[WEB SITE] Stroke: systems of care and rehabilitation – The Lancet

Executive Summary

Stroke, the third leading cause of death and disability, requires timely delivery of best-practice care to improve patient outcomes. In high-income countries, major developments have streamlined systems of care and improved the speed of recognition, response, triage, and delivery of acute treatments. In low-income and middle-income countries, despite disparities in wealth, education, baseline health indicators, and funding of health-care expenditures, stroke services can be improved with a few adaptations and infrastructural remodelling. This three-part series discusses various aspects of stroke care, challenges, and opportunities for improvement of systems of care and highlights approaches for rapid uptake of evidence-based practice for rehabilitation. Finally, a call to action urges educators and the stroke rehabilitation clinical, research, and not-for-profit communities to work together for greater effect and to accelerate progress.

Series

• Stroke systems of care in high-income countries: what is optimal?Langhorne et alThe Lancet, Vol. 396, No. 1026Published: October 31, 2020 Full-Text HTML PDF
• Stroke systems of care in low-income and middle-income countries: challenges and opportunities Pandian et al. The Lancet, Vol. 396, No. 10260 Published: October 31, 2020 Full-Text HTML PDF
• Stroke rehabilitation in low-income and middle-income countries: a call to action Bernhardt et al. The Lancet, Vol. 396, No. 10260 Published: October 31, 2020 Full-Text HTML PDF

Source

[Abstract] Evidence based practice ‘on-the-go’: using ViaTherapy as a tool to enhance clinical decision making in upper limb rehabilitation after stroke – a quality improvement initiative

Abstract

Recovery of upper limb function after stroke is currently sub-optimal, despite good quality evidence showing that interventions enabling repetitive practice of task-specific activity are effective in improving function. Therapists need to access and engage with such evidence to optimise outcomes with people with stroke, but this is challenging in fast-paced stroke rehabilitation services. This quality improvement project aimed to investigate acceptability and service impact of a new, international tool for accessing evidence on upper limb rehabilitation after stroke- ‘ViaTherapy’- in a team of community rehabilitation therapists. Semi-structured interviews were undertaken at baseline to determine confidence in, and barriers to, evidence-based practice (EBP) to support clinical decision making. Reported barriers included time, lack of access to evidence, and a research-practice disconnect. The clinicians then integrated use of ‘ViaTherapy’ into their practice for four weeks. Follow-up interviews explored the accessibility of the tool in community rehabilitation practice, and its impact on clinician confidence, treatment planning and provision. Clinicians found the tool, used predominantly in mobile device app format, to be concise and simple to use, providing evidence “on-the-go.” Confidence in accessing and using EBP grew by 22% from baseline. Clinicans reported changes in intensity of delivery of interventions, as rapid access to recommended doses via the tool was available. Following this work, the participating health and social care service provider changed provision of therapists’ technology to enable use of apps. Barriers to use of EBP in stroke rehabilitation persist; the baseline situation here supported the need for more accessible means of integrating best evidence into clinical processes. This quality improvement project successfully integrated ViaTherapy into clinical practice, and found that the tool has potential to underpin positive changes in upper limb therapy service delivery after stroke, by increasing accessibility to, use of, and confidence in evidence-based practice. Definitive evaluation is now indicated.

via Evidence based practice ‘on-the-go’: using ViaTherapy as a tool to enhance clinical decision making in upper limb rehabilitation after stroke – a quality improvement initiative – UEA Digital Repository

 

[Abstract] Towards strengthening rehabilitation in health systems: Methods used to develop a WHO Package of Rehabilitation Interventions

Abstract

Achieving universal health coverage (UHC) is a World Health Organization (WHO) strategic priority. UHC means “all people receive quality health services that meet their needs without being exposed to financial hardship in paying for the services”. Rehabilitation is among the services included in UHC. As part of the WHO Rehabilitation 2030 call for action, WHO is developing its Package of Rehabilitation Interventions (PRI) to support ministries of health in planning, budgeting and integrating rehabilitation interventions into health systems. The aim of this paper is to introduce and describe the PRI and its methodology.

