The effects and experiences of goal setting in stroke rehabilitation – a systematic review

Co-design of a walking activity intervention for stroke survivors

Introduction

Stroke survivors may not maintain gains made in gait performance after task-oriented circuit training. Behavior change interventions may enhance the long-term adoption of physical activity. This study uses a co-design methodology to develop an intervention and tools to facilitate physical and exercise therapists in supporting an active lifestyle in stroke survivors, which is defined as a lifestyle that integrates daily walking performance with day-to-day activity.

Objectives

(1) To describe the insights generated during the co-design process; and (2) To describe the tools that were developed during the co-design process.

Methods

A multidisciplinary team consisting of staff members of the Royal Dutch Society for Physical Therapy, exercise and physical therapists specializing in neurorehabilitation and conducting task-oriented circuit class training in primary care settings or day therapy centers within residential care facilities, stroke survivors and their carers, experts in measuring movement behavior in stroke survivors, a company specializing in manufacturing sensors and related software, behavior change specialists, and co-designers all collaborated in a three-stage (define, develop, and deliver) co-design process.

Results

In the design process, the team iteratively developed a prototype accelerometer system for measuring walking performance with a feedback function for stroke survivors and their therapists and a prototype toolbox for therapists to support the facilitation of behavior change in their stroke survivors.

Discussion

This study shows how co-design can be applied to develop interventions for stroke survivors. Both the prototype system for measuring walking performance and the toolbox incorporate behavior change techniques to support a more physically active lifestyle in stroke survivors. Further research will investigate the feasibility of the intervention.

'We don't have to do it together': a qualitative study of physiotherapists' and patients' perceptions about collaborative goal setting in Nigeria

BACKGROUND

The adoption of Collaborative Goal Setting (CGS) is limited in most rehabilitation settings in Nigeria despite its recommendations in clinical practice guidelines.

OBJECTIVE

To explore the perceptions of physiotherapists and patients about CGS at a tertiary healthcare facility in Ibadan, Nigeria.

METHODS

We conducted focus group discussions among purposively selected physiotherapists (n = 8) and patients (4 stroke survivors, 3 patients with brain injury) to qualitatively explore their perceptions. Audio-taped discussions were transcribed verbatim and thematically analyzed.

RESULTS

We identified four themes around CGS which were: 1) paternalistic view of goal setting; 2) physiotherapists as goal setters; 3) perceived benefits of collaborative goal setting; and 4) barriers and facilitators to CGS. The physiotherapists articulated goals as expected outcomes from treatment and believed they were better poised and experienced to determine what patients could achieve during each phase of treatment. Patients' view of goal setting agreed with the physio-therapists', as they also opined that goal setting is the responsibility of physiotherapists. Time constraint, inadequate knowledge and the inability of patients to appropriately articulate their goals and expectations from treatment were barriers to CGS. Concerns about who to collaborate with when dealing with patients with impaired cognition and/or disorders of consciousness were raised by the physiotherapists. Participants in both groups indicated that education on how to set patient-oriented goals could facilitate CGS.

CONCLUSIONS

Though rarely practiced, participants agreed that collaborative goal setting could be beneficial. Both the physiotherapists and patients require education on how to appropriately collaborate in setting goals of rehabilitation.

Implementing strategy training in Taiwan: perspectives of individuals with Acquired brain injury

PURPOSE

Strategy training is a rehabilitation intervention that aims to enhance problem-solving skills with respect to daily activity-related challenges and has achieved favorable results in Western countries. This study explored the perspectives of individuals with acquired brain injury (ABI) in Taiwan who received strategy training.

MATERIALS AND METHODS

Semi-structured interviews with community-dwelling adults with ABI were conducted, and reflective memos made by research team members were recorded. Interviews and memos were analyzed through thematic analysis.

RESULTS

This study included 55 participants. The analysis of the participants' interview responses and memos yielded nine themes under three categories: 1) expectations regarding strategy training, 2) perceived benefits of strategy training, and 3) barriers affecting the process and outcomes of strategy training.

CONCLUSIONS

All the participants endorsed strategy training through different gains. Most participants' expectations before the intervention were uncertain. Including family members into the strategy training is of key importance for a successfulness of their goals. The participants' experiences about strategy training were affected by various barriers (i.e., health and medical problems, the physical environment, and natural events). Clinicians and researchers should consider these expectations, benefits, and barriers when studying and implementing strategy training in non-Western contexts.IMPLICATIONS FOR REHABILITATIONStrategy training provides clients the opportunity to actively engage in their own goal setting and decision making.Strategy training increases the client's confidence in their ability to participate in the community, communicate, and perform daily living and physical activities.Therapists should consider the health conditions and physical environment of clients when helping them set goals and before facilitating their engagement in the community.Taiwanese family members play a crucial role in supporting acquired brain injury survivors in strategy training.

A joint venture: patients' experiences with goal setting in rheumatology rehabilitation - a qualitative study

PURPOSE

To explore how patients with rheumatic musculoskeletal diseases (RMDs) perceive participation in the goal setting process prior to interdisciplinary rehabilitation.

METHODS

We conducted semi-structured interviews with 22 participants admitted to an interdisciplinary rehabilitation stay for patients with RMDs at two Danish rehabilitation centres. Qualitative content analysis was applied.

RESULTS

The participants perceived goal setting as a joint venture between two parties: the health professionals and the participant. Three categories were formed, which described both facilitators and barriers in the process. Responsibility for goal setting described the importance of shared responsibility, or health professionals as experts, taking full responsibility for goal setting. Equipped for goal setting included perceptions of being well prepared for the process, or considerations that goal setting was difficult because of a lack of information. An equal member of the team entailed both the feeling of being recognised as one in the team, or feeling like an outsider.

CONCLUSION

Goal setting is perceived as a challenge by some patients. Participation in goal setting depends on both the capacity and the opportunity to participate which are factors linked to patients' level of health literacy.

Characteristics of goal-setting tools in adult rehabilitation: A scoping review

OBJECTIVES

This scoping review aims to map the literature on goal-setting tools in adult rehabilitation, exploring their characteristics, target users and supporting evidence to inform practice and future research in this area.

METHODS

We completed a comprehensive search of four databases to identify relevant articles on tools for goal setting in rehabilitation. We followed Arkey and O'Malley's scoping review process to guide article selection, data extraction and data analysis.

RESULTS

We identified a total of 165 studies that reported on 55 different goal-setting tools, including tools for goal selection and goal documentation (n = 31), goal setting and intervention planning (n = 15), and for measuring the quality of the goal-setting process (n = 9). Over half of the tools were primarily designed for use in rehabilitation of physical disabilities (n = 32). Some tools fell under multiple sub-categories based on their characteristics as follows: 22 framework tools, 12 interview tools, 9 outcome measurement tools for goal achievement, 6 outcome measurement tools for goal quality and 25 documentation tools. The majority of goal-setting instruments targeted goals at the level of activity and participation (n = 51) and aimed to facilitate a client-centred or shared decision-making approach to rehabilitation planning (n = 46).

CONCLUSIONS

This study provides a comprehensive overview of existing goal-setting tools, highlighting their characteristics, target users and identified needs. These findings can enhance practitioners' awareness of the range of goal-setting tools available and can enable more effective utilization of these tools in clinical practice. Further research should investigate how clinicians can combine multiple tools to deliver goal setting.

An umbrella review of the literature on the effectiveness of goal setting interventions in improving health outcomes in chronic conditions

PURPOSE

To identify the contexts in which goal setting has been used in chronic disease management interventions and to estimate the magnitude of its effect on improvement of health outcomes.

METHODS

The strength of evidence and extent of potential bias in the published systematic reviews of goal setting interventions in chronic conditions were summarized using AMSTAR2 quality appraisal tool, number of participants, 95% prediction intervals, and between-study heterogeneity. Components of goal setting interventions were also extracted.

RESULTS

Nine publications and 35 meta-analysis models were identified, investigating 25 health outcomes. Of the 35 meta-analyses, none found strong evidence and three provided some suggestive evidence on symptom reduction and perceived well-being. There was weak evidence for effects on eight health outcomes (HbA1c, self-efficacy, depression, anxiety, distress, medication adherence, health-related quality of life and physical activity), with the rest classified as non-significant. Half of the meta-analyses had high level of heterogeneity.

CONCLUSION

Goal setting by itself affects outcomes of chronic diseases only to a small degree. This is not unexpected finding as changing outcomes in chronic diseases requires a complex and individualized approach. Implementing goal setting in a standardized way in the management of chronic conditions would seem to be a way forward.IMPLICATIONS FOR REHABILITATIONThe link between goal setting and health outcomes seems to be weak.Some levels of positive behavioural change could be of benefits to patients as seen by improved self-efficacy, patients' satisfaction and overall quality of life.Systematic and consistent application of personalized goal-oriented interventions considering patient's readiness to change could better predict improved outcomes.Incorporation of various goal setting components while actively engaging patient and/or their care givers in the process could appraise how goal setting could help with challenges in faced by people living with chronic conditions in different areas.

