The process of stroke rehabilitation: what happens and why

The adaptation and validation of the satisfaction with stroke care questionnaire (Homesat) (SASC10-My™) for use in public primary healthcare facilities caring for long- term stroke survivors residing at home in the community

Background

Satisfaction with post stroke services would assist stakeholders in addressing gaps in service delivery. Tools used to evaluate satisfaction with stroke care services need to be validated to match healthcare services provided in each country. Studies on satisfaction with post discharge stroke care delivery in low- and middle-income countries (LMIC) are scarce, despite knowledge that post stroke care delivery is fragmented and poorly coordinated. This study aims to modify and validate the HomeSat subscale of the Dutch Satisfaction with Stroke Care-19 (SASC-19) questionnaire for use in Malaysia and in countries with similar public healthcare services in the region.

Methods

The HomeSat subscale of the Dutch SASC-19 questionnaire (11 items) underwent back-to-back translation to produce a Malay language version. Content validation was done by Family Medicine Specialists involved in community post-stroke care. Community social support services in the original questionnaire were substituted with equivalent local services to ensure contextual relevance. Internal consistency reliability was determined using Cronbach alpha. Exploratory factor analysis was done to validate the factor structure of the Malay version of the questionnaire (SASC10-My™). The SASC10-My™ was then tested on 175 post-stroke patients who were recruited at ten public primary care healthcentres across Peninsular Malaysia, in a trial-within a trial study.

Results

One item from the original Dutch SASC19 (HomeSat) was dropped. Internal consistency for remaining 10 items was high (Cronbach alpha 0.830). Exploratory factor analysis showed the SASC10-My™ had 2 factors: discharge transition and social support services after discharge. The mean total score for SASC10-My™ was 10.74 (SD 7.33). Overall, only 18.2% were satisfied with outpatient stroke care services (SASC10-My™ score ≥ 20). Detailed analysis revealed only 10.9% of respondents were satisfied with discharge transition services, while only 40.9% were satisfied with support services after discharge.

Conclusions

The SASC10-My™ questionnaire is a reliable and valid tool to measure caregiver or patient satisfaction with outpatient stroke care services in the Malaysian healthcare setting. Studies linking discharge protocol patterns and satisfaction with outpatient stroke care services should be conducted to improve care delivery and longer-term outcomes.

Trial registration

No.: ACTRN12616001322426 (Registration Date: 21st September 2016.

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patient satisfaction in home health care

AIMS AND OBJECTIVES

  To assess the current use of patient satisfaction measures in home health care and to examine the reliability and validity of current measures of patient satisfaction in home health care.

BACKGROUND

  Patient satisfaction has been one of the widely used measures in home health care as an indicator of quality of care. A few efforts have been made to develop psychometrically sound patient satisfaction scales for use in home health care.

DESIGN

  A critical review of the literature.

METHODS

  Electronic databases were systematically searched to identify the studies or publications that measured and addressed patient satisfaction and its measurement in home health care.

RESULTS

  The review of the literature showed that patient satisfaction measures have been used in the evaluation of care programmes including rehabilitation programmes, discharge and home follow-up programmes, care process and management practices. Also, patient satisfaction measures were used to evaluate new care protocols and treatments.

CONCLUSIONS

  Home healthcare agencies need valid and reliable patient satisfaction scales. Frameworks of patient satisfaction are still in their early developmental stage. Only some of the variables related to patient satisfaction are explained by many frameworks.

RELEVANCE TO CLINICAL PRACTICE

  Home healthcare mangers and researchers need to take in consideration the reliability and validity of measures and tools of patient satisfaction.

[Role of nursing in physical rehabilitation]

This study reviews the literature concerning improvement of rehabilitation nurse role, suggesting paths to reach this goal and evoking a still poorly discussed area. Some questions were raised to provoke reflection and discussion. It is evident, based on the literature, that nurses have a total role in rehabilitation, however the boundaries are not clearly defined. Professional nurses must must join rehabilitation practice with permanent education, that will contribute for a more efficient and influence in processes and rehabilitation services.

Characteristics of physiotherapy sessions from the patient's and therapist's perspective

PURPOSE

The purpose was to explore, describe and compare the characteristics of physiotherapy sessions with patients after stroke from two perspectives: the patients' and the physiotherapists', in relation to observed behaviour.

METHODS

A qualitative, descriptive, comparative approach was used. Nine patients and 10 physiotherapists participated. Data from observations and semi-structured interviews were used.