An advisory board composed of members from different WHO departments is overseeing the project, which is led by the WHO Rehabilitation Programme in collaboration with Cochrane Rehabilitation.

The development of the PRI is conducted in six steps: (1) Selection of health conditions (for which rehabilitation interventions will be included in the PRI) based on prevalences, related levels of disability and expert opinion; (2) identification of rehabilitation interventions and related evidence for the selected health conditions from clinical practice guidelines and Cochrane Reviews; (3) expert agreement on the inclusion of rehabilitation interventions in the PRI; (4) description of resources required for the provision of selected interventions; (5) peer review process, and (6) production of an open source web-based tool. Rehabilitation experts and consumers from all world regions will collaborate in the different steps.

In developing the PRI, WHO is taking an important step towards strengthening rehabilitation in health systems and thus, enabling more people to benefit from rehabilitation.

via Towards strengthening rehabilitation in health systems: Methods used to develop a WHO Package of Rehabilitation Interventions – Archives of Physical Medicine and Rehabilitation

[Letter to the Editor] Societá Italiana de Fisioterapia and the Physiotherapy Evidence Database (PEDro) – Full Text

Abstract

This paper provides an overview of a free resource that can be used by physiotherapists to assist their efforts to undertake evidence-based practice. The resource is the Physiotherapy Evidence Database (PEDro; www.pedro.org.au) – a searchable online database that in February 2019 indexes the details of over 42,000 pieces of published evidence about the effects of physiotherapy interventions. PEDro is searched millions of times each year by users worldwide. Societá Italiana de Fisioterapia (SIF; www.sif-fisioterapia.it) has entered into a collaboration with the developers of PEDro. In addition to describing the evidence available on PEDro and who uses it, this paper also summarises the features of PEDro that can facilitate evidence-based physiotherapy. This paper concludes by outlining the collaboration between SIF and PEDro.

Evidence-based physiotherapy

The approach to the clinical care of patients known as “evidence-based practice” is becoming more widely accepted within the physiotherapy profession. The approach was defined by its developers as the “integration of the best research evidence with clinical expertise and patient values” [1]. Clinical physiotherapists who want their practice to be evidence-based must therefore identify the best evidence that is available to help inform their decisions about patient management.

It is difficult for physiotherapists to keep abreast of all the research that might be relevant to the types of patients they treat in clinical practice. One contributor to this difficulty is that, with ongoing publications, the number of trials of physiotherapy interventions is growing exponentially [2, 3]. If we consider physiotherapists who graduated in 2011, their university training could only have been based on about half of the evidence that currently exists about the efficacy of physiotherapy interventions. Another issue is that it can be laborious to find the relevant evidence on databases. For example, if a physiotherapist wanted to find evidence about the effects of physiotherapy treatments for knee osteoarthritis, a search of ‘knee osteoarthritis’ on the PubMed database in February 2019 returned over 31,500 articles, many of which have nothing to do with physiotherapy interventions. Searching can be targeted towards more relevant articles but this requires a knowledge of sophisticated search strategies, which involve category searches, Medical Subject Headings (MeSH) terms, Boolean operators, truncation and quotations [4, 5]. This inefficiency is an important issue because most clinical physiotherapists have limited time to find and read evidence. It would be simpler and more efficient if physiotherapists seeking evidence to guide their clinical practice could use a database that indexed only research publications about the effects of physiotherapy interventions.