"Coming home was a disaster, I didn't know what was going to happen": a qualitative study of survivors' and family members' experiences of navigating care post-stroke

PURPOSE

Understanding navigational barriers and facilitators has the potential to advance equitable stroke care delivery. The aim of this study was to explore, using a qualitative study, the experiences of stroke survivors and their families as they journey through the stroke care system, both before and during the COVID-19 pandemic.

METHODS

In-depth semi-structured interviews were conducted with 18 stroke survivors and 12 family members during 2021 and 2022. Participants were recruited through voluntary organisations, social media, and stroke support groups. Data analysis followed a systematic process guided by the framework method with steps including familiarisation, coding, framework development, and charting and interpretation.

RESULTS

The experiences of navigating stroke care were particularly challenging following discharge from hospital into the community. Barriers to stroke care continuity included insufficient appropriate services and information, unsatisfactory relationships with healthcare professionals and distressed mental health. There were particular navigational challenges for survivors with aphasia. Facilitators to effective navigation included having prior knowledge of the health system, harnessing support for care co-ordination, and being persistent.

CONCLUSION

Greater support for patient navigation, and person-centred referral pathways, particularly during times of increased pressure on the system, have the potential to improve access to services and wellbeing among stroke survivors.

Individualized goals expressed by patients undergoing stroke rehabilitation: an observational study

OBJECTIVES

To explore the rehabilitation goals measured with the Patient-Specific Functional Scale (PSFS) in patients undergoing acute and subacute stroke rehabilitation. In addition, to assess whether PSFS goals corresponded to impairments and activity limitations, as identified by standardized measures.

DESIGN

Observational study.

PARTICIPANTS

A total of 71 participants undergoing inpatient stroke rehabilitation.

METHODS

The PSFS goals were linked to second-level categories in the International Classification of Functioning, Disability and Health (ICF), using established linking rules. Frequencies of the linked ICF categories were calculated. Frequencies of participants with limitations in walking, activities of daily living (ADL), vision, language, and cognition, were calculated, along with goals in corresponding areas of functioning.

RESULTS

The participants' goals were linked to 50 second-level ICF categories, comprising areas such as walking and moving, ADL, language, vision, and cognition. The most frequent ICF categories were "Moving around in different locations" (n = 24), "Walking" (n = 23), "Toileting" (n = 16), "Hand and arm use (n = 12) and "Fine hand use (n = 12)". Of participants with limitations in walking, cognition, and vision, 85%, 10%, and 16%, respectively, had goals in these areas.

CONCLUSION

Participants' goals included walking, ADL, language, vision, and cognition. Few with impairments in cognition or vision had goals in these corresponding areas on the PSFS.

Development of a menu of recovery goals to facilitate goal setting after critical illness

OBJECTIVE

To develop an expert-informed (including end users) recovery goal menu for adults recovering from critical illness applicable to the community/home setting.

RESEARCH METHODOLOGY/DESIGN

Stage 1 Item generation: iterative development of domains, sub-domains, and goals in consultation with former intensive care patients, family members and expert clinicians. Stage 2 Content validity assessment: cognitive interviews and the content validity index.

SETTING

Virtual consultation meetings facilitated by the research team at King's College London and Guy's and St Thomas' NHS Foundation Trust.

MAIN OUTCOME MEASURES

Content validity as assessed by: the Item-Content Validity Index (I-CVI), Scale Level-Content Validity Index/Universal Agreement (S-CVI/UA) score, the Scale Level-Content Validity Index/Average (S-CVI/Ave) score and Average Content Validity Ratio (CVR).

RESULTS

Item generation resulted in a goal menu comprising 4 domains, 22 sub-domains and 95 goals assigned as follows: Self-care: 9 sub-domains with 37 goals, Productivity: 7 sub-domains with 13 goals, Leisure: 3 sub-domains with 25 goals, and Person domain 3 sub-domains with 20 goals. Cognitive interviews resulted in addition of 79 goals and modification of 7, addition of 4 new sub-domains and modification of 4, thus resulting in 4 domains, 26 sub-domains with a total of 174 goals. Twenty-four sub-domains (169 goals) were deemed relevant with Item-Content Validity Index (I-CVI) scores ranging from 0.72 to 1. Two sub-domains (5 goals) did not meet the 0.7 cut-off and were removed. The Scale Level-Content Validity Index/Universal Agreement (S-CVI/UA) score was 0.46; the Scale Level-Content Validity Index/Average (S-CVI/Ave) 0.91. Average Content Validity Ratio (CVR) was 0.93.

CONCLUSION

An expert informed recovery goal menu for former intensive care patients has been developed with excellent content validity. The final goal menu comprises 169 goals within 24 sub-domains grouped under 4 domains.

IMPLICATIONS FOR CLINICAL PRACTICE

This menu will help patients to set goals and increase our understanding of how individuals recover from critical illness.

Patient-centered goal setting in very early supported discharge with continued rehabilitation after stroke

PURPOSE

To examine patients' perception of performance and satisfaction with the activities in their set goals before and after very early supported discharge (VESD) with continued rehabilitation.

MATERIALS AND METHODS

A descriptive cohort study with data extracted from a randomized controlled trial. Sixty-nine patient allocated to the intervention group were eligible. Before discharge, the patients were asked to set rehabilitation goals, and they were asked to rate the performance and satisfaction of their set goals. At discharge from the rehabilitation, the patients were asked to re-evaluate their experience and satisfaction with the goal performance.

RESULTS

One hundred and forty goals were registered. At 81.5% of the set goals, the patients estimated that they performed the task better at discharge than at enrolment and at 86.5% of the set goals the patients were more satisfied with the performance at discharge than at enrolment.

CONCLUSIONS

Patients with mild to moderate stroke, undergoing a VESD after stroke, reported high performance level for their set goals and were satisfied with their performance execution. Further research is needed to investigate whether the goal should be set preferably at home or at hospital before discharge.Implications for rehabilitationMany of the patients can formulate achievable goals with their rehabilitation after stroke.Patients ongoing rehabilitation after stroke are satisfied with their performance of the set goals.As part of patient-centered care, stroke patients should be given the opportunity to formulate their own goals with their rehabilitation.Short hospital times and fast planning of goal-meetings, seems to influence patient goal setting in early discharge rehabilitation.

Understanding stroke survivors' preferences regarding wearable sensor feedback on functional movement: a mixed-methods study

BACKGROUND

In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors' preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback preferences from stroke survivors. This project aims to determine the ease of understanding and movement encouragement of feedback based on wearable sensor data (both arm/hand use and mobility) for stroke survivors and to identify preferences for feedback metrics (mode, content, frequency, and timing).

METHODS

A sample of 30 chronic stroke survivors wore a multi-sensor system in the natural environment over a 1-week monitoring period. The sensor system captured time in active movement of each arm, arm use ratio, step counts and stance time symmetry. Using the data from the monitoring period, participants were presented with a movement report with visual displays of feedback about arm/hand use, step counts and gait symmetry. A survey and qualitative interview were used to assess ease of understanding, actionability and components of feedback that users found most meaningful to drive lasting behavior change.

RESULTS

Arm/hand use and mobility sensor-derived feedback metrics were easy to understand and actionable. The preferred metric to encourage arm/hand use was the hourly arm use bar plot, and similarly the preferred metric to encourage mobility was the hourly steps bar plot, which were each ranked as top choice by 40% of participants. Participants perceived that quantitative (i.e., step counts) and qualitative (i.e., stance time symmetry) mobility metrics provided complementary information. Three main themes emerged from the qualitative analysis: (1) Motivation for behavior change, (2) Real-time feedback based on individual goals, and (3) Value of experienced clinicians for prescription and accountability. Participants stressed the importance of having feedback tailored to their own personalized goals and receiving guidance from clinicians on strategies to progress and increase functional movement behavior in the unsupervised home and community setting.

CONCLUSION

The resulting technology has the potential to integrate engineering and personalized rehabilitation to maximize participation in meaningful life activities outside clinical settings in a less structured environment.

Goal-Setting in clinical practice: a study of health-care professionals' perspectives in outpatient multidisciplinary rehabilitation of patients with spinal cord injury

PURPOSE

Spinal cord injury is a complex condition requiring long-term rehabilitation. Goal-setting is considered an essential part of rehabilitation, however, knowledge of how goal-setting is practised across health-care professions, settings and diagnoses are scarce. The purpose of the study was therefore to explore health-care professionals' perspectives on goal-setting practice in outpatient multidisciplinary rehabilitation targeting patients with spinal cord injury.

MATERIALS AND METHODS

An anthropological study combining participant-observation and focus group interviews. Data were analysed using reflexive thematic analysis. COREQ checklist was used to report the study quality.

RESULTS

Health-care professionals experienced a field of tension between internationally recommended goal-setting criteria, requiring goals to be specific, measurable, realistic and time-based, and a practice influenced by patients presenting complex needs. The challenges were managed using a negotiation strategy characterized by a tinkering approach to adjust notions of measurability, realism and time frame into practice. Also, health-care professionals were challenged in relation to practising a person-centred rehabilitation approach.

