Naoimh E McMahon

A formative evaluation of the implementation of an upper limb stroke rehabilitation intervention in clinical practice: a qualitative interview study

BackgroundThe Graded Repetitive Arm Supplementary Program (GRASP) is a hand and arm exercise programme designed to increase the intensity of exercise achieved in inpatient stroke rehabilitation. GRASP was shown to be effective in a randomised controlled trial in 2009 and has since experienced unusually rapid uptake into clinical practice. The aim of this study was to conduct a formative evaluation of the implementation of GRASP to inform the development and implementation of a similar intervention in the United Kingdom.MethodsSemi-structured interviews were conducted with therapists who were involved in implementing GRASP at their work site, or who had experience of using GRASP. Normalisation Process Theory (NPT), a sociological theory used to explore the processes of embedding innovations in practice, was used to develop an interview guide. Intervention components outlined within the GRASP Guideline Manual were used to develop prompts to explore how therapists use GRASP in practice. Interview transcripts were analysed using a coding frame based on implementation theory.ResultsTwenty interviews were conducted across eight sites in British Columbia Canada. Therapists identified informal networks and the free online availability of GRASP as key factors in finding out about the intervention. All therapists reported positive opinions about the value of GRASP. At all sites, therapists identified individuals who advocated for the use of GRASP, and in six of the eight sites this was the practice leader or senior therapist. Rehabilitation assistants were identified as instrumental in delivering GRASP in almost all sites as they were responsible for organising the GRASP equipment and assisting patients using GRASP. Almost all intervention components were found to be adapted to some degree when used in clinical practice; coverage was wider, the content adapted, and the dose, when monitored, was less.ConclusionsAlthough GRASP has translated into clinical practice, it is not always used in the way in which it was shown to be effective. This formative evaluation has informed the development of a novel intervention which aims to bridge this evidence-practice gap in upper limb rehabilitation after stroke.

Development of a behaviour change intervention to increase upper limb exercise in stroke rehabilitation

BackgroundTwo thirds of survivors will achieve independent ambulation after a stroke, but less than half will recover upper limb function. There is strong evidence to support intensive repetitive task-oriented training for recovery after stroke. The number of repetitions needed is suggested to be in the order of hundreds, but this is not currently being achieved in clinical practice. In an effort to bridge this evidence-practice gap, we have developed a behaviour change intervention that aims to increase provision of upper limb repetitive task-oriented training in stroke rehabilitation. This paper aims to describe the systematic processes that took place in collaboratively developing the behaviour change intervention.MethodsThe methods used in this study were not defined a priori but were guided by the Behaviour Change Wheel. The process was collaborative and iterative with four stages of development emerging (i) establishing an intervention development group; (ii) structured discussions to understand the problem, prioritise target behaviours and analyse target behaviours; (iii) collaborative design of theoretically underpinned intervention components and (iv) piloting and refining of intervention components.ResultsThe intervention development group consisted of the research team and stroke therapy team at a local stroke rehabilitation unit. The group prioritised four target behaviours at the therapist level: (i) identifying suitable patients for exercises, (ii) provision of exercises, (iii) communicating exercises to family/visitors and (iv) monitoring and reviewing exercises. It also provides a method for self-monitoring performance in order to measure fidelity. The developed intervention, PRACTISE (Promoting Recovery of the Arm: Clinical Tools for Intensive Stroke Exercise), consists of team meetings and the PRACTISE Toolkit (screening tool and upper limb exercise plan, PRACTISE exercise pack and an audit tool).ConclusionsThis paper provides an example of how the Behaviour Change Wheel may be applied in the collaborative development of a behaviour change intervention for health professionals. The process involved was resource-intensive, and the iterative process was difficult to capture. The use of a published behaviour change framework and taxonomy will assist replication in future research and clinical use. The feasibility and acceptability of PRACTISE is currently being explored in two other stroke rehabilitation units.

Prescribing upper limb exercises after stroke: a survey of current UK therapy practice.