RESULTS

Six themes were identified: setting and attaining goals, focusing on motor activity, finding the optimal training strategy, facilitating active patient involvement, making use of environmental factors and adjusting to the structural reorganization of the rehabilitation services. The physiotherapists and the patients made similar descriptions in some of the themes but differed in some. The physiotherapists expressed what they perceived to be their lack of scientific knowledge, while the patients trusted their physiotherapists' competence. The physiotherapists wanted to take the patients' personal experiences into account in the sessions, which was not obvious to the patients.

CONCLUSION

Differences in physiotherapists' and patients' descriptions of characteristics of physiotherapy sessions have to be taken into consideration in the rehabilitation of stroke patients. In order to empower the patient to take a more active part in the rehabilitation process, there is a need to explore how to incorporate the patients' personal experiences and knowledge into the rehabilitation process.

Engaging service users in the development of stroke services: an action research study

AIMS AND OBJECTIVES

To develop local stroke services by involving, in a meaningful way, those affected by stroke in identifying and prioritising service development issues.

BACKGROUND

Consideration should be given to including the views of service users in the evaluation and re-design of services. In stroke, the involvement of patients and carers in the development of services has generally been at a consultative level. There is a need to explore strategies to engage patients and carers more fully with the service development agenda.

DESIGN

Action research.

METHODS

Within the Reflection Phase of this action research study patients' and carers' experiences of stroke services were explored by semi-structured interviews and focus groups. In the Planning and Action Phases, externally facilitated workgroups comprising patients, carers and professionals used a synthesis of the data to identify a range of service development priorities, which informed the development of action plans.

RESULTS

Information provision, preparation for transfer of care and the integration of social and leisure activities appear to be priorities for the development of stroke services from the perspective of patients and carers. These findings informed the work of four collaborative workgroups to lead developments in the stroke pathway as follows: stroke prevention and immediate care, early and continuing rehabilitation, transfer of care and long-term support and information provision.

CONCLUSION

Stroke patients and carers played a key and meaningful part in the identification and prioritisation of service development issues. External facilitation ensured progress with service development and maintaining patient and carer participation. Several pragmatic recommendations for enhancing the local delivery of stroke services were made.

RELEVANCE TO CLINICAL PRACTICE

With external facilitation it is possible for stroke service users to take a meaningful role in service developments that moves beyond consultation.

Patient satisfaction with circuit class therapy and individual physiotherapy

The purpose of this observational study was to determine patients' levels of satisfaction with circuit class therapy and individual physiotherapy sessions on a stroke rehabilitation unit.

Forty-nine persons participated in both circuit class therapy and individual physiotherapy sessions as part of standard inpatient rehabilitation following stroke. A purpose-designed questionnaire was administered to investigate patient satisfaction.

High degrees of satisfaction were reported with both methods of physiotherapy service delivery. Individual sessions were perceived as being more tailored to participants' goals, whereas participants reported that circuit classes offered a more supportive environment than the individual therapy sessions. Participants were satisfied with the amount of supervision and assistance provided in both forms of physiotherapy service delivery. No distinct advantage was seen for one form of therapy over the other in terms of patient satisfaction.

Comparison of patients' assessments of the quality of stroke care with audit findings

OBJECTIVE

To determine the extent of correlation between stroke patients' experiences of hospital care with the quality of services assessed in a national audit.

METHODS

Patients' assessments of their care derived from survey data were linked to data obtained in the National Sentinel Stroke Audit 2004 for 670 patients in 51 English NHS trusts. A measure of patients' experience of hospital stroke care was derived by summing responses to 31 survey items and grouping these into three broad concept domains: quality of care; information; and relationships with staff. Audit data were extracted from hospital admissions data and management information to assess the organisation of services, and obtained retrospectively from patient records to evaluate the delivery of care. Patient survey responses were compared with audit measures of organisation of care and compliance with clinical process standards.

RESULTS

Patient experience scores were positively correlated with clinicians' assessment of the organisational quality of stroke care, but were largely unrelated to clinical process standards. Responses to individual questions regarding communication about diagnosis revealed a discrepancy between clinicians' and patients' reports.

CONCLUSIONS

Better organised stroke care is associated with more positive patient experiences. Examining areas of disparity between patients' and clinicians' reports is important for understanding the complex nature of healthcare and for identifying areas for quality improvement. Future evaluations of the quality of stroke services should include a validated patient experience survey in addition to audit of clinical records.