CONCLUSIONS

We suggest rethinking the goal-setting process by allowing recommended goal-setting criteria to be adapted to a specific practice context while acknowledging goal-setting practice in its variety and flexibility as a strength. Furthermore, improved incorporation of patients' perspectives in the practice is needed. Implications for rehabilitationTo strengthen person-centred rehabilitation practice, clinicians should actively search for and engage patient-identified needs and preferences in shared goal-setting.Standard criteria of goal-setting should comply with the individual and specific participation in the everyday life of patients with SCI.SMART goals are not always the right way to formulate rehabilitation goals.A flexible and pragmatic approach is needed to reach a balance between the patients' complex needs and the recommendations for goals to be specific, measurable, realistic, and time-based.

Using the capability, opportunity, and motivation model of behaviour to assess provider perception of implementing solution-focused goal-setting in paediatric rehabilitation

Adoption of family and child goal-setting in paediatric rehabilitation is important to positive long-term outcomes. Solution-focused coaching (SFC) has been identified as a promising approach to ensuring this type of goal-setting occurs, while the actual implementation of SFC by health care providers (HCPs) is low. This study utilized the capacity, opportunity, and motivation model of behaviour change (COM-B) to identify which strengths and difficulties health care providers (HCPs) perceived with respect to SFC goal-setting in paediatric rehabilitation. A self-report survey was developed and administered to HCPs at a paediatric rehabilitation hospital. Each survey question was based upon a COM-B sub-component. Demographic information was collected from HCPs, and descriptive statistics were used to rank perceived COM-B components from strongest to weakest. Results indicate HCPs view the provision of SFC goal-setting as an important practice, while they also perceive difficulties to actual delivery due to: lack of adequate individual skill, lack of experience with this type of goal-setting, and insufficient preparation for clients to engage in sharing their goals. HCPs also perceived lack of organizational processes to support the practice within their teams. Recommendations for intervention are provided.

The Conceptual Analysis of Collaboration in the Occupational Therapy by Combining the Scoping Review Methodology

BACKGROUND

Collaboration is an important concept in goal-setting in occupational therapy. However, this concept is not stable due to various definitions. The purpose of this study was to clarify the concept of collaboration in occupational therapy.

METHOD

A scoping review was used to search for all articles related to occupational therapy and collaboration. PubMed, Web of Science, CINAHL, and OT Seeker searches were conducted using predetermined keywords. Three examiners independently reviewed and assessed the quality of each study using Walker and Avant's concept analysis method.

RESULTS

Results of the database searches yielded 1873 studies, 585 of which were deemed eligible to include in this review. Results showed five attributes ("active participation for the common objective", "existence of something to share", "matured communication and interaction", "relationship founded on the respect and trust" and "complementing each other") and two antecedents and several consequences.

CONCLUSIONS

Our findings may contribute to collaborative goal-setting and occupational therapy.

Getting to know our patients and what matters: exploring the elicitation of patient values, preferences, and circumstances in neurological rehabilitation

PURPOSE

Patient values, preferences, and circumstances are critical to decision-making in both patient-centred and evidence-based practice models of healthcare. Despite the established importance of integrating these patient attributes, the ways they are elicited in rehabilitation remain unclear. This study aimed to explore how health professionals elicit and share patients' 'values', 'preferences', and 'circumstances', and what they understand by the terms.

METHODS

This exploratory qualitative descriptive study used interviews with 13 clinicians from interprofessional teams in inpatient neurological rehabilitation. Data were analysed using a general inductive approach.

RESULTS

Participants understood 'values' to mean what is important and meaningful; 'preferences' as likes/dislikes and choices; and 'circumstances' as the social, physical, and environmental context surrounding the person. Formal and informal strategies were used to gather information directly from patients or indirectly from other sources. The processes of eliciting and communicating this information were influenced by relationships and relied on contributions from many people. Elicitation involved a flexible approach tailored to the individual and considering each unique context.

CONCLUSION

The strategies used and the approach used to implement these strategies were both essential to eliciting patient values, preferences, and circumstances in neurological rehabilitation. These findings offer insights into the practices of interprofessional rehabilitation clinicians. Implications for rehabilitationEliciting patient values, preferences, and circumstances involves a combination of strategies and approaches that are applied gradually throughout the continuum of rehabilitation.These processes are flexible, and strategies should be tailored to individual patients/families and phases of rehabilitation.Clinicians should be attentive to informal opportunities to gather valuable information throughout rehabilitation.Establishing positive relationships and using effective communication is foundational to these processes.

'Like going into a chocolate shop, blindfolded': What do people with primary progressive aphasia want from speech and language therapy?

BACKGROUND

Primary progressive aphasia (PPA) describes a group of language-led dementias. PPAs are complex, diverse and difficult to diagnose, and therefore conventional models of aphasia and dementia treatment do not meet their needs. The research evidence on intervention for PPA is developing, but to date there are only a few case studies exploring the experiences of people with PPA (PwPPA) themselves.

AIMS

To explore the experiences and opinions of PwPPA and their communication partners (CPs) to understand how speech and language therapy (SLT) services can better meet their needs.

METHODS & PROCEDURES

A qualitative research approach was used whereby PwPPA and their friends or family members were recruited to participate in focus groups, via advertisements in the Rare Dementia Support PPA group newsletters. Consenting participants were allocated to attend one of four focus groups hosted on an online video conferencing platform. Participants were asked about their communication difficulties, and how SLT could address these needs. All meetings were transcribed, and data were examined using reflexive thematic analysis.

OUTCOMES & RESULTS

Six PwPPA and 14 CPs representing all three PPA variants and mixed PPA participated in the focus groups. Four main themes were identified during the analysis of the focus group discussions: (1) CPs' burden, (2) adjusting to the diagnosis, (3) communication abilities and difficulties and (4) beyond language. A further 10 subthemes were identified.

CONCLUSIONS & IMPLICATIONS

This study provides a greater understanding of the experiences and needs of PwPPA and their families in relation to SLT. This work underlines the importance of a person-centred approach that considers the broader needs of both the PwPPA and the people around them. This will enable service providers to deliver SLT that meets the needs of PwPPA and their families and will also inform future research in this field.

WHAT THIS PAPER ADDS

What is already known on this subject We know that PwPPA can maintain or even make improvements in word retrieval and speech fluency with SLT exercises. There is also developing evidence of the benefits of interventions such as CP training, communication aid support and other functional interventions. What this paper adds to existing knowledge This study provides an understanding of the experiences and opinions of people living with PPA and their families in relation to SLT. Results demonstrate that PwPPA and their families have to navigate a complex journey, identifying strategies to support communication but also the influence of personality and other cognitive symptoms. SLT was useful, but not always available. What are the potential or actual clinical implications of this work? This study will enable service providers to better plan, justify funding for and delivery of SLT that will meet the needs of PwPPA and their families. Most importantly this work underlines the importance of a person-centred approach, incorporating the broader needs of the person with PPA and those around them.

Understanding preferences of stroke survivors for feedback provision about functional movement behavior from wearable sensors: a mixed-methods study

Background

In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors' preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback preferences from stroke survivors. This project aims to determine stroke survivors' satisfaction with feedback from wearable sensors (both mobility and arm/hand use) and to identify preferences for feedback type and delivery schedule.

Methods

A sample of 30 chronic stroke survivors wore a multi-sensor system in the natural environment over a 1-week monitoring period. The sensor system captured time in active movement of each arm, arm use ratio, step counts and stance time symmetry. Using the data from the monitoring period, participants were presented with a movement report with visual displays of quantitative and qualitative feedback. A survey and qualitative interview were used to assess ease of understanding, actionability and components of feedback that users found most meaningful to drive lasting behavior change.

Results

Arm/hand use and mobility sensor-derived feedback metrics were easy to understand and actionable. The preferred metric to encourage arm/hand use was the hourly arm use bar plot, and similarly the preferred metric to encourage mobility was the hourly steps bar plot, which were each ranked as top choice by 40% of participants. Participants perceived that quantitative (i.e., step counts) and qualitative (i.e., stance time symmetry) mobility metrics provided complementary information. Three main themes emerged from the qualitative analysis: 1) Motivation for behavior change, 2) Real-time feedback based on individual goals, and 3) Value of experienced clinicians for prescription and accountability. Participants stressed the importance of having feedback tailored to their own personalized goals and receiving guidance from clinicians on strategies to progress and increase functional movement behavior in the unsupervised home and community setting.

Conclusion

The resulting technology has the potential to integrate engineering and personalized rehabilitation to maximize participation in meaningful life activities outside clinical settings in a less structured environment-one where stroke survivors live their lives.