OBJECTIVE To investigate the current practice of physiotherapists and occupational therapists in prescribing upper limb exercises to people after stroke and to explore differences between professions and work settings. DESIGN A cross-sectional survey design. PARTICIPANTS Occupational therapists and physiotherapists working in UK stroke rehabilitation. RESULTS The surveys response rate was 21.0% (n = 322); with 295 valid responses. Almost two thirds of therapists (64.7%, n = 191) agreed that they always prescribe upper limb exercises to a person with stroke if they can actively elevate their scapula and have grade 1 finger/wrist extension. Most therapists (98.6%, n = 278) prescribed exercises to be completed outside of therapy time, with exercises verbally communicated to family. Standardised upper limb specific outcome measures were used to evaluate the prescribed exercises by 21.9% (n = 62) OF THERAPISTS. DIFFERENCES WERE FOUND BETWEEN PROFESSIONS AND ACROSS WORK SETTINGS. CONCLUSION The majority of prescribed upper limb exercises were of low intensity (range of motion or stretching exercises) rather than repetitive practice or strengthening exercises. The use of standardised outcome measures was low. Progression of exercises and the provision of written instructions on discharge occur less frequently in inpatient settings than outpatient and community settings.

Repetitive Task Training for Improving Functional Ability After Stroke: A Major Update of a Cochrane Review

Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation.1 Primary objective is to determine whether RTT improves upper limb function/reach and lower limb function/balance in adults after stroke. Secondary objectives are (1) to determine the effect of RTT on secondary outcome measures, including activities of daily living, global motor function, quality of life/health status, and adverse events, (2) to determine the factors that could influence primary and secondary outcome measures, including the effect of dose of task practice, type of task (whole therapy, mixed, or single task), and timing of the intervention and type of intervention. We searched the Cochrane Stroke Group …

Activities to support the implementation of complex interventions as part of routine care: a review of the quality of reporting in cluster randomised controlled trials

Objective To review a sample of cluster randomised controlled trials and explore the quality of reporting of (1) enabling or support activities provided to the staff during the trial, (2) strategies used to monitor fidelity throughout the trial and (3) the extent to which the intervention being tested was delivered as planned. Design A descriptive review. Data sources and study selection We searched MEDLINE for trial reports published between 2008 and 2014 with combinations of the search terms ‘randomised’, ‘cluster’, ‘trial’, ‘study’, ‘intervention’ and ‘implement*’. We included trials in which healthcare professionals (HCPs) implemented the intervention being tested as part of routine practice. We excluded trials (1) conducted in non-health services settings, (2) where the intervention explicitly aimed to change the behaviours of the HCPs and (3) where the trials were ongoing or for which only trial protocols were available. Data collection We developed a data extraction form using the Template for Intervention Description and Replication (TIDieR checklist). Review authors independently extracted data from the included trials and assessed quality of reporting for individual items. Results We included 70 publications (45 results publications, 25 related publications). 89% of trials reported using enabling or support activities. How these activities were provided (75.6%, n=34) and how much was provided (73.3%, n=33) were the most frequently reported items. Less than 20% (n=8) of the included trials reported that competency checking occurred prior to implementation and data collection. 64% (n=29) of trials reported collecting measures of implementation. 44% (n=20) of trials reported data from these measures. Conclusions Although enabling and support activities are reported in trials, important gaps exist when assessed using an established checklist. Better reporting of the supports provided in effectiveness trials will allow for informed decisions to be made about financial and resource implications for wide scale implementation of effective interventions.

Health promotion knowledge, attitudes and practices of chartered physiotherapists in Ireland: A national survey

Background: A growing emphasis is being placed on the role of health promotion in tackling chronic conditions faced by the health services. This research study sought to investigate the health promotion knowledge, attitudes and practices of chartered physiotherapists in Ireland, as it has been suggested that physiotherapists are particularly well positioned to engage in health promotion strategies in the 21st century. Methods: An online self-administered questionnaire, which had been modified from a previously established tool, was emailed to 2753 registered members of the Irish Society of Chartered Physiotherapists on two occasions. 526 completed surveys were returned giving a response rate of 19.1%. Data was analysed using PASW Statistics 18. Results: Physiotherapists hold a traditional view of health promotion relating it primarily to the provision of information and advice to bring about individual behaviour change. Self reported knowledge of the wider determinants of health and key action areas of health promotion was low. Physiotherapists displayed positive attitudes to their role in health promotion but identified significant barriers to its implementation in the form of time constraints, lack of health promotion training and patient attitudes. Conclusions: Collaboration must take place between the disciplines of health promotion and physiotherapy to ensure that clarity in both roles and terminology is established. Interventions to improve health are complex. Pre- and post-registration physiotherapy education should be reviewed to ensure that physiotherapists have the knowledge base and skill set required to successfully engage in health promotion action.

