Limitations in utilization and prioritization of standardized somatosensory assessments after stroke: A cross-sectional survey of neurorehabilitation clinicians

BACKGROUND AND PURPOSE

Somatosensory impairments are common after stroke, but receive limited evaluation and intervention during neurorehabilitation, despite negatively impacting functional movement and recovery.

OBJECTIVES

Our objective was to understand the scope of somatosensory assessments used by clinicians in stroke rehabilitation, and barriers to increasing use in clinical practice.

METHODS

An electronic survey was distributed to clinicians (physical therapists, occupational therapists, physicians, and nurses) who assessed at least one individual with stroke in the past 6 months. The survey included questions on evaluation procedures, type, and use of somatosensory assessments, as well as barriers and facilitators in clinical practice.

RESULTS

Clinicians (N = 431) indicated greater familiarity with non-standardized assessments, and greater utilization compared to standardized assessments (p < 0.0001). Components of tactile sensation were the most commonly assessed modality of somatosensation (25%), while proprioception was rarely assessed (1%). Overall, assessments of motor function were prioritized over assessments of somatosensory function (p < 0.0001).

DISCUSSION

Respondents reported assessing somatosensation less frequently than motor function and demonstrated a reliance on rapid and coarse non-standardized assessments that ineffectively capture multi-modal somatosensory impairments, particularly for proprioceptive deficits common post-stroke. In general, clinicians were not familiar with standardized somatosensory assessments, and this knowledge gap likely contributes to lack of translation of these assessments into practice.

CONCLUSIONS

Clinicians utilize somatosensory assessments that inadequately capture the multi-modal nature of somatosensory impairments in stroke survivors. Addressing barriers to clinical translation has the potential to increase utilization of standardized assessments to improve the characterization of somatosensory deficits that inform clinical decision-making toward enhancing stroke rehabilitation outcomes.

Current clinical practice in managing somatosensory impairments and the use of technology in stroke rehabilitation

Stroke-induced somatosensory impairments seem to be clinically overlooked, despite their prevalence and influence on motor recovery post-stroke. Interest in technology has been gaining traction over the past few decades as a promising method to facilitate stroke rehabilitation. This questionnaire-based cross-sectional study aimed to identify current clinical practice and perspectives on the management of somatosensory impairments post-stroke and the use of technology in assessing outcome measures and providing intervention. Participants were 132 physiotherapists and occupational therapists currently working with stroke patients in public hospitals and rehabilitation centres in Singapore. It was found that the majority (64.4%) of the therapists spent no more than half of the time per week on somatosensory interventions. Functional or task-specific training was the primary form of intervention applied to retrain somatosensory functions in stroke survivors. Standardised assessments (43.2%) were used less frequently than non-standardised assessments (97.7%) in clinical practice, with the sensory subscale of the Fugl-Meyer Assessment being the most popular outcome measure, followed by the Nottingham Sensory Assessment. While the adoption of technology for assessment was relatively scarce, most therapists (87.1%) reported that they have integrated technology into intervention. There was a common agreement that proprioception is an essential component in stroke rehabilitation, and that robotic technology combined with conventional therapy is effective in enhancing stroke rehabilitation, particularly for retraining proprioception. Most therapists identified price, technology usability, and lack of available space as some of the biggest barriers to integrating robotic technology in stroke rehabilitation. Standardised assessments and interventions targeting somatosensory functions should be more clearly delineated in clinical guidelines. Although therapists were positive about technology-based rehabilitation, obstacles that make technology integration challenging ought to be addressed.

What is "usual care" in the rehabilitation of upper limb sensory loss after stroke? Results from a national audit and knowledge translation study

PURPOSE

To characterise the assessments and treatments that comprise "usual care" for stroke patients with somatosensory loss, and whether usual care has changed over time.

MATERIALS AND METHODS

Comparison of cross-sectional, observational data from (1) Stroke Foundation National Audit of Acute (2007-2019) and Rehabilitation (2010-2018) Stroke Services and (2) the SENSe Implement multi-site knowledge translation study with occupational therapists and physiotherapists (n = 115). Descriptive statistics, random effects logistic regression, and content analysis were used.

RESULTS

Acute hospitals (n = 172) contributed 24 996 cases across audits from 2007 to 2019 (median patient age 76 years, 54% male). Rehabilitation services (n = 134) contributed organisational survey data from 2010 to 2014, with 7165 cases (median 76 years, 55% male) across 2016-2018 clinical audits (n = 127 services). Somatoensory assessment protocol use increased from 53% (2007) to 86% (2019) (odds ratio 11.4, 95% CI 5.0-25.6). Reported use of sensory-specific retraining remained stable over time (90-93%). Therapist practice reports for n = 86 patients with somatosensory loss revealed 16% did not receive somatosensory rehabilitation. The most common treatment approaches were sensory rehabilitation using everyday activities (69%), sensory re-education (68%), and compensatory strategies (64%).