Physiotherapy Evidence Database (PEDro)

To address the situation described above, a group of physiotherapists established the Physiotherapy Evidence Database. More commonly referred to as ‘PEDro’, the database is freely available for anyone to use at www.pedro.org.au. This section of the paper will describe the content and features of PEDro, relating these to how they can assist physiotherapists who want to keep abreast of the growing body of evidence about physiotherapy interventions. This section will conclude with a review of how often and how widely PEDro is used

Content of PEDro

Evidence indexed on PEDro

PEDro indexes the bibliographic details and abstracts of three types of documents. One type of document is randomised clinical trials of physiotherapy interventions (or interventions that could become part of physiotherapy care). Another type of document is systematic reviews that include at least one randomised trial of a physiotherapy intervention.¹ The third type of document is clinical practice guidelines that are based on a systematic literature search and that contain at least one recommendation relevant to physiotherapy practice. Although there are other forms of evidence (for example, inception cohort studies provide evidence about prognosis), the most unbiased evidence about the effects of interventions comes from the forms of evidence indexed on PEDro: randomised trials, systematic reviews and clinical practice guidelines.

In February 2019, PEDro indexed over 33,000 trials, over 8000 systematic reviews, and over 650 clinical practice guidelines. The trials examine interventions from a wide range of subdisciplines, as shown in Fig. 1. This figure illustrates that the subdisciplines musculoskeletal, cardiothoracics, neurology and gerontology contribute the greatest share of records to PEDro, although even the subdisciplines with the fewest records have substantial evidence for interested users.

[…]

Continue —> Societá Italiana de Fisioterapia and the Physiotherapy Evidence Database (PEDro) | Archives of Physiotherapy | Full Text

[Abstract] Knowledge Translation: The Bridging Function of Cochrane Rehabilitation

Abstract

Cochrane Rehabilitation is aimed to ensure that all rehabilitation professionals can apply Evidence Based Clinical Practice and take decisions according to the best and most appropriate evidence in this specific field, combining the best available evidence as gathered by high-quality Cochrane systematic reviews, with their own clinical expertise and the values of patients. This mission can be pursued through knowledge translation.

The aim of this article is to shortly present what knowledge translation is, how and why Cochrane (previously known as Cochrane Collaboration) is trying to reorganize itself in light of knowledge translation, and the relevance that this process has for Cochrane Rehabilitation and in the end for the whole world of rehabilitation. It is well known how it is difficult to effectively apply in everyday life what we would like to do and to apply the scientific knowledge in the clinical field: this is called the know-do gap.

In the field of evidence-based medicine, where Cochrane belongs, it has been proven that high-quality evidence is not consistently applied in practice. A solution to these problems is the so-called knowledge translation.

In this context, Cochrane Rehabilitation is organized to provide the best possible knowledge translation in both directions (bridging function), obviously toward the world of rehabilitation (spreading reviews), but also to the Cochrane community (production of reviews significant for rehabilitation). Cochrane is now strongly pushing to improve its knowledge translation activities, and this creates a strong base for Cochrane Rehabilitation work, focused not only on spreading the evidence but also on improving its production to make it more meaningful for the world of rehabilitation.

 

via Knowledge Translation: The Bridging Function of Cochrane Rehabilitation – ScienceDirect

[ARTICLE] Moving Research From the Bedside Into Practice | Physical Therapy Journal – Full Text

Evidence-based practice (EBP) is firmly entrenched in the lexicon of physical therapist practice,^1,2 but beliefs about how best to translate scientific evidence into clinical practice are far from settled. There are major gaps in our scientific knowledge; however, even more disturbing is the fact that an enormous amount of existing scientific knowledge remains unused in practice. As noted in the Institute of Medicine (IOM) report titled Crossing the Quality Chasm, “Between the health care we have and the care we could have lies not just a gap, but a chasm.”³

Thankfully, the infamous 264-year period between the discovery of citrus’s benefit in preventing scurvy and the widespread use of citrus on British ships is no longer the norm.⁴ But the frequently quoted statement about the lag time between publication and adoption of research—only 14% of original research is applied for the benefit of patient care, and that takes 17 years^5,6—is alarming enough. There is consensus that the transfer of evidence from proven health care discoveries to patient care is unpredictable and highly variable and needs to be accelerated.^4,7,8

For those of us who want to speed the adoption of EBP in physical therapy and across health care more broadly, Naylor⁹ described 4 distinct phases or strategies that are instructive:

Phase 1, the “Era of Optimism,” is characterized by a belief in passive diffusion of scientific evidence into practice. In this (still-dominant) phase, students and clinicians are trained to critically appraise the scientific literature to identify valid new information that could be applied to practice.