Use of programme theory to understand the differential effects of interventions across socio-economic groups in systematic reviews—a systematic methodology review

BackgroundSystematic review guidance recommends the use of programme theory to inform considerations of if and how healthcare interventions may work differently across socio-economic status (SES) groups. This study aimed to address the lack of detail on how reviewers operationalise this in practice.MethodsA methodological systematic review was undertaken to assess if, how and the extent to which systematic reviewers operationalise the guidance on the use of programme theory in considerations of socio-economic inequalities in health. Multiple databases were searched from January 2013 to May 2016. Studies were included if they were systematic reviews assessing the effectiveness of an intervention and included data on SES. Two reviewers independently screened all studies, undertook quality assessment and extracted data. A narrative approach to synthesis was adopted.ResultsA total of 37 systematic reviews were included, 10 of which were explicit in the use of terminology for ‘programme theory’. Twenty-nine studies used programme theory to inform both their a priori assumptions and explain their review findings. Of these, 22 incorporated considerations of both what and how interventions do/do not work in SES groups to both predict and explain their review findings. Thirteen studies acknowledged 24 unique theoretical references to support their assumptions of what or how interventions may have different effects in SES groups. Most reviewers used supplementary evidence to support their considerations of differential effectiveness. The majority of authors outlined a programme theory in the “Introduction” and “Discussion” sections of the review to inform their assumptions or provide explanations of what or how interventions may result in differential effects within or across SES groups. About a third of reviews used programme theory to inform the review analysis and/or synthesis. Few authors used programme theory to inform their inclusion criteria, data extraction or quality assessment. Twenty-one studies tested their a priori programme theory.ConclusionsThe use of programme theory to inform considerations of if, what and how interventions lead to differential effects on health in different SES groups in the systematic review process is not yet widely adopted, is used implicitly, is often fragmented and is not implemented in a systematic way.

Mechanisms of action of an implementation intervention in stroke rehabilitation: a qualitative interview study

BackgroundDespite best evidence demonstrating the effectiveness of increased intensity of exercise after stroke, current levels of therapy continue to be below those required to optimise motor recovery. We developed and tested an implementation intervention that aims to increase arm exercise in stroke rehabilitation. The aim of this study was to illustrate the use of a behaviour change framework, the Behaviour Change Wheel, to identify the mechanisms of action that explain how the intervention produced change.MethodsWe implemented the intervention at three stroke rehabilitation units in the United Kingdom. A purposive sample of therapy team members were recruited to participate in semi-structured interviews to explore their perceptions of how the intervention produced change at their work place. Audio recordings were transcribed and imported into NVivo 10 for content analysis. Two coders separately analysed the transcripts and coded emergent mechanisms. Mechanisms were categorised using the Theoretical Domains Framework (TDF) (an extension of the Capability, Opportunity, Motivation and Behaviour model (COM-B) at the hub of the Behaviour Change Wheel).ResultsWe identified five main mechanisms of action: ‘social/professional role and identity’, ‘intentions’, ‘reinforcement’, ‘behavioural regulation’ and ‘beliefs about consequences’. At the outset, participants viewed the research team as an external influence for whom they endeavoured to complete the study activities. The study design, with a focus on implementation in real world settings, influenced participants’ intentions to implement the intervention components. Monthly meetings between the research and therapy teams were central to the intervention and acted as prompt or reminder to sustain implementation. The phased approach to introducing and implementing intervention components influenced participants’ beliefs about the feasibility of implementation.ConclusionsThe Behaviour Change Wheel, and in particular the Theoretical Domains Framework, were used to investigate mechanisms of action of an implementation intervention. This approach allowed for consideration of a range of possible mechanisms, and allowed us to categorise these mechanisms using an established behaviour change framework. Identification of the mechanisms of action, following testing of the intervention in a number of settings, has resulted in a refined and more robust intervention programme theory for future testing.