CONCLUSION

Sensory assessment protocol use has increased over time while sensory-specific training has remained stable. Sensory rehabilitation in the context of everyday activities is a common treatment approach. Clinical trial registration number: ACTRN12615000933550IMPLICATIONS FOR REHABILITATIONOnly a small proportion of upper limb assessments conducted with stroke patients focus specifically on sensation; increased use of standardised upper limb assessments for sensory loss is needed.Stroke patients assessed as having upper limb sensory loss frequently do not receive treatment for their deficits.Therapists typically use everyday activities to treat upper limb sensory loss and may require upskilling in sensory-specific retraining to benefit patients.

Factors influencing allied health professionals' implementation of upper limb sensory rehabilitation for stroke survivors: a qualitative study to inform knowledge translation

OBJECTIVES

Somatosensory loss is common after stroke with one-in-two individuals affected. Although clinical practice guidelines recommend providing somatosensory rehabilitation, this impairment often remains unassessed and untreated. To address the gap between guideline recommendations and clinical practice, this study sought to understand the factors influencing delivery of evidence-based upper limb sensory rehabilitation after stroke.

DESIGN

Qualitative study involving focus groups and interviews. Data analysis used an inductive approach (thematic analysis) and deductive analysis using implementation theory (the Theoretical Domains Framework and Normalisation Process Theory).

SETTING

Eight healthcare organisations in metropolitan and regional areas of Victoria and New South Wales, Australia.

PARTICIPANTS

Eighty-seven rehabilitation therapists (79% occupational therapists and 21% physiotherapists) were purposively sampled and participated in a knowledge translation study with staggered recruitment from 2014 to 2018.

RESULTS

Three types of factors influenced therapists' delivery of upper limb somatosensory rehabilitation: individual ('The uncertain, unskilled therapist'), patient ('Patient understanding and priorities') and organisational ('System pressures and resources'). Deductive analysis using implementation theory identified key determinants of practice change, such as opportunities to consolidate new skills, the anticipated benefits of upskilling as a therapy team and the work anticipated by therapists to incorporate a new somatosensory rehabilitation approach.

CONCLUSIONS

Occupational therapists and physiotherapists hold valuable insights towards practice change in somatosensory rehabilitation from the 'frontline'. Therapists experience barriers to change including a lack of knowledge and skills, lack of resources and organisational pressures. Facilitators for change were identified, including social support and therapists' perceived legitimacy in using new somatosensory rehabilitation approaches. Results will inform the design of a tailored implementation strategy to increase the use of evidence-based somatosensory rehabilitation in Australia.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12615000933550).

The effectiveness of somatosensory retraining for improving sensory function in the arm following stroke: a systematic review

OBJECTIVE

The aim of this study was to evaluate if somatosensory retraining programmes assist people to improve somatosensory discrimination skills and arm functioning after stroke.

DATA SOURCES

Nine databases were systematically searched: Medline, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, Embase, Amed, Web of Science, Physiotherapy Evidence Database, OT seeker, and Cochrane Library.

REVIEW METHODS

Studies were included for review if they involved (1) adult participants who had somatosensory impairment in the arm after stroke, (2) a programme targeted at retraining somatosensation, (3) a primary measure of somatosensory discrimination skills in the arm, and (4) an intervention study design (e.g. randomized or non-randomized control designs).

RESULTS

A total of 6779 articles were screened. Five group trials and five single case experimental designs were included ( N = 199 stroke survivors). Six studies focused exclusively on retraining somatosensation and four studies focused on somatosensation and motor retraining. Standardized somatosensory measures were typically used for tactile, proprioception, and haptic object recognition modalities. Sensory intervention effect sizes ranged from 0.3 to 2.2, with an average effect size of 0.85 across somatosensory modalities. A majority of effect sizes for proprioception and tactile somatosensory domains were greater than 0.5, and all but one of the intervention effect sizes were larger than the control effect sizes, at least as point estimates. Six studies measured motor and/or functional arm outcomes ( n = 89 participants), with narrative analysis suggesting a trend towards improvement in arm use after somatosensory retraining.

CONCLUSION

Somatosensory retraining may assist people to regain somatosensory discrimination skills in the arm after stroke.

Changing practice in the assessment and treatment of somatosensory loss in stroke survivors: protocol for a knowledge translation study

BACKGROUND

The treatment of somatosensory loss in the upper limb after stroke has been historically overshadowed by therapy focused on motor recovery. A double-blind randomized controlled trial has demonstrated the effectiveness of SENSe (Study of the Effectiveness of Neurorehabilitation on Sensation) therapy to retrain somatosensory discrimination after stroke. Given the acknowledged prevalence of upper limb sensory loss after stroke and the evidence-practice gap that exists in this area, effort is required to translate the published research to clinical practice. The aim of this study is to determine whether evidence-based knowledge translation strategies change the practice of occupational therapists and physiotherapists in the assessment and treatment of sensory loss of the upper limb after stroke to improve patient outcomes.

METHOD/DESIGN

A pragmatic, before-after study design involving eight (n = 8) Australian health organizations, specifically sub-acute and community rehabilitation facilities. Stroke survivors (n = 144) and occupational therapists and physiotherapists (~10 per site, ~n = 80) will be involved in the study. Stroke survivors will be provided with SENSe therapy or usual care. Occupational therapists and physiotherapists will be provided with a multi-component approach to knowledge translation including i) tailoring of the implementation intervention to site-specific barriers and enablers, ii) interactive group training workshops, iii) establishing and fostering champion therapists and iv) provision of written educational materials and online resources. Outcome measures for occupational therapists and physiotherapists will be pre- and post-implementation questionnaires and audits of medical records. The primary outcome for stroke survivors will be change in upper limb somatosensory function, measured using a standardized composite measure.

DISCUSSION

This study will provide evidence and a template for knowledge translation in clinical, organizational and policy contexts in stroke rehabilitation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) retrospective registration ACTRN12615000933550 .

Change in Functional Arm Use Is Associated With Somatosensory Skills After Sensory Retraining Poststroke

OBJECTIVE. We investigated changes in functional arm use after retraining for stroke-related somatosensory loss and identified whether such changes are associated with somatosensory discrimination skills.

METHOD. Data were pooled (N = 80) from two randomized controlled trials of somatosensory retraining. We used the Motor Activity Log to measure perceived amount of arm use in daily activities and the Action Research Arm Test to measure performance capacity. Somatosensory discrimination skills were measured using standardized modality-specific measures.

RESULTS. Participants’ arm use improved after somatosensory retraining (z = −6.80, p &lt; .01). Change in arm use was weakly associated with somatosensation (tactile, β = 0.31, p &lt; .01; proprioception, β = −0.17, p &gt; .05; object recognition, β = 0.13, p &lt; .05).

CONCLUSION. Change in daily arm use was related to a small amount of variance in somatosensory outcomes. Stroke survivors’ functional arm use can increase after somatosensory retraining, with change varying among survivors.

Relationship between touch sensation of the affected hand and performance of valued activities in individuals with chronic stroke

OBJECTIVE

To investigate the association between touch sensation of the affected hand and performance and satisfaction with performance of valued activities in individuals with chronic stroke.

METHODS

Using a cross-sectional study design, this study correlated factors related to hand sensation and activity performance in individuals with chronic stroke. The Touch Test Evaluators and Canadian Occupational Performance Measure (COPM) were used. Correlations were used to determine the relationships between touch sensation of the affected hand and individuals' performance and satisfaction with performance of valued activities.

RESULTS

There was a good to excellent relationship between sensation and performance and satisfaction with performance of valued activities for individuals with intact touch sensation of the affected hand who scored higher on the COPM. There was little to no relationship between touch sensation of the affected hand and performance of valued activities for individuals with impaired sensation.

CONCLUSION

This is the first study to relate touch sensation of the affected hand and performance and satisfaction with performance of valued activities in individuals with stroke. The findings suggest that rehabilitation therapists need to continue to address sensory function in evaluation and intervention as it relates to performance in valued activities. This study serves as a foundation for future research in sensation and performance of valued activities in individuals with chronic stroke.

Sensory impairment after stroke: Exploring therapists' clinical decision making

BACKGROUND

Stroke survivors experience sensory impairments that significantly limit upper-limb functional use. Lack of clear research-based guidelines about their management exacerbates the uncertainty in occupational therapists' decision making to support these clients.

PURPOSE

This study explores occupational therapists' clinical decision making regarding upper-limb, post-stroke sensory impairments that can ultimately inform approaches to support therapists working with such clients.

METHOD

Twelve therapists participated in a qualitative descriptive study. Transcripts of semi-structured interviews were analyzed using content analysis.

FINDINGS

Three overarching categories were identified: deciding on the focus of interventions (describing intervention choices), it all depends (outlining factors considered when choosing interventions), and managing uncertainty in decision making (describing uncertainty and actions taken to resolve it).

IMPLICATIONS

Providing training about post-stroke sensory impairment and decision making may improve therapists' decision making and ultimately improve client outcomes. Further research is needed to understand the impact of uncertainty on occupational therapy decision making and resulting care practices.

Feasibility and Effect of a Professional Education Workshop for Occupational Therapists’ Management of Upper-Limb Poststroke Sensory Impairment

OBJECTIVE. We examined the development, implementation, and effectiveness of a theory-based workshop to facilitate knowledge translation for occupational therapists addressing upper-limb poststroke sensory impairments.

METHOD. Nineteen therapists participated in a quasi-experimental pretest–posttest study that included an 8-hr evidence-based workshop designed using the Theory of Planned Behavior. We measured changes in knowledge, attitudes, and perceived behavioral control and intended behaviors regarding sensory impairment management, research utilization, and shared decision making.

RESULTS. We noted significant changes in knowledge, attitudes, and perceived behavioral control and intended behaviors about sensory impairment management, research utilization, and shared decision making and made recommendations for changes in recruitment strategies, outcome measures, and workshop content.

CONCLUSION. A theory-based workshop can potentially affect knowledge, attitudes, and intended behaviors about sensory impairment management, research utilization, and shared decision making. A randomized controlled trial evaluating this intervention is warranted and will potentially improve understanding of methods to facilitate knowledge translation.