Communicative participation in goal-setting meetings for patients with aphasia after stroke. A study using patients' and healthcare professionals' self-ratings

PURPOSE

Communicative participation poses a challenge in meetings between healthcare professionals (HCPs) and people with aphasia (PwA). How communication is affected by aphasia in group meetings, where several healthcare professionals participate together with the patient, is largely unexplored. The aim of this study was to investigate self-rated communicative participation during goal-setting meetings among PwA compared to patients without aphasia and to investigate whether communicative participation among PwA was associated with self-rated knowledge about aphasia among HCPs. A further aim was to investigate if there was a difference in the use of communication strategies among HCPs in the respective situations.

METHODS

Nine PwA and nine control patients without aphasia rated their experience of communication during a goal-setting meeting. Thirty-eight HCPs rated their knowledge about aphasia and communication, and their use of communication strategies during goal-setting meetings.

RESULTS

The PwA reported being listened to by the HCPs as well as being able to comprehend the meeting. PwA with more severe language impairment did not report a lower level of communicative participation compared to PwA with milder impairment. Half of the patients from both groups indicated some difficulty asking questions during the meeting. Patients' ratings of communication were not correlated to HCPs' knowledge of communication strategies. There was a significant difference in self-rated use of communication strategies among HCPs for the two conditions, although the individual variation was large.

CONCLUSION

Results from both PwA and controls imply that patients may need more support to be able to ask questions in meetings with HCPs. Although self-ratings increase the ecological validity of the study of participation, further studies could benefit from using video observations in combination with self-reported experience, since awareness might influence results.

WHAT THIS PAPER ADS

What is already known on this subject Aphasia is an acquired language disorder that affects patient-provider communication. In stroke rehabilitation, person-centred goal setting is a key component. If healthcare professionals (HCPs) are not able to use adequate communication strategies, a lack of accessible communication can become a barrier to person-centredness. There are evidence-based communication strategies which can be used to overcome this barrier. What this paper adds to existing knowledge This study aimed to investigate communicative participation during goal-setting meetings from the perspective of patients with aphasia and HCPs. To our knowledge, this is the first study where persons with aphasia are asked to rate communicative participation in goal-setting meetings. To broaden the perspective on communication and goal setting, ratings of patients with aphasia are compared to ratings by patients with stroke but no aphasia. The results of this study indicate that there is room for improvement regarding communication during goal-setting meetings. However, asking direct questions on communicative participation to persons with severe aphasia may not be feasible. What are the potential or actual clinical implications of this work? The results of this study imply that both patients with and without aphasia may need more support to be able to express themselves during goal-setting meetings. There also seems to be a need for further education on aphasia and communication strategies among rehabilitation professionals.

Effects of Stroke Rehabilitation Using Gait Robot-Assisted Training and Person-Centered Goal Setting: A Single Blinded Pilot Study

Many stroke survivors have difficulties due to the mobility and activities required in daily living. A walking impairment negatively affects the independent lifestyle of stroke patients, requiring intensive post-stroke rehabilitation. Therefore, the purpose of this study was to examine the effects of stroke rehabilitation using gait robot-assisted training and person-centered goal setting on mobility, the activities of daily living, stroke self-efficacy, and health-related QoL in stroke patients with hemiplegia. An assessor-blinded quasi-experimental study with a pre-posttest nonequivalent control group was used. Participants who were admitted to the hospital with a gait robot-assisted training system were assigned to the experimental group, and those without gait robots were assigned to the control group. Sixty stroke patients with hemiplegia from two hospitals specialized in post-stroke rehabilitation participated. Stroke rehabilitation using gait robot-assisted training and person-centered goal setting for stroke patients with hemiplegia was conducted for a total of six weeks. There were significant differences between the experimental group and control group in the Functional Ambulation Category (t = 2.89, p = 0.005), balance (t = 3.73, p < 0.001), Timed Up and Go (t = -2.27, p = 0.027), Korean Modified Barthel Index (t = 2.58, p = 0.012), 10 m Walking test (t = -2.27, p = 0.040), stroke self-efficacy (t = 2.23, p = 0.030), and health-related quality of life (t = 4.90, p < 0.001). A gait robot-assisted rehabilitation using goal setting for stroke patients with hemiplegia improved gait ability, balance ability, stroke self-efficacy, and health-related quality of life in stroke patients.

Effects of a Rehabilitation Program Combined with Pain Management That Targets Pain Perception and Activity Avoidance in Older Patients with Acute Vertebral Compression Fracture: a Randomised Controlled Trial

This study aimed to investigate the effect of a rehabilitation program combined with pain management targeting pain perception and activity avoidance on multifaceted outcomes in older patients with acute vertebral compression fractures (VCFs). We randomised 65 older adults with acute VCFs to either an intervention group (n = 32), involving usual rehabilitation combined with pain management that targeted pain perception and activity avoidance, or a control group (n = 33), involving only usual rehabilitation. The usual rehabilitation was initiated immediately after admission. All patients were treated conservatively. Pain management aimed to improve the patients' daily behaviour by increasing their daily activities despite pain, rather than by focusing on eliminating the pain. Pain intensity and psychological statuses such as depression, pain catastrophising, and physical activity levels were assessed on admission. Two weeks postadmission and at discharge, physical performance measures were assessed along with the above-given measurements. A significant main effect of the group was observed for the intensity of lower back pain, favouring the intervention group (F = 5.135, p = 0.027). At discharge, it was significantly better in the intervention group than in the control group (p = 0.011). A time-by-group interaction emerged for magnification of the pain catastrophising scale (p = 0.012), physical activity levels (p < 0.001), and six-minute walking distance (p = 0.006), all favouring the intervention group. Rehabilitation programs combined with pain management targeting pain perception and activity avoidance could be an effective conservative treatment for older patients with acute VCFs.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke

OBJECTIVE

Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals.

METHOD

A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis.

RESULTS

Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD.

CONCLUSION

The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

Reliability and validity of the Danish version of the Self-Assessment of Modes Questionnaire

BACKGROUND

The Self-Assessment of Modes Questionnaire (SAMQ) is developed to help therapists identify their preferred use of modes when interacting with clients in clinical practice. A Danish translation of the SAMQ has been developed (D-SAMQ). To provide a robust instrument for occupational therapy practice and research, evaluation of the psychometric properties of the D-SAMQ is needed.

OBJECTIVES

The study aims to evaluate test-retest reliability, measurement error and content validity in terms of cultural relevance of the D-SAMQ.

MATERIAL AND METHODS

Danish occupational therapists were recruited to represent diverse clinical settings and to work with various age groups. The D-SAMQ consists of 20 clinical cases. A repeated measures design was employed with evaluation of content validity at the second timepoint. The Content Validity Index and Kappa statistics were employed.

RESULTS

In most cases (n = 12, 60%) agreement (test-retest reliability and measurement error) was moderate or strong. Also, there was a moderate (n = 6 cases, 30%), strong (n = 4 cases, 20%) or almost perfect agreement (n = 10 cases, 50%) on the cultural relevance of the cases.

CONCLUSIONS

Acceptable test-retest reliability, measurement error and content validity were found. The SAMQ may support occupational therapists to adapt their therapeutic style to meet the needs of the clients.

Setting Goals to Reduce Cardiovascular Risk: A Retrospective Chart Review of a Pharmacist-Led Initiative in the Workplace

Background: Cardiovascular diseases (CVD) are the second leading cause of death in Canada with many modifiable risk factors. Pharmacists at a Canadian university delivered a novel CVD risk management program, which included goal-setting and medication management. Aim: This study aimed to describe what CVD prevention goals are composed of in a workplace CVD risk reduction program, and how might these goals change over time. Methods: A longitudinal, descriptive qualitative study using a retrospective chart review of clinical care plans for 15 patients enrolled in a CVD prevention program. Data across 6 visits were extracted from charts (n = 5413 words) recorded from May 2019-November 2020 and analyzed using quantitative content analysis and descriptive statistics. Results: Behavioural goals were most popular among patients and were more likely to change over the 12-month follow-up period, compared to health measure goals. Behavioural goals included goals around diet, physical activity (PA), smoking, medication, sleep and alcohol; health measure goals centered on weight measures, blood pressure (BP) and blood lipid levels. The most common behavioural goals set by patients were for diet (n = 11) and PA (n = 9). Over time, goals around PA, medication, alcohol and weight were adapted while others were added (e.g. diet) and some only continued. Patients experienced a number of barriers to their goal(s) which informed how they adapted their goal(s). These included environmental limitations (including COVID-19) and work-related time constraints. Conclusions: This study found CVD goal-setting in the pharmacist-led workplace wellness program was complex and evolved over time, with goals added and/or adapted. More detailed qualitative research could provide further insights into the patient-provider goal-setting experience in workplace CVD prevention.