Phase 2, the “Era of Innocence Lost and Regained,” acknowledges that much of clinical practice is not evidence based and that it is virtually impossible for clinicians to keep up with the explosion of medical literature. This understanding has led to the emergence of evidence-based clinical practice guidelines, in which the literature is systematically reviewed and summary recommendations are graded according to the strength of the supporting evidence. Guidelines are widely disseminated on the assumption that providers will read them and that practice will change accordingly.

Phase 3, the “Era of Industrialization,” is on the rise, as evidence mounts that the passive efforts of phases 1 and 2 fail to actually change practice. In this phase, aggressive strategies are implemented by regulatory entities or professions to improve care. These efforts frequently involve performance measurement and reporting,¹⁰ which are intended to encourage providers to become more accountable and more focused on quality improvement. Many professions have risen to this challenge and have developed their own approaches to change patient management as described by Naylor.⁹APTA’s Physical Therapy Outcomes Registry,¹¹ an organized system for collecting data to evaluate patient function and other clinically relevant measures, is a phase 3 effort, with improving practice and fulfilling quality reporting requirements as 2 of its major goals.

Phase 4, the final phase, is the “Era of Information Technology and Systems Engineering,” which is driven by the belief that it is not sufficient to focus on individual practitioners, but rather the redesign of service delivery systems to address barriers and incentives is required to bridge the wide gap between best evidence and common practice. For this phase, a different type of evidence base—one describing the most effective ways to change provider behavior^9,12—is needed. Hence the emergence of the relatively new field of implementation research.

Continue —> Moving Research From the Bedside Into Practice | Physical Therapy Journal

[Literature Review] Cognitive Rehabilitation After Traumatic Brain Injury – Full Text HTML/PDF

Abstract

Nearly 1.7 million Americans sustain a traumatic brain injury (TBI) each year. These injuries can result in physical, emotional, and cognitive consequences. While many individuals receive cognitive rehabilitation from occupational therapists (OTs), the interdisciplinary nature of TBI research makes it difficult to remain up-to-date on relevant findings. We conducted a literature review to identify and summarize interdisciplinary evidence-based practice targeting cognitive rehabilitation for civilian adults with TBI. Our review summarizes TBI background, and our cognitive remediation section focuses on the findings from 37 recent (since 2006) empirical articles directly related to cognitive rehabilitation for individuals (i.e., excluding special populations such as veterans or athletes). This manuscript is offered as a tool for OTs engaged in cognitive rehabilitation and as a means to highlight arenas where more empirical, interdisciplinary research is needed.

 

Introduction

Imagine this scenario: An occupational therapist (OT) at a rehabilitation hospital receives the schedule for the day. From this list of names, the OT has 30 min to complete a chart review and make treatment plans. For clients with physical injuries, the treatment plan is clear. These patients will work with the OT to increase their limb flexibility, strength, and utility. The OT will provide adaptive equipment to compensate for the physical deficits that cannot be remediated. However, there is one client listed who has a traumatic brain injury (TBI). She needs cognitive rehabilitation so she can return home safely. The OT recognizes that rehabilitation should focus on improving the client’s attention, learning, and memory, but it is not always clear what approach is optimal. The client’s injury is internal and invisible. The OT wants to believe that the activities the client completes will lead to meaningful improvements to her brain function. But is there any certainty of this? Do improvements during acute therapy translate to real-life functionality? At what time point does an OT assume that remediatory approaches are futile, and compensatory interventions are best practice? What factors regarding patient management from other intervention stages must be considered to predict optimal cognitive outcomes? When should rehabilitation end? What literatures can be tapped to address unexpected issues?