Older adults experiences of rehabilitation in acute health care

Rehabilitation is a key component of nursing and allied healthcare professionals' roles in most health and social care settings. This paper reports on stage 2 of an action research project to ascertain older adult's experience of rehabilitation. Twenty postdischarge interviews were conducted and the interview transcripts were analysed using thematic content analysis. All older adults discharged from an acute older acute rehabilitation ward to their own homes in the community were eligible to participate. The only exclusion criterion was older adults who were thought to be unable to give consent to participate by the nurse in charge and the researcher. Whilst 92 older adults were eligible to participate in this research study, only 20 were interviewed. The findings from this study suggest that older adults valued communication with health professionals but were aware of their time constraints that hindered communication. This study suggests that both nurses and allied health professionals are not actively providing rehabilitative services to promote health and well-being, which contradicts the focus of active ageing. Furthermore, there was evidence of unmet needs on discharge, and older adults unable to recall the professions that were involved in their interventions and the rationale for therapy input. It is suggested that further research is needed to explore the effectiveness of allied health rehabilitation in the acute setting. This study highlights the need for further research into older adults' perceptions of the rehabilitation process in the acute setting.

Circuit Class Therapy Versus Individual Physiotherapy Sessions During Inpatient Stroke Rehabilitation: A Controlled Trial

OBJECTIVE

To compare the effectiveness of circuit class therapy and individual physiotherapy (PT) sessions in improving walking ability and functional balance for people recovering from stroke.

DESIGN

Nonrandomized, single-blind controlled trial.

SETTING

Medical rehabilitation ward of a rehabilitation hospital.

PARTICIPANTS

Sixty-eight persons receiving inpatient rehabilitation after a stroke.

INTERVENTIONS

Subjects received group circuit class therapy or individual treatment sessions as the sole method of PT service delivery for the duration of their inpatient stay.

MAIN OUTCOME MEASURES

Five-meter walk test (5MWT), two-minute walk test (2MWT), and the Berg Balance Scale (BBS) measured 4 weeks after admission. Secondary outcome measures included the Iowa Level of Assistance Scale, Motor Assessment Scale upper-limb items, and patient satisfaction. Measures were taken on admission and 4 weeks later.

RESULTS

Subjects in both groups showed significant improvements between admission and week 4 in all primary outcome measures. There were no significant between group differences in the primary outcome measures at week 4 (5MWT mean difference, .07m/s; 2MWT mean difference, 1.8m; BBS mean difference, 3.9 points). A significantly higher proportion of subjects in the circuit class therapy group were able to walk independently at discharge (P=.01) and were satisfied with the amount of therapy received (P=.007).

CONCLUSIONS

Circuit class therapy appeared as effective as individual PT sessions for this sample of subjects receiving inpatient rehabilitation poststroke. Favorable results for circuit classes in terms of increased walking independence and patient satisfaction suggest this model of service delivery warrants further investigation.

Patient, carer and staff experience of a hospital-based stroke service

OBJECTIVE

Here, the aim is to study the experiences of patients, carers and staff throughout a hospital stroke care pathway.

DESIGN

Focus groups of patients, carers and staff followed a semi-structured format to elucidate experiences. The groups were recorded, transcribed and subjected to thematic analysis. Analyses were verified by researchers and participants.

RESULTS

Patients and carers produced four overlapping themes: 'information', 'staff attitudes', 'availability of care/treatment' and 'considering the whole person in context'. The carers' group produced two additional themes: 'accommodation of patients' individual needs' and 'burden of care'. Their experiences were complex and multi-faceted; positive views of the whole service co-existed with negative views of some aspects. The staff groups produced six themes: 'specialist service', 'split service', 'availability of care', 'consistency of care', 'staff morale' and 'wish for change'. Positive views of the specialist service were tempered by problems with physical and professional separation, staff shortages and 'hierarchical practice' that reduced collective decision-making.

CONCLUSION

Some of the patients' and carers' perspectives have not been previously reported in the stroke literature, including a desire for individualized treatment, the consideration of wider, non-physical needs and the carers' sense of burden. In addition, the study revealed how staff, carers and patients viewed each other and the service and demonstrated the concordance of their perceptions. However, staff showed little insight into the users' need for information and negative experiences of care. In contrast with previous research, lack of emotional care, poor continuity of care and lack of staff knowledge and skills were not identified as problems.