Engaging children and adolescents with acquired brain injury and their families in goal setting: The family perspective

This study explored the experiences of goal setting in paediatric rehabilitation from the perspectives of children and adolescents with acquired brain injury (ABI) and their parents in paediatric rehabilitation. Using a qualitative research design, 15 semi-structured interviews were conducted with 13 parents and 8 young people with ABI aged between 9 and 18 years who were engaged in outpatient rehabilitation. Interview transcripts were analysed using constructivist grounded theory methods. Two main themes and several sub-themes emerged: Experiences of goal setting: The role of professionals; The role of the young person; and The role of the parents. Working as a team: Understanding each other and building trust; Communicating, sharing knowledge and different perspectives; and Being flexible. These themes reflect parent's and young people's experience of goal setting during paediatric rehabilitation for ABI and suggest clinicians play an important role in educating young people and their families about goal setting in the outpatient rehabilitation context. Young people and their parents also perceive the focus of outpatient rehabilitation as working collaboratively with clinicians to gain knowledge to manage the consequences of ABI. Our findings emphasize the importance of the therapeutic consumer-clinician relationship and the need to actively engage young people in goal setting.

Conceptualization, use, and outcomes associated with empathy and compassion in physical medicine and rehabilitation: a scoping review

The purpose of this review is to scope the literature on the conceptualization, use, and outcomes associated with empathy and compassion in physical medicine and rehabilitation. Eligible studies included quantitative, qualitative, or mixed-methods research that presented primary data on the conceptualization, use, and outcomes associated with empathy and compassion in physical medicine and rehabilitation. Relevant studies were identified through CINAHL, Cochrane Library, EMBASE, MEDLINE, and PEDRO. Twenty-four studies were included (participant n = 3715): 13 quantitative, six mixed-methods, and five qualitative. In qualitative analysis, empathy and compassion were conceptualized as both intrinsic and exhibitory. Where self-compassion was examined as an intervention for patients, improvements in anxiety, depression, and quality of life were reported. Survey data suggested that when rehabilitation health care providers were perceived to be more empathic, patients reported greater treatment satisfaction, acceptance, adherence, and goal attainment. Individuals receiving and health care providers who deliver rehabilitative care conceptualize empathy and compassion as valuable in physical medicine and rehabilitation settings, with cognitive and behavioural elements described. Health care provider empathy and compassion-based interventions may influence outcomes positively in this context. More research is needed to understand the mechanisms of action of empathy and compassion and effectiveness in physical medicine and rehabilitation settings.

Rehabilitation goals described by patients with rheumatic and musculoskeletal diseases: content and attainment during the first year after rehabilitation

PURPOSE

We explored the content and attainment of rehabilitation goals the first year after rehabilitation among patients with rheumatic and musculoskeletal diseases.

METHODS

Participants (n = 523) recorded goals in the Patient Specific Functional Scale at admission and reported goal attainment at admission, discharge, and 12 months after rehabilitation on an 11-point numeric rating scale. Goal content was linked to the ICF coding system and summarized as high, maintained, or no attainment. Changes in absolute scores were investigated using paired samples t-tests.

RESULTS

Goals had high attainment with a significant positive change (-1.83 [95% CI -2.0, -1.65], p > 0.001) during rehabilitation, whereas goals had no attainment with a significant negative change (0.36 [0.14, 0.57], p > 0.001) between discharge and 12 months after rehabilitation. Goals focusing on everyday routines, physical health, pain management, and social or work participation were highly attained during rehabilitation. Goals that were difficult to enhance or maintain after rehabilitation addressed everyday routines, physical health, and work participation.

CONCLUSION

The positive changes in goal attainment largely occurred during rehabilitation, but they appeared more difficult to maintain at home. Therefore, rehabilitation goals should be reflected in the follow-up care planned at discharge.Implications for rehabilitationThe contents of rehabilitation goals reflect the complexity and wide range of challenges patients with rheumatic and musculoskeletal diseases experience.Positive changes in goal attainment largely occur during rehabilitation and appear to be more difficult to enhance or maintain at home.Rehabilitation interventions and follow-up care should be tailored to support patients in maintaining their attained goals for healthy self-management.Rehabilitation goals should be reflected in the follow-up care planned at discharge.

Facilitators and barriers to patient-centred goal-setting in rehabilitation: A scoping review

Objective

Identify, map, and synthesize existing reviews, to extract and analyse the most prominent barriers and facilitators to applying patient-centred goal-setting practice in rehabilitation using the Capability, Opportunity Motivation Behaviour (COM-B) model.

Design

Scoping review.

Data source

A primary search was conducted in MEDLINE, CINAHL, EMBASE, PsychInfo, and Cochrane. Citation chaining was employed.

Review methods

All types of review (systematic, scoping, and narrative) studies published up to June 14, 2022 that included physical and neurological rehabilitation, patient-centeredness, and goal-setting were reviewed. Studies were scrutinized for relevance, quality was not assessed. The most prominent barriers and facilitators were synthesized using thematic content analysis and mapped onto the COM-B model.

Results

Twenty-six review studies covering a range of conditions and settings, acute to community were included. Barrier and facilitators were identified at patient, provider, and organizational level. Barrier themes include provider's existing beliefs about goal-setting, lack of skills, and integration into clinical routines. Patient barriers related to capacity and opportunity to participate. Organizational barriers include lack of clinical guidelines, patient preparation, insufficient provider time, and high productivity expectations. Facilitators included goal-setting guidelines, training and education of providers and patients, revised clinical routines, performance monitoring, adequate time, and resources.

Conclusion

Healthcare providers should be the primary target of intervention. A provider's motivation to change current practice is the most prominent barrier, followed closely by capacity and opportunity. Patients require information, training, and structured engagement opportunities. Organizations play a key role in creating the optimal environmental conditions to enable patient-centred goal-setting.

Time to reconcile research findings and clinical practice on upper limb neurorehabilitation

The problem

In the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs.

Proposed solutions

The objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions.

Conclusions

It's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery.

Access G-AP: development of an accessible goal setting and action planning resource for stroke survivors with aphasia

PURPOSE

Goal setting is key to stroke rehabilitation, but access for people with aphasia is challenging. Based on the Goal setting and Action Planning (G-AP) framework, we developed an accessible goal setting resource (Access G-AP).

METHODS

Access G-AP was designed using a three-phase, user-centred design process. Phase 1: Access G-AP Draft A was designed using evidence-based recommendations. Phase 2: Draft A was reviewed by stroke survivors with aphasia (focus groups 1&2) and rehabilitation staff (questionnaire). Phase 3: Suggested recommendations informed Access G-AP Draft B, which was further reviewed by stroke survivors with aphasia (focus group 3). The final version of Access G-AP was approved by stroke survivors with aphasia at a debrief meeting. Data were analysed using content analysis.

RESULTS

Recommended design improvements included reducing text, adding bullet points, and diversifying images. Both participant groups highlighted that Access G-AP should be used collaboratively to support stroke survivor involvement. Staff recommended Access G-AP training and additional resources to support stroke survivors with severe aphasia.

CONCLUSIONS

Access G-AP was co-developed to support people with aphasia to access and engage in stroke rehabilitation goal setting. Further research is required to establish the feasibility of Access G-AP in clinical practice.IMPLICATIONS FOR REHABILITATIONEvidence-based accessible formatting strategies and an iterative design process can inform the design of accessible goal setting resources.Accessible goal setting materials should be relevant to stroke survivors with aphasia and responsive to their needs.Rehabilitation staff require training and support to use accessible goal setting resources (like Access G-AP) with stroke survivors with aphasia, especially those with severe aphasia.Evaluation of the feasibility of Access G-AP in clinical practice is now required.

Important-performance analysis to conceptualize goal priorities in community dwelling stroke survivors

BACKGROUND

It is important for clinicians to have a better understanding of stroke survivor's goals. Important performance analysis (IPA) is a tool that could be utilized to identify goal priorities in rehabilitation.

OBJECTIVES

To examine the utility of the IPA method to identify goal priorities in a diverse group of community dwelling stroke survivors.

METHODS

Thirty-eight stroke survivors completed private structured interviews and were asked to rate their perceived importance and performance of 37 goal areas. Important-performance analysis (IPA) was utilized to determine goal priorities for the overall sample. Different IPA methods used to identify goal priorities were compared. Goal priorities were also compared by age (dichotomized as <65 and ≥65 years) and sex (male or female).

RESULTS

The IPA method effectively separated the goals into the four quadrants, and distinguished which goals were a priority for the sample of stroke survivors. The five goals that were consistently identified as a focus area were: hand function, driving, balance, memory, and arm strength. Men rated mood control as more important than women (p = .046). The two goals rated as being more important for those older than 65 were home accessibility (p = .008) and skin health (p < .001).

CONCLUSIONS

Stroke survivors continue to have goals related to their stroke recovery in the years after their stroke. Both current performance as well as perceived importance should be considered during goal discussions with stroke survivors. IPA can help identify goal priorities in this population.

The utility of short-term goal achievement as an early indicator of discharge destination in people admitted to neurological rehabilitation with severe functional deficits

PURPOSE

This study investigates whether short-term goal achievement in the early phase of neurological rehabilitation is an accurate indicator of discharge destination in patients with severe disability in comparison to change in scores in the motor domain of the Functional Independence Measure (FIM motor).

