilitation trials and postacute care to lessen impairments and disability after stroke, spinal cord injury, and traumatic brain injury almost never include training to promote long-term self-management of skills practice, strengthening and fitness. Without behavioral training to develop self-efficacy, clinical trials, and home-based therapy may fail to show robust results.

RECENT FINDINGS

Behavioral theories about self-management and self-efficacy for physical activity have been successfully incorporated into interventions for chronic diseases, but rarely for neurologic rehabilitation. The elements of behavioral training include education about the effects of practice and exercise that are relevant to the person, goal setting, identification of possible barriers, problem solving, feedback about performance, tailored instruction, decision making, and ongoing personal or social support. Mobile health and telerehabilitation technologies offer new ways to remotely enable such training by monitoring activity from wearable wireless sensors and instrumented exercise devices to allow real-world feedback, goal setting, and instruction.

SUMMARY

Motivation, sense of responsibility, and confidence to practice and exercise in the home can be trained to increase adherence to skills practice and exercise both during and after formal rehabilitation. To optimize motor learning and improve long-term outcomes, self-management training should be an explicit component of rehabilitation care and clinical trials.

Person-centred rehabilitation: what exactly does it mean? Protocol for a scoping review with thematic analysis towards framing the concept and practice of person-centred rehabilitation

INTRODUCTION

Person-centredness is a philosophy for organising and delivering healthcare based on patients' needs, preferences and experiences. Although widely endorsed, the concept suffers from a lack of detail and clarification, in turn accounting for ambiguous implementation and outcomes. While a conceptual framework based on a systematic review defines person/patient-centred care components (Scholl et al, 2014), it applies across healthcare contexts and may not be sensitive to the nuances of the rehabilitation of adults with physical impairments. Accordingly, this study aims to build a conceptual framework, based on existing literature, of what person-centredness means in the rehabilitation of adults with physical impairments in the clinical encounter and broader health service delivery.

METHODS AND ANALYSIS

We will use a scoping review methodology. Searches on relevant databases will be conducted first, combining keywords for 'rehabilitation', 'person-centered' and associated terms (including patient preferences/experiences). Next, snowball searches (citation tracking, references lists) will be performed. Papers will be included if they fall within predefined selection categories (seen as most likely informative on elements pertaining to person-centred rehabilitation) and are written in English, regardless of design (conceptual, qualitative, quantitative). Two reviewers will independently screen titles and abstracts, followed by screening of the full text to determine inclusion. Experts will then be consulted to identify relevant missing papers. This can include elements other than the peer-reviewed literature (eg, book chapters, policy/legal papers). Finally, information that helps to build the concept and practice of person-centred rehabilitation will be abstracted independently by two reviewers and analysed by inductive thematic analysis to build the conceptual framework.

DISSEMINATION

The resulting framework will aid clarification regarding person-centred rehabilitation, which in turn is expected to conceptually ground and inform its operationalisation (eg, measurement, implementation, improvement). Findings will be disseminated through local, national and international stakeholders, both at the clinical and service organisation levels.

Methodological issues in the design and evaluation of supported communication for aphasia training: a cluster-controlled feasibility study

OBJECTIVE

To assess the feasibility and acceptability of training stroke service staff to provide supported communication for people with moderate-severe aphasia in the acute phase; assess the suitability of outcome measures; collect data to inform sample size and Health Economic evaluation in a definitive trial.

DESIGN

Phase II cluster-controlled, observer-blinded feasibility study.

SETTINGS

In-patient stroke rehabilitation units in the UK matched for bed numbers and staffing were assigned to control and intervention conditions.

PARTICIPANTS

70 stroke rehabilitation staff from all professional groups, excluding doctors, were recruited. 20 patients with moderate-severe aphasia were recruited.

INTERVENTION

Supported communication for aphasia training, adapted to the stroke unit context versus usual care. Training was supplemented by a staff learning log, refresher sessions and provision of communication resources.

MAIN OUTCOME MEASURES

Feasibility of recruitment and acceptability of the intervention and of measures required to assess outcomes and Health Economic evaluation in a definitive trial. Staff outcomes: Measure of Support in Conversation; patient outcomes: Stroke and Aphasia Quality of Life Scale; Communicative Access Measure for Stroke; Therapy Outcome Measures for aphasia; EQ-5D-3L was used to assess health outcomes.

RESULTS

Feasibility of staff recruitment was demonstrated. Training in the intervention was carried out with 28 staff and was found to be acceptable in qualitative reports. 20 patients consented to take part, 6 withdrew. 18 underwent all measures at baseline; 16 at discharge; and 14 at 6-month follow-up. Of 175 patients screened 71% were deemed to be ineligible, either lacking capacity or too unwell to participate. Poor completion rates impacted on assessment of patient outcomes. We were able to collect sufficient data at baseline, discharge and follow-up for economic evaluation.

CONCLUSIONS

The feasibility study informed components of the intervention and implementation in day-to-day practice. Modifications to the design are needed before a definitive cluster-randomised trial can be undertaken.

TRIAL REGISTRATION NUMBER

ISRCTN37002304; Results.

Coaching or gaming? Implications of strategy choice for home based stroke rehabilitation

Background

The enduring aging of the world population and prospective increase of age-related chronic diseases urge the implementation of new models for healthcare delivery. One strategy relies on ICT (Information and Communications Technology) home-based solutions allowing clients to pursue their treatments without institutionalization. Stroke survivors are a particular population that could strongly benefit from such solutions, but is not yet clear what the best approach is for bringing forth an adequate and sustainable usage of home-based rehabilitation systems. Here we explore two possible approaches: coaching and gaming.

Methods

We performed trials with 20 healthy participants and 5 chronic stroke survivors to study and compare execution of an elbow flexion and extension task when performed within a coaching mode that provides encouragement or within a gaming mode. For each mode we analyzed compliance, arm movement kinematics and task scores. In addition, we assessed the usability and acceptance of the proposed modes through a customized self-report questionnaire.

Results

In the healthy participants sample, 13/20 preferred the gaming mode and rated it as being significantly more fun (p < .05), but the feedback delivered by the coaching mode was subjectively perceived as being more useful (p < .01). In addition, the activity level (number of repetitions and total movement of the end effector) was significantly higher (p < .001) during coaching. However, the quality of movements was superior in gaming with a trend towards shorter movement duration (p = .074), significantly shorter travel distance (p < .001), higher movement efficiency (p < .001) and higher performance scores (p < .001). Stroke survivors also showed a trend towards higher activity levels in coaching, but with more movement quality during gaming. Finally, both training modes showed overall high acceptance.

Conclusions

Gaming led to higher enjoyment and increased quality in movement execution in healthy participants. However, we observed that game mechanics strongly determined user behavior and limited activity levels. In contrast, coaching generated higher activity levels. Hence, the purpose of treatment and profile of end-users has to be considered when deciding on the most adequate approach for home based stroke rehabilitation.

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.