This vignette depicts some of the challenges facing OTs involved in the cognitive rehabilitation of people with TBI. TBI is defined as brain damage that disrupts cognitive function in variable ways with diverse consequences (The Merck Manual of Diagnosis and Therapy, 2006). Nearly 1.7 million Americans sustain a TBI each year, prompting 275,000 hospitalizations (Faul, Xu, Wald, & Coronado, 2010). Acutely, TBI severity is assessed using the Glasgow Coma Scale (GCS; Teasdale & Jennett, 1974). GCS scores can be grouped according to TBI severity: mild (13+), moderate (8-12), or severe (<8; Decuypere & Klimo, 2012). GCS scores can be predictive of future cognitive dysfunction, which is associated with future disability (Skandsen et al., 2010). Perhaps, surprisingly, there is no “gold standard” for cognitive rehabilitation (Gordon, 2011) and, consequently, no systematic approach to cognitive remediation. Therapists, of course, use theoretical models to guide interventions, but empirical evidence can help expedite interventions and maximize gains. Without a systematic, evidence-based approach, a patient with TBI may receive varied cognitive interventions until one works, or worse, until reimbursed rehabilitation ends. Cognitive rehabilitation, by nature, results in gains, losses, and plateaus. It is estimated that at least 300 hr of appropriate therapy are needed to promote optimal outcomes. Therefore, it is essential that OT and other therapists use those hours effectively (Leon-Carrion, Dominguez-Morales, Barroso y Martin, & Leon-Dominguez, 2012). In this review, we sought to identify evidence-based cognitive rehabilitation interventions that exist within TBI literature.

Unfortunately, there is no single, uniform TBI literature to support the development of comprehensive best practices. Instead, physicians, nurses, neuropsychologists, therapists, researchers, and other professionals publish relevant findings in field-specific journals. This makes it challenging to stay current with the literature(s). This criticism was highlighted in a recent paper that described the heterogeneity of both TBI patients and TBI literature (Maas et al., 2013). The authors noted that clinical research is often derailed by non-standardized data collection and insufficient multidisciplinary collaboration. The purpose of this article is to summarize relevant findings across the TBI literatures for an OT readership. In short, this review is intended as an “update” for busy OTs conducting cognitive rehabilitation. Our secondary goal is to expand cross talk between related fields as TBI is inherently interdisciplinary and to encourage OTs to promote research that will supply much-needed empirical basis for refining evidence-based practices. We review issues that influence and improve cognitive recovery from the moment of the TBI itself. These topics include successful early medical interventions, assessment, and empirically based cognitive rehabilitation strategies.

There are systematic, broad review papers of evidence-based cognitive rehabilitation (see Carney et al., 1999; Cicerone et al., 2000; Cicerone et al., 2005; Rees, Marshall, Hartridge, Mackie, & Weiser, 2007). This review adds to these papers by focusing on the recent literature and explicitly targeting an audience of OTs. Using the search term TBI cognitive rehabilitation in humans in PubMed, we found 932 articles published between 2006 and 2014. We focus on cognitive rehabilitation for the non-veterans/athletes adult TBI population, and therefore excluded articles specific to other populations, and articles that did not explicitly describe effective cognitive treatment strategies.¹ The remaining relevant articles were used to create this review. We also used additional search engines (e.g., Cochrane Library, PEDro, Google Scholar) to ensure that the cognitive rehabilitation section provided as close tocomprehensive coverage of recent empirical articles as possible.