METHOD

A prospective observational cohort study.

PARTICIPANTS

A consecutive sample of 53 patients admitted to rehabilitation with a neurological diagnosis and FIM motor score below 47.Measures: Short-term goal achievement and FIM motor change in the first 2 weeks following admission and discharge destination.

RESULTS

Short-term goal achievement showed good prognostic utility [area under the curve (AUC) of 0.75; 95% confidence intervals (CI) 0.6, 0.89] for discharge destination, dichotomized as home or semi-independent living versus nursing home care, similar to that demonstrated by change in FIM motor scores (AUC of 0.69; 95% CI 0.55, 0.84), p = 0.55. A cut-off was established for short-term goal achievement at more than half of goals achieved, with an AUC of 0.73 (95% CI 0.58, 0.87); sensitivity 71.4% and specificity 74.4%.

CONCLUSIONS

Short-term goal achievement in the early phase post-admission is a good indicator of the person's potential to return home.Implications for RehabilitationShort-term goal setting should be a key practice feature of neurological rehabilitation.Goal achievement is an indicator of a person's potential to return home or to semi-independent living in people with severe neurological deficits.Evaluation of short-term goal achievement may inform the ongoing rehabilitation program and discharge planning.

Conceptions of healthcare professionals about rehabilitees' participation in goal setting in an acute hospital: A phenomenographic study

PURPOSE

In acute care, effective goal-setting is an essential phase of a successful rehabilitation process. However, professionals' knowledge and skills in rehabilitee-centered practice may not always match the ways of implementing goal-setting. This study aimed to describe the variation in how acute hospital professionals perceive and comprehend rehabilitee participation in rehabilitation goal-setting.

METHODS

Data were collected by interviewing 27 multidisciplinary rehabilitation team members in small groups shortly after rehabilitation goal-setting sessions. A qualitative research design based on phenomenography was implemented.

RESULTS

We identified four conceptions of rehabilitee participation, based on four hierarchically constructed categories: 1) Professional-driven rehabilitee participation; 2) Awakening rehabilitee participation; 3) Coaching participation; and 4) Shared participation. These categories varied according to four themes: 1) Use of power; 2) Ability to involve; 3) Interaction process; and 4) Atmosphere. Three critical aspects between the categories were also identified: 1) Appreciative listening; 2) Trustful relationship; and 3) Collaborative partnership.

CONCLUSION

The study generated new insights into the meaning of rehabilitee participation, as conceptualized in relation to rehabilitation goal-setting and an acute hospital context. The identified critical aspects can be useful for planning and developing continuing professional education (CPE) in rehabilitation goal-setting for professionals.

Development and psychometric evaluation of a questionnaire for assessing self-management behaviors in stroke survivors

OBJECTIVES

To develop and examine the psychometric properties of the Stroke Self-management Behaviors Performance Scale (SSBPS).

MATERIALS AND METHODS

This is a cross-sectional descriptive correlational study. An 11-item SSBPS was developed. Its content validity was reviewed by an expert panel, and it was piloted among six stroke survivors. Participants completed the SSBPS and four additional measures, namely Stroke Self-Efficacy Questionnaire, Stroke Specific Quality of Life Scale, Geriatric Depression Scale and Reintegration to Normal Living Index, at baseline and the SSBPS again after four weeks. Principal component factor analysis was performed to examine the factor structure. Internal consistency, convergent validity and test-test reliability were evaluated.

RESULTS

128 stroke survivors completed the SSBPS and additional measures. Thirty-four of them completed the SSBPS again after four weeks. A two-factor structure of "Psychosocial management" and "Medical management" consisting of nine items was identified and accounted for 62% of the total variance. The SSBPS had acceptable internal consistency (Cronbach's alpha=0.65-0.88) and test-retest reliability (Intra-class correlation coefficient=0.57-0.73). The SSBPS total score was significantly correlated with the Stroke Self-Efficacy Questionnaire total (r=0.63, p<0.01), Reintegration to Normal Living Index total and subscales (r=0.60-0.69, p<0.01), Stroke Specific Quality of Life Scale total and all domains (r=0.19-0.61, p<0.05), and Geriatric Depression Scale total (r=-0.50, p<0.01) scores.

CONCLUSIONS

The desirable psychometric properties of the SSBPS provide evidence that the scale may be reliable and valid for assessing stroke survivors' performance of self-management behaviors. It would inform the development of effective strategies to promote positive self-management behavioral performance for optimal recovery.

A Performance-Based Teleintervention for Adults in the Chronic Stage after Acquired Brain Injury: An Exploratory Pilot Randomized Controlled Crossover Study

This pilot study aimed to investigate the initial effect of a remotely delivered performance-based client-centered intervention on activity performance and participation among adults in the chronic phase after acquired brain injury (ABI). Sixteen participants living at home with little to no assistance in basic daily activities were allocated into intervention or waitlist control groups. Assessments were conducted at the baseline, after the 3-month intervention/wait period, and at a 3-month follow-up. The primary outcomes were activity performance using the Canadian Occupational Performance Measure (COPM) and the Performance Quality Rating Scale (PQRS) and participation using the Mayo-Portland Adaptability Inventory-4 (MPAI-4). The intervention included weekly videoconferencing sessions using the Cognitive Orientation to Daily Occupational Performance approach (tele-CO-OP). The participants identified five functional goals, of which three were directly addressed. Wilcoxon signed-ranks test results showed no significant improvements in the control group at the end of the 3-month wait period. Pooled data from both groups showed significant improvements in COPM scores for trained and untrained goals following the intervention. Significant improvements were also found in the PQRS and MPAI-4 scores. Improvements were partially maintained at follow-up. Our preliminary results suggest that tele-CO-OP may positively impact the lives of adults after ABI who are coping with long-term disability.

Goal planning in mental health service delivery: A systematic integrative review

INTRODUCTION

Goal planning is routinely employed in mental health service delivery to identify priorities for treatment and support the achievement and evaluation of outcomes. Previous systematic reviews of the literature have focused on the use of goal planning in a range of physical and cognitive disability settings, but there is a lack of information regarding how goal planning is used in mental healthcare.

AIMS

This systematic integrative review aimed to understand the types of goals, effectiveness of goal planning, the experience of goal planning and barriers and facilitators to effective goal planning in mental healthcare settings.

METHODS

Five databases were systematically searched using key terms related to mental health AND goal planning. The search was supplemented through citation chaining. Due to the heterogeneity of the studies, a narrative synthesis approach to data analysis was undertaken.

RESULTS

Fifty-four studies were identified through the search of the literature following the PRISMA guidelines. Data was systematically extracted and thematically organized. There was a high level of heterogeneity among the studies, originating from a range of countries and with diverse characteristics and focus. Four themes emerged from the data analysis and included: (i) goal planning as a central aspect of interventions; (ii) types of goals planned; (iii) factors that influenced goal planning and/or attainment; and (iv) collaboration and concordance in goal planning.

CONCLUSION

This review found some support for the use of goal planning to improve outcomes in mental healthcare although there was no identified standardized approach to the use of goal planning. Individualized, recovery-oriented and collaborative goal planning was recommended but not always used in practice. Further research to understanding the most appropriate skills and training needed to support collaborative and effective goal planning is needed.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42020220595].

Finding Goal Focus With People With Severe Traumatic Brain Injury in a Person-Centered Multi-Component Community Connection Program (M-ComConnect)

Background and Objectives: Loss of social connections in the community is a common consequence of severe traumatic brain injury (TBI), resulting in reduced well-being and quality of life. M-ComConnect is an individualized multi-component community connection intervention with the key objectives of increasing social activity, developing social relationships, and supporting community participation following severe TBI. As part of the M-ComConnect approach, semi-structured initial interviews were conducted to develop a holistic understanding of each participant and their goal focus for the project. In this paper we describe how clinicians worked with participants to identify a desired community-based social activity in which to participate. Method: Transcripts of initial interviews between participant and clinician were analyzed using the phases of reflexive thematic analysis developed by Braun and Clarke. Participants were ten individuals aged between 24 and 75 with severe TBI. All were living in the community and reported reduced social connections since their TBI. The aim of the analysis was to evaluate the skills and strategies used by clinicians in their interactions with participants to derive goal focus for the program. Results: Thematic analysis of initial interview data revealed three main categories and fourteen sub-categories of clinical strategies. These were: (1) Humanizing (curiosity; demonstrating respect and empathy; providing compliments and affirmations; simple reflections; revealing aspects of self; and humor and laughter), (2) Empowering (emphasizing choice and control; highlighting strengths; identifying roadblocks and reframing to reveal opportunities; and collaborative problem solving), and (3) Focusing (making suggestions; identifying preferences; working with ideas; and negotiating). These strategies aligned with the program's relational approach and supported the core processes of the goal-focussing framework, namely understanding and connecting with you, building a relationship, and working together with you to find focus. Conclusion: The goal-focusing framework and clinical strategies outlined provide guidance for clinicians working with people with TBI in the community and is a promising way to engage clients when focusing on individualized social activity-based goals.