Pharmacologic management of ischemic stroke: relevance to stem cell therapy

Pharmacologic management of the acute phase of the ischemic stroke includes treating the physical and medical conditions that can worsen cerebral injury; administering intravenous thrombolytic therapy (recombinant tissue plasminogen activator) in those who meet current guidelines; instituting prophylactic measures to prevent medical complications; and initiating passive rehabilitation measures. New approaches under investigation include intra-arterial thrombolytic therapy; endovascular embolectomy and clot disruption; and neuroprotective treatments to preserve surviving ischemic tissue. One neuroprotective agent given within 6 h after stroke onset, NXY059, recently met the primary outcome measure in a phase III clinical trial. Pharmacologic management of the subacute and chronic phases involves treatment of risk factors for recurrent stroke and other forms of cardiovascular disease, including hypercholesterolemia, hypertension, and diabetes mellitus. In this phase, antiplatelet therapy can be initiated or continued; smoking, obesity and alcohol intake can be managed; and active rehabilitation can begin through physical, occupational, and speech therapy. A few medications to augment rehabilitation have shown promising results in small clinical trials, but none have been tested in large phase III trials or approved by the US or European regulatory agencies. Thus, there are no pharmacologic measures available to enhance central nervous system restorative processes after acute stroke, and implantation of stem cells provides one promising approach, not only for cell replacement but also for the provision of therapeutic molecules.

Discharge from physiotherapy following stroke: the management of disappointment

Stroke tends to result in a range of disabilities which have been shown to benefit from rehabilitation, in particular physiotherapy. Patients tend to have high expectations of the extent of recovery they can achieve through physiotherapy, and subsequently view discharge from physiotherapy before they have achieved that degree of recovery as disappointing and distressing. Current literature suggest that explicit discussion between physiotherapists and patients of the anticipated extent of recovery tends to be avoided during the programme of physiotherapy treatment, making discharge from physiotherapy the point at which potentially differing expectations might be expected to be confronted. This paper explores how the process of discharge is managed and experienced by patients and physiotherapists. It draws on Craib's (1994) ideas about how disappointment is managed in modern society. A qualitative longitudinal study was conducted with 16 stroke patients and their physiotherapists. These data comprise interview and observational material. The study found that the discharge of stroke patients from physiotherapy is not a point when patients' expectations and optimism about recovery are confronted. The notion of natural recovery that was raised with patients by physiotherapists at discharge and the information physiotherapists gave about exercise post-discharge had the effect of maintaining patients' high expectations and hopes about recovery. This has implications for the process of adaptation and adjustment that the patient eventually goes through in order to accommodate their altered abilities and identity. We argue that a number of factors contribute to the denial of disappointment within this interaction and that services need to be developed in ways that enable physiotherapists to engage with the possibility of disappointment about stroke outcome with patients, thereby making a positive contribution to the process of adaptation and adjustment that stroke survivors experience following discharge.

Adherence to postacute rehabilitation guidelines is associated with functional recovery in stroke

BACKGROUND AND PURPOSE

The purpose of this study was to determine if compliance with poststroke rehabilitation guidelines was associated with better functional outcomes.

METHODS

An inception cohort of 288 stroke patients in 11 Department of Veteran Affairs Medical Centers hospitalized between January 1998 and March 1999 were followed prospectively for 6 months. Data were abstracted from medical records and telephone interviews. The primary study outcome was the Functional Independence Motor Score (FIM). Secondary outcomes included Instrumental Activities of Daily Living (IADL), SF-36 physical functioning, and the Stroke Impact Scale (SIS). Acute and postacute rehabilitation guideline compliance scores (range 0 to 100) were derived from an algorithm. All outcomes were adjusted for case-mix.

RESULTS

Average compliance scores in acute and postacute care settings were 68.2% (SD 14) and 69.5% (SD 14.4), respectively. After case-mix adjustment, level of compliance with postacute rehabilitation guidelines was significantly associated with FIM motor, IADL, and the SIS physical domain scores. SF-36 physical function was not associated with guideline compliance. Level of compliance with rehabilitation guidelines in acute settings was unrelated to any of the outcome measures.

CONCLUSION

Greater levels of adherence to postacute stroke rehabilitation guidelines were associated with improved patient outcomes. Compliance with guidelines may be viewed as a quality-of-care indicator with which to evaluate new organizational and funding changes involving postacute stroke rehabilitation.

What is Intermediate Care? Looking at Needs

Managing operational change using a whole‐systems approach will be the key to re‐engineering services, including intermediate care and rehabilitation for older people. This article outlines an approach used in Sheffield which is based on eight categories of need.