Repetitive task training after stroke: A Cochrane review [Abstract no.116]

Introduction: Aphasia affects a third of stroke survivors (~5.6 million worldwide annually). The social and emotional impact of aphasia makes timely and effective rehabilitation vital. Speech and language therapy benefits recovery; however the specific patient, stroke, aphasia and intervention factors which optimise recovery and rehabilitation are unclear. We will explore these uncertainties in our RELEASE study (NIHR HS&DR 14/04/22). In Phase I of this study we aimed to create a large, collaborative, international database of individual patient data (IPD) from pre-existing aphasia research. Method: Eligible datasets included IPD of ≥10 people with stroke-related aphasia, with time poststroke specified and aphasia severity data. Contributions were invited from international, multidisciplinary, aphasia research collaborators via the EU COST funded Collaboration of Aphasia Trialists. We also conducted a systematic search of the literature [Cochrane Stroke Group Trials, MEDLINE, CINAHL, AMED, Cochrane Library Databases (CDSR, DARE, CENTRAL, HTA), EMBASE, LLBA and SpeechBITE from inception to Sept 2015 for additional datasets. Two independent reviewers considered full texts, a third resolved any conflicts. Results: As of June 2016 our database included 2,531 IPD from 11 countries (33 datasets). Nine were in the public domain. Following the systematic search of 5,272 records (of which 75 duplicates, 2,395 reference titles and 965 abstracts were excluded) further datasets were identified and the investigators of these datasets invited to collaborate. Conclusion: We succeeded in creating a large, collaborative, international aphasia database of preexisting IPD. A systematic search process to identify additional datasets eligible for inclusion supplemented more informal dataset recruitment methods.Introduction: Shortening the time to delivery of IV thrombolysis improves patient outcomes and reduces adverse events. This research aimed to explore patient and service delivery factors that increase or decrease DTN time for thrombolysis. Method: We conducted a Service Evaluation from July 2011 to March 2013, using stroke data from SINAP and DASH databases. Data was provided by 6 acute trusts in Lancashire and Cumbria which used telemedicine, and 11 stroke services within the North East of England which instead used face-to-face. Our investigation concentrates on admissions to hospital occurring out of routine working hours, when resources are particularly constrained. Descriptive and inferential analyses, focusing on multivariate Cox regressions models selected using a forward stepwise approach, were then carried out to determine which factors impacted on DTN time, our main outcome variable. Results: After testing alternative specifications, our final model included these potential risk factors: mode of thrombolysis decision-making (either face-to-face or telemedicine); hospital; age; sex. Our results show that DTN time was strongly influenced by patient’s age (p<0.01), with older people receiving thrombolysis more quickly. Among the statistically significant variables, type of hospital (p<0.001) appeared to affect DTN times, together with patient’s sex (p¼0.01), suggesting that males had shorter DTN times. Conclusion: Older age was associated with shorter DTN times, with this effect being independent of other factors. Therefore, our research suggests that age played a predominant role in the delivery of thrombolysis, rather than solely through the choice of assessing acute strokethrough face-to-face or telemedicine.Introduction: Repetitive task training involves the active practice of task-specific motor activities. We updated our Cochrane Review published in 2007. Method: We searched MEDLINE (01/10/2006 – 08/03/2016), EMBASE (01/10/2006 – 07/03/2016) and the Cochrane Stroke Trials Register (04/03/2016). 2 authors independently screened abstracts, extracted data and appraised trials. Quality of evidence within each study and outcome group was determined using the Cochrane Collaboration Risk of Bias Tool (CCRBT) and GRADE criteria. Results: 29 trials with 1759 participants were included. Results were statistically significant for arm function (standardised mean difference (SMD) 0.25, 95% CI 0.11 to 0.40), hand function (SMD 0.28, 95% CI 0.12 to 0.44), sitting balance/reach (SMD 0.28, 95% CI 0.01 to 0.55), walking distance (MD 38.80, 95% CI 24.75 to 52.86), walking speed (SMD 0.33, 95% CI 0.18 to 0.49), functional ambulation (SMD 0.26, 95% CI 0.08 to 0.43), sit-to-stand (Standardised effect 0.