Development and field testing of a standardised goal setting package for person-centred discharge care planning in stroke

Objective

Develop and test a person-centred goal-setting package for discharge care planning in acute and rehabilitation stroke units.

Methods

A multidisciplinary, expert working group (n = 15), and consumer group (n = 4) was convened. A multistage iterative approach was used to develop and test the package. Stages included: (i) contextual understanding, (ii) package development, and (iii) clinician training and field-testing in acute and rehabilitation settings. Observational field notes were taken and clinicians' perspectives captured using semi-structured focus groups post-testing.

Results

The final package included a 34-item menu aligned with a manual containing: guideline summaries; common goals; goal metrics based on the SMART Goal Evaluation Method (SMART-GEM); evidence-based strategies; and worked examples. Twenty-three clinicians attended training. Clinician observations (n = 5) indicated that: the package could be incorporated into practice; a range of person-centred goals were set; and opportunities provided to raise additional issues. Clinician feedback (n = 8) suggested the package was useful and facilitated person-centred goal-setting. Enablers included potential for incorporation into existing processes and beliefs that it promoted person-centred care. Barriers included additional time.

Conclusion

The package demonstrated potential to facilitate comprehensive person-centred goal-setting for patients with stroke.

Innovation

We developed an innovative approach to support structured person-centred goal setting in clinical and research settings.

Goal adjustment by people living with long-term conditions: A scoping review of literature published from January 2007 to June 2018

Long-term health conditions can limit achievement of personal goals. We aimed to map and synthesize definitions of goal adjustment, theoretical underpinnings, associations with recovery and supportive interventions for adults with long-term conditions. We searched multiple databases (January 2007-June 2018) and identified peer-reviewed research relating to goal adjustment. Data were charted, mapped and synthesized using content analysis and descriptive summaries. Two stakeholder consultations informed the review. Ninety-one articles were included. A range of long-term conditions were represented including cancer (22%), stroke (12%) and mixed neurological conditions (8%). Goal adjustment was one available option when faced with unattainable goals; other options were goal disengagement and goal re-engagement. Most studies were quantitative (58%), reporting mainly positive associations between goal adjustment, disengagement, reengagement and recovery. The Dual Process Model, Goal Adjustment Model and Self-Regulation Theory were most cited underpinning models/theory. Five interventions were identified; only one (self-system therapy) was evaluated in a randomized controlled trial. Our review provides original and significant insights into goal adjustment definitions, theoretical underpinnings and association with recovery. Effective interventions to support goal adjustment, disengagement and reengagement are lacking. This research-practice gap warrants attention to ensure people with long-term conditions are optimally supported when facing unattainable goals.

The Person-Centered Rehabilitation Model: Framing the concept and practice of person-centered adult physical rehabilitation based on a scoping review and thematic analysis of the literature

OBJECTIVE

To develop a cross-professional model framing the concept and practice of Person-Centered Rehabilitation (PCR) in adult populations, based on a scoping review and thematic analysis of the literature.

DATA SOURCES

Key databases (PubMed, Scopus, CINAHL), snowballing searches, and experts' consultation were the data sources for English-language empirical or conceptual papers, published from January 2007 to February 2020.

STUDY SELECTION

Two independent reviewers selected adult-based papers addressing at least one of the six categories of PCR-related content, a priori specified in the published review protocol. From 6527 unique references, 147 were finally included in the analysis. Of those, 26 were exclusively conceptual papers.

DATA EXTRACTION

Two independent reviewers extracted textual data on what PCR entails conceptually or as a practice. No quality appraisals were performed as is typical in scoping reviews.

DATA SYNTHESIS

A thematic analysis produced thematic categories that were combined into an emergent model (the PCR Model), which was reviewed by five external experts. PCR was framed as a way of thinking about and providing rehabilitation services "with" the person. PCR is embedded in rehabilitation structures and practice across three levels: 1) the person-professional dyad, 2) the micro-system level (typically an interprofessional team, involving significant others) and 3) a macro-system level (organization within which rehabilitation is delivered). Thematic categories are articulated within each level, detailing both the conceptual and practice attributes of PCR.

CONCLUSION

The PCR model can inform both clinical and service organization practices. The PCR Model may benefit from further developments including obtaining wider stakeholders' input, determining relevance in different cultural and linguistic groups, and further operationalization and testing in implementation projects.

Goal-setting in geriatric rehabilitation: Can the nursing profession meet patients' needs? A narrative review

STUDY OBJECTIVE

To provide an overview of patients' needs concerning goal-setting, and indications of how those needs can be met by nurses.

METHODS

A narrative review. Pubmed and Cinahl were searched through March 1, 2020 for: patients' experiences concerning goal-setting and the role of nursing in rehabilitation. Additional articles were found through snowballing. A total of 22 articles were reviewed on patients' experiences, and 12 on the nursing role.

RESULTS

Patients need to be prepared for collaborating in goal-setting and to receive an explanation about their part in that process. The multiplicity of disciplines may cloud patients' understanding of the process. The nurse's planning of the rehabilitation process should be aimed at resolving this issue. Goals need to be meaningful, and patients need support in attaining them. The interpretive, integrative, and consoling functions of Kirkevold's nursing role are suitable to meet these needs.

CONCLUSIONS

Both the literature about patients' needs regarding goal-setting and the nursing role make clear that the way nurses work in rehabilitation can gain in clarity. Strengthening the role of nurses will improve the goal-setting process for patients. Interprofessional collaboration, clear work procedures, continuity of care, time and trust, and the physical environment all are important to reinforce this role.

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

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

Formative Evaluation der Schlaganfall-Bezugstherapie Phase-E Schleswig-Holstein aus Sicht der Therapeutinnen und Therapeuten

Hintergrund Fokussierung auf Körperfunktionsstörungen, mangelnde Teilhabe-Orientierung und Leitlinienimplementierung, Sektoren- und Professionsgrenzen kennzeichnen die Schlaganfall-Rehabilitation Phase-E. Hauptproblem ist ein fehlendes Case Management mit selektiver Einzel- statt koordinierter interprofessioneller Versorgung. Kernelement des Pilotprojekts Schlaganfall-Bezugstherapie (BZT), Phase-E, ist eine Schulung zur interprofessionellen teilhabeorientierten Ziel- bzw. Therapieplanung. Als Case-Mangerinnen und Case-Manager legen Bezugstherapeutinnen und -therapeuten Art, Frequenz und Dauer der Heilmittelverordnungen fest und unterstützen Patientinnen und Patienten beim Selbstmanagement.

Ziel Formative Evaluation aus Sicht der Therapeutinnen und Therapeuten, um die Intervention zu optimieren und auf weitere Regionen bzw. Krankheitsbilder auszuweiten.

Methode 18 ausgebildete Bezugstherapeutinnen und -therapeuten (Ergo-, Sprach- und Physiotherapie) wurden mittels halbstandardisiertem Fragebogen-Interview zur Schulung und Tätigkeit als Bezugstherapeutinnen und -therapeuten sowie zu Veränderungsbedarfen befragt.

Ergebnisse Für die Befragten gehören Fallkonferenzen und Ressourcenerfassung zu den wichtigsten Aspekten. Teilhabeorientierte Zielplanung werden als das am weitesten umgesetzte, Fallkonferenzen als das am wenigsten umgesetzte Prinzip benannt. Eine koordiniertere und patientenzentriertere Versorgung gelten ebenso als Vorteile wie eine leistungsbezogenere Vergütung, ein besserer Ressourceneinsatz durch Teilhabeorientierung und eine leichtere Integration der Bezugspersonen. Schwierigkeiten in der Zusammenarbeit mit nicht durch das BZT-Projekt geschulte Therapeutinnen und Therapeuten werden als Nachteil benannt.

Schlussfolgerung Alle Befragten bewerten Schulung und Konzeption positiv und bestätigen die Wichtigkeit der teilhabeorientierten Zielplanung und Top-down-Vorgehensweise. Weitere Maßnahmen sollten dazu dienen, das Implementieren von Assessments, Leitlinien und Fallkonferenzen zu fördern. BZT besitzt Modellcharakter für das Erproben in weiteren Regionen bzw. bei weiteren Diagnosegruppen.

Individualised Responsible Artificial Intelligence for Home-Based Rehabilitation

Socioeconomic reasons post-COVID-19 demand unsupervised home-based rehabilitation and, specifically, artificial ambient intelligence with individualisation to support engagement and motivation. Artificial intelligence must also comply with accountability, responsibility, and transparency (ART) requirements for wider acceptability. This paper presents such a patient-centric individualised home-based rehabilitation support system. To this end, the Timed Up and Go (TUG) and Five Time Sit To Stand (FTSTS) tests evaluate daily living activity performance in the presence or development of comorbidities. We present a method for generating synthetic datasets complementing experimental observations and mitigating bias. We present an incremental hybrid machine learning algorithm combining ensemble learning and hybrid stacking using extreme gradient boosted decision trees and k-nearest neighbours to meet individualisation, interpretability, and ART design requirements while maintaining low computation footprint. The model reaches up to 100% accuracy for both FTSTS and TUG in predicting associated patient medical condition, and 100% or 83.13%, respectively, in predicting area of difficulty in the segments of the test. Our results show an improvement of 5% and 15% for FTSTS and TUG tests, respectively, over previous approaches that use intrusive means of monitoring such as cameras.

