Lessons Learned: The Difficulties of Incorporating Intensity Principles Into Inpatient Stroke Rehabilitation

Bowden, Mark G.; Monsch, Eric D.; Middleton, Addie; Daughtry, Chris; Powell, Troy; Kraft, Sara

doi:10.1016/j.arrct.2020.100052

Cited by 7 publications

(13 citation statements)

References 26 publications

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“…Remarkably, the vast majority of the patients had already received intensive rehabilitation previously. Previous research showed small differences in ADL abilities only for longer time in rehabilitation with higher therapy intensity [ 19 , 20 ]. The median therapy intensity at P.A.N.…”

Section: Discussionmentioning

confidence: 99%

Effects of transsectoral long-term neurorehabilitation

Schrader,

Sterr,

Strank

et al. 2024

Neurol. Res. Pract.

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Background Acquired brain injuries are among the most common causes of disability in adulthood. An intensive rehabilitation phase is crucial for recovery. However, there is a lack of concepts to further expand the therapeutic success after the standard rehabilitation period. Hereafter, the characteristics of a transsectoral, multiprofessional long-term neurorehabilitation concept and its effects on outcome at different ICF levels are described. Methods The P.A.N. Center for Post-Acute Neurorehabilitation combines living with 24/7 support of pedagogical staff with on-site outpatient therapy and medical care. A secondary data analysis was conducted on the records of all patients with completeted P.A.N. treatment between 01.01.2015 and 09.04.2022. Outcome parameters included demographic characteristics, diagnostics, Barthel Index (BI), the German scale „Hilfebedarf von Menschen mit Behinderung für den Lebensbereich Wohnen “ (HMBW), the Canadian Occupational Performance Measure (COPM) and the destination after discharge. For BI and discharge destination, potential determinants of therapy success are evaluated. Results 168 patients were enrolled in the analyses. Significant improvements were observed in the BI (p < .001), with median values increasing from 55 to 80 points. The HMBW showed a significant decrease in the need for assistance in everyday living (p < .001), individual basic care (p < .001), shaping social relationship (p = .003) and communication (p < .001). Significant improvements were reported in the COPM total score for performance (p < .001) and satisfaction (p < .001). 72% of the patients were able to move in a community living arrangement with moderate need for support. Main predictive factor for discharge destination was the initial cognitive deficit. The comparison of the third-person scales BI and HMBW with the self-reported COPM showed that individually formulated patient goals are only insufficiently reflected in these global scales. Discussion The data show that a highly coordinated, trans-sectoral 24/7 approach of goal-oriented practice as pursued at P.A.N. is feasible and effective. We assume that the success of the intervention is due to the high intensity of therapies delivered over a long time and its interlink with real world practice. For a comprehensive analysis of rehabilitation success, it is necessary to record and evaluate individual patient goals, as these are not always reflected in the commonly used global scales.

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Section: Discussionmentioning

confidence: 99%

Effects of transsectoral long-term neurorehabilitation

Schrader,

Sterr,

Strank

et al. 2024

Neurol. Res. Pract.

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“…There is still work to be done related to translating research into practice and decreasing the research-to-practice gap in the rehabilitation settings despite many efforts being made by many teams (26,28). The shorter time it takes for the latest evidence to be applied to clinical practice, the greater chance for patients to receive better care (39).…”

Section: Discussionmentioning

confidence: 99%

“…There are multiple examples of pragmatic research projects that use the KTA and the CFIR in a rehabilitation setting. Studies suggest that using the CFIR may increase the replicability and generalizability of study findings (26)(27)(28), and the KTA cycle can contribute to positive changes in stroke rehabilitation practices (21).…”

Section: Introductionmentioning

confidence: 99%

The Implementation Process of Two Evidence-Based Protocols: A Spatial Neglect Network Initiative

Hreha

Barrett

Gillen³

et al. 2022

Front.Health Serv.

