Following orthopaedic injury or stroke, there is clear evidence that people who do more practice in rehabilitation achieve better outcomes.1, 2, 3, 4, 5 In stroke survivors, a pooled analysis of eight trials3 established that if the therapy dose provided is increased by more than two times, the effect size on activity outcomes is 0.59 (95% CI 0.23 to 0.94). Scrivener et al established that the number of lower limb repetitions achieved in the first week of rehabilitation after a stroke is a good clinical predictor of walking speed at discharge from rehabilitation.4 This dose-response relationship has also been shown in people with orthopaedic conditions. Inpatients having rehabilitation following a hip fracture achieved better functional outcomes if they were more active in therapy sessions.6 Inpatients with lower limb orthopaedic conditions achieved better functional outcomes and had a shorter length of stay if they were more active throughout the entire day.2
Despite the evidence that increased amounts of practice result in better outcomes, patientsin rehabilitation do not generally engage in large amounts of physical practice. The time spent in physiotherapy for stroke survivors in inpatient rehabilitation ranges from 24 to 87 minutes per day.7, 8, 9, 10, 11, 12, 13, 14, 15, 16 Similarly, the time spent in physiotherapy for patients with orthopaedic conditions is only 45 minutes per day.13 Additionally, the time spent in active practice during therapy sessions is low, with many studies reporting that less than half of a therapy session is spent in active practice.11, 17, 18, 19, 20 The main reason for these short times spent in therapy and in active practice is that the most common mode of delivery of therapy in the gym area is one-to-one therapy (ie, the patient practises under direct supervision of one or more therapists, therapy students or therapy assistants). This results in a very limited number of patients being in the therapy area at one time, and high therapist to patient ratios. A recent study on inpatient stroke rehabilitation reported that the mean number of staff per patient was two, and patients were participating in less than 30 minutes of physiotherapy a day.21 One potential solution to this problem is to provide opportunities for ‘semi-supervised practice’, meaning that patients practise in the therapy area without the direct supervision of a therapist. This provides the opportunity for patients to spend much longer periods of the day in the gym area with the potential for achieving more time in active practice.
The following strategies can be used to facilitate the provision of semi-supervised practice for patients in rehabilitation. First, the environment of the therapy area can be structured to provide permanent practice areas.22 For example, all the required equipment for different exercises can be placed at workstations, allowing efficient set up for practice. Second, the environment at these workstations can be modified to provide safety when patients are practising without a therapist (eg, the use of adjacent walls, benches and plinths). Third, therapists or therapy assistants can supervise many patients at the same time in class or group settings.7 Additionally, members of the patient’s family can provide assistance with practice. Interestingly, when families are involved in therapy, this not only improves outcomes for stroke survivors but decreases the caregiver strain experienced by the family members.23
Currently, in the risk-averse setting of a hospital, semi-supervised practice is generally not provided24 and in some settings is actually not permitted. To date, it appears that the provision of semi-supervised practice has not been evaluated to establish what percentage of practice occurs as semi-supervised practice when that option is provided, whether patients continue to practise when they are not under direct supervision of a therapist, and whether semi-supervised practice can be provided without compromising patient safety. This information could help to change current clinical management to include more semi-supervised practice, thereby enabling patients in rehabilitation to achieve greater amounts of practice and spend more of their time active.
Therefore, the research questions for this observational study were as follows. When a hospital gymnasium used for inpatient rehabilitation is set up to facilitate semi-supervised practice:
- What percentage of practice is performed as semi-supervised practice?
- What percentage of patients in the gym are actively engaged in practice (as opposed to resting) at any time?
- Is the semi-supervised practice that occurs safe?