'They get the opportunity to say what is important for them': exploring staff's early perceptions of the implementation of a new communicative approach to patients with aphasia

PURPOSE

This study explored the perceptions of staff members regarding the implementation of a new communicative approach at a multidisciplinary neurorehabilitation centre in Denmark. Communication partner training according to Supported Conversation for Adults with Aphasia (SCA^TM) was combined with augmentative strategies from the KomHIT programme to increase the influence of patients with aphasia on their own rehabilitation process.

METHODS

A qualitative approach was used involving two semi-structured group interviews with multidisciplinary staff in two wards. Three staff members from each ward participated. The recorded interviews were transcribed, and a thematic analysis of the data was conducted.

RESULTS

Three main themes emerged from the analysis. Participants reported increased influence of patients with aphasia on their own rehabilitation process, as well as an increased focus on communication with patients with aphasia. Challenges included time restrictions and dilemmas in goal setting.

CONCLUSIONS

Increasing staff knowledge of communication support and augmentative strategies seemed to improve the influence of patients with aphasia on their own rehabilitation process. Because the results were based on interviews with a small number of staff, they cannot be generalized and require further investigation that should also include interviews with the patients themselves and their families.IMPLICATIONS FOR REHABILITATIONThe combination of partner training with augmentative strategies may increase staff understanding of all individuals' rights to have their communicative needs met.The combination of partner training with augmentative strategies may support the influence of persons with aphasia on their own rehabilitation.Goal setting discrepancies between staff and patients with aphasia can be brought to light by more successful communication.The implementation of a new communicative approach can be challenged by a number of factors, e.g., time restrictions.The implementation process needs to be supported by actions on a higher organisational level.

Impacts of goal setting on engagement and rehabilitation outcomes following acquired brain injury: a systematic review of reviews

PURPOSE

To appraise and synthesize evidence from previous systematic reviews (SRs) concerning the impacts of goal setting on engagement in the rehabilitation process and on outcomes of participation and occupational performance for individuals with acquired brain injury (ABI).

MATERIALS AND METHODS

Systematic review of SRs following the preferred reporting items for SRs and meta-analysis guidelines. Sixteen full text articles were assessed for eligibility, from which four were included in the review. The Critical Appraisal Skills Programme checklists for SRs was used to rate quality and risk of bias.

RESULTS

Four SRs of moderate to high quality included a variety of methodologies. Evidence of moderate quality showed clients' active participation in goal setting had positive impacts on the client and their engagement in the process. Findings suggested that goal-directed interventions, particularly in outpatient rehabilitation, may improve occupational performance. There was some indication that goal setting may support adherence to therapeutic exercises, but relevance to rehabilitation outcomes was less clear. Findings related to participation outcomes were minimal.

CONCLUSIONS

Goal setting is a complex and multidimensional process. Goal setting may contribute to improved engagement in rehabilitation although few studies explored occupational performance and participation outcomes for individuals with ABI.Implications for rehabilitationActive goal setting may contribute to improved engagement in rehabilitation, however, including individual clients in the goal setting process requires creativity and flexibility on behalf of professionals.A model is presented to promote understanding of the personal and environmental barriers and facilitators that may interact with goal setting approaches to promote engagement in rehabilitation.There is a need for more research exploring impact of active client-centered goal setting on occupational performance and participation outcomes for people with acquired brain injury.

The Applicability of the Patient-Specific Functional Scale (PSFS) in Rehabilitation for Patients with Acquired Brain Injury (ABI) - A Cohort Study

Aim

The primary aim of this study was to investigate the applicability of the Patient-Specific Functional Scale (PSFS) in patients with acquired brain injury (ABI) admitted to a specialized rehabilitation unit in a regional hospital. A secondary aim was to identify patient characteristics and functioning that predicted changes in the PSFS.

Patients and Methods

In a cohort study, 59 patients with ABI were assessed for the ability to complete the PSFS. A trained multidisciplinary team applied the PSFS as part of a collaborative development of rehabilitation goals. The modified Rankin Scale (mRS), the Functional Ambulation Categories (FAC), the Rivermead Behavioural Memory Test (RBMT), the Norwegian Basic Aphasia Assessment (NBAA) and the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) were used to identify characteristics of the sample. Multivariate regression analyses were performed to investigate associations between changes in the PSFS score from admission to discharge and a selected set of participant baseline characteristics and functioning.

Results

Fifty-four patients (92%) of the patients with ABI were able to complete the PSFS. The five (8%) who were unable to complete the PSFS had severe cognitive or language impairment. The PSFS score improved by a mean of 2.6 (SD 2.0) points from admission to discharge. The LOTCA score made the strongest unique contribution to explain the change in the PSFS score (beta = 0.477, p= 0.020).

Conclusion

In the present study, most patients with ABI (92%) were able to complete the PSFS. Cognitive function on admission was a predictor of improved functioning on the PSFS.

Robot-assisted training compared with an enhanced upper limb therapy programme and with usual care for upper limb functional limitation after stroke: the RATULS three-group RCT

BACKGROUND

Loss of arm function is common after stroke. Robot-assisted training may improve arm outcomes.

OBJECTIVE

The objectives were to determine the clinical effectiveness and cost-effectiveness of robot-assisted training, compared with an enhanced upper limb therapy programme and with usual care.

DESIGN

This was a pragmatic, observer-blind, multicentre randomised controlled trial with embedded health economic and process evaluations.

SETTING

The trial was set in four NHS trial centres.

PARTICIPANTS

Patients with moderate or severe upper limb functional limitation, between 1 week and 5 years following first stroke, were recruited.

INTERVENTIONS

Robot-assisted training using the Massachusetts Institute of Technology-Manus robotic gym system (InMotion commercial version, Interactive Motion Technologies, Inc., Watertown, MA, USA), an enhanced upper limb therapy programme comprising repetitive functional task practice, and usual care.

MAIN OUTCOME MEASURES

The primary outcome was upper limb functional recovery 'success' (assessed using the Action Research Arm Test) at 3 months. Secondary outcomes at 3 and 6 months were the Action Research Arm Test results, upper limb impairment (measured using the Fugl-Meyer Assessment), activities of daily living (measured using the Barthel Activities of Daily Living Index), quality of life (measured using the Stroke Impact Scale), resource use costs and quality-adjusted life-years.

RESULTS

A total of 770 participants were randomised (robot-assisted training, n = 257; enhanced upper limb therapy, n = 259; usual care, n = 254). Upper limb functional recovery 'success' was achieved in the robot-assisted training [103/232 (44%)], enhanced upper limb therapy [118/234 (50%)] and usual care groups [85/203 (42%)]. These differences were not statistically significant; the adjusted odds ratios were as follows: robot-assisted training versus usual care, 1.2 (98.33% confidence interval 0.7 to 2.0); enhanced upper limb therapy versus usual care, 1.5 (98.33% confidence interval 0.9 to 2.5); and robot-assisted training versus enhanced upper limb therapy, 0.8 (98.33% confidence interval 0.5 to 1.3). The robot-assisted training group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale) than the usual care group at 3 and 6 months. The enhanced upper limb therapy group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale), better mobility (as measured by the Stroke Impact Scale mobility domain) and better performance in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the usual care group, at 3 months. The robot-assisted training group performed less well in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the enhanced upper limb therapy group at 3 months. No other differences were clinically important and statistically significant. Participants found the robot-assisted training and the enhanced upper limb therapy group programmes acceptable. Neither intervention, as provided in this trial, was cost-effective at current National Institute for Health and Care Excellence willingness-to-pay thresholds for a quality-adjusted life-year.

CONCLUSIONS

Robot-assisted training did not improve upper limb function compared with usual care. Although robot-assisted training improved upper limb impairment, this did not translate into improvements in other outcomes. Enhanced upper limb therapy resulted in potentially important improvements on upper limb impairment, in performance of activities of daily living, and in mobility. Neither intervention was cost-effective.

FUTURE WORK

Further research is needed to find ways to translate the improvements in upper limb impairment seen with robot-assisted training into improvements in upper limb function and activities of daily living. Innovations to make rehabilitation programmes more cost-effective are required.

LIMITATIONS

Pragmatic inclusion criteria led to the recruitment of some participants with little prospect of recovery. The attrition rate was higher in the usual care group than in the robot-assisted training or enhanced upper limb therapy groups, and differential attrition is a potential source of bias. Obtaining accurate information about the usual care that participants were receiving was a challenge.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN69371850.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 54. See the NIHR Journals Library website for further project information.