Although grant funding and research programs target TBI in veterans and athletes, our goal was to highlight the consequences of TBI in adult non-veterans/athletes. Recently, falls have replaced motor vehicle accidents as the leading cause of TBI. In the United States, the older adult population is rapidly growing, and older adults are particularly vulnerable to TBI from falls (Wick, 2012). Therefore, it is essential that research also focus on rehabilitation for everyday individuals who sustain TBI. As stated above, our goal was to provide a targeted integration across multiple fields to support OTs engaged in cognitive rehabilitation. At the end of each segment is a brief statement recapitulating the direct relevance of the section to the occupational therapy interventions for TBI. In closing the review, we provide a breakdown of the empirical evidence by cognitive domain to promote our view that increased research is needed. Finally, as a textual note, to avoid excessive qualification (given the variability inherent in TBI), we acknowledge that there can always be exceptions to the general patterns of results described below.

Full Text (PDF)

Continue —-> Cognitive Rehabilitation After Traumatic Brain Injury

[REVIEW] Cognitive Rehabilitation After Traumatic Brain Injury – Full Text HTML/PDF

Abstract

Nearly 1.7 million Americans sustain a traumatic brain injury (TBI) each year. These injuries can result in physical, emotional, and cognitive consequences. While many individuals receive cognitive rehabilitation from occupational therapists (OTs), the interdisciplinary nature of TBI research makes it difficult to remain up-to-date on relevant findings. We conducted a literature review to identify and summarize interdisciplinary evidence-based practice targeting cognitive rehabilitation for civilian adults with TBI.

Our review summarizes TBI background, and our cognitive remediation section focuses on the findings from 37 recent (since 2006) empirical articles directly related to cognitive rehabilitation for individuals (i.e., excluding special populations such as veterans or athletes). This manuscript is offered as a tool for OTs engaged in cognitive rehabilitation and as a means to highlight arenas where more empirical, interdisciplinary research is needed.

Full Text HTML —> Cognitive Rehabilitation After Traumatic Brain Injury

[REVIEW] Cognitive Rehabilitation After Traumatic Brain Injury – Full Text HTML/PDF

Abstract

Nearly 1.7 million Americans sustain a traumatic brain injury (TBI) each year. These injuries can result in physical, emotional, and cognitive consequences. While many individuals receive cognitive rehabilitation from occupational therapists (OTs), the interdisciplinary nature of TBI research makes it difficult to remain up-to-date on relevant findings.

We conducted a literature review to identify and summarize interdisciplinary evidence-based practice targeting cognitive rehabilitation for civilian adults with TBI. Our review summarizes TBI background, and our cognitive remediation section focuses on the findings from 37 recent (since 2006) empirical articles directly related to cognitive rehabilitation for individuals (i.e., excluding special populations such as veterans or athletes).

This manuscript is offered as a tool for OTs engaged in cognitive rehabilitation and as a means to highlight arenas where more empirical, interdisciplinary research is needed.

Continue —> Cognitive Rehabilitation After Traumatic Brain Injury

[REVIEW] Cognitive Rehabilitation After Traumatic Brain Injury: A Reference for Occupational Therapists – Full Text HTML

Abstract

Nearly 1.7 million Americans sustain a traumatic brain injury (TBI) each year. These injuries can result in physical, emotional, and cognitive consequences. While many individuals receive cognitive rehabilitation from occupational therapists (OTs), the interdisciplinary nature of TBI research makes it difficult to remain up-to-date on relevant findings.

We conducted a literature review to identify and summarize interdisciplinary evidence-based practice targeting cognitive rehabilitation for civilian adults with TBI. Our review summarizes TBI background, and our cognitive remediation section focuses on the findings from 37 recent (since 2006) empirical articles directly related to cognitive rehabilitation for individuals (i.e., excluding special populations such as veterans or athletes).

This manuscript is offered as a tool for OTs engaged in cognitive rehabilitation and as a means to highlight arenas where more empirical, interdisciplinary research is needed.

Read Full Article —> Cognitive Rehabilitation After Traumatic Brain Injury.