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IntroductionSpatial neglect, a neurocognitive disorder of lateralized spatial attention, is prevalent among stroke survivors especially in inpatient rehabilitation facilities (IRFs). The ultimate goal of the project was to improve spatial neglect care in inpatient rehabilitation and trained as many OTs as possible using both tools in their regular practices as the means to achieve our overall objective. Therefore, we conducted a project aimed at implementing two evidence-based protocols, one for assessment (KF-NAP®) and the other for treatment (KF-PAT®), and share the implementation process, which included barriers and facilitators identified during and after the process, and implementation outcomes.MethodsSixteen IRFs were involved. The Knowledge-To-Action Cycle was used to describe the process of knowledge inquiry (training), translating knowledge (implementation) and evaluating the use of knowledge in clinical practice (outcomes). Barriers and strategies were reported using the Consolidated Framework for Implementation Research and identified through a survey, after the study concluded.ResultsThirty-two therapists at the participating sites were trained to some level of the KF-NAP and KF-PAT. Throughout the project and also once after it finished, different barriers were identified by researchers and clinicians, who then determined together actions to eliminate or minimize the barriers. For example, multiple sites reported: “not having time to train other staff at their hospital due to high patient volume and other responsibilities.”DiscussionThe project shared our implementation process which demonstrated the importance of using implementation methods and incorporating a researcher-clinician partnership, not only for knowledge generation but also knowledge translation. Frequent communications and exchanging information with stakeholders at different levels, may be determinant to the success of each implementation phase. Further research is needed.

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“…Barriers to performing HIT during routine inpatient rehabilitation post-stroke are multifactorial and may include minimal didactic education and training on psychomotor skills used to provide HIT in lower functioning individuals, lack of heart rate monitoring and gait training equipment, patient safety concerns, and the extent of many patients' physical deficits. 14,15 However, previous studies have shown that such implementation is feasible. 1,16 In particular, a cohort study of 201 individuals post-stroke receiving HIT focused on stepping during inpatient rehabilitation performed approximately 1500 steps/day, with substantial gains in locomotor function as well as balance and transfers despite reduced attention towards these latter tasks.…”

Section: Introductionmentioning

confidence: 99%

Increasing the Amount and Intensity of Stepping Training During Inpatient Stroke Rehabilitation Improves Locomotor and Non-Locomotor Outcomes

Henderson

Plawecki

Lucas

et al. 2022

Neurorehabil Neural Repair

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Background The efficacy of traditional rehabilitation interventions to improve locomotion post-stroke, including providing multiple exercises targeting impairments and activity limitations, is uncertain. Emerging evidence rather suggests attempts to prioritize stepping practice at higher cardiovascular intensities may facilitate greater locomotor outcomes. Objective The present study was designed to evaluate the comparative effectiveness of high-intensity training (HIT) to usual care during inpatient rehabilitation post-stroke. Methods Changes in stepping activity and functional outcomes were compared over 9 months during usual-care (n = 131 patients < 2 months post-stroke), during an 18-month transition phase with attempts to implement HIT (n = 317), and over 12 months following HIT implementation (n = 208). The transition phase began with didactic and hands-on education, and continued with meetings, mentoring, and audit and feedback. Fidelity metrics included percentage of sessions prioritizing gait interventions and documenting intensity. Demographics, training measures, and outcomes were compared across phases using linear or logistic regression analysis, Kruskal-Wallis tests, or χ2 analysis. Results Across all phases, admission scores were similar except for balance (usual-care>HIT; P < .02). Efforts to prioritize stepping and achieve targeted intensities during HIT vs transition or usual-care phases led to increased steps/day ( P < .01). During HIT, gains in 10-m walk [HIT median = 0.13 m/s (interquartile range: 0-0.35) vs usual-care = 0.07 m/s (0-0.24), P = .01] and 6-min walk [50 (9.3-116) vs 2.1 (0-56) m, P < .01] were observed, with additional improvements in transfers and stair-climbing. Conclusions Greater efforts to prioritize walking and reach higher intensities during HIT led to increased steps/day, resulting in greater gains in locomotor and non-locomotor outcomes.

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Lessons Learned: The Difficulties of Incorporating Intensity Principles Into Inpatient Stroke Rehabilitation

Cited by 7 publications

References 26 publications

Effects of transsectoral long-term neurorehabilitation

Effects of transsectoral long-term neurorehabilitation

The Implementation Process of Two Evidence-Based Protocols: A Spatial Neglect Network Initiative

Increasing the Amount and Intensity of Stepping Training During Inpatient Stroke Rehabilitation Improves Locomotor and Non-Locomotor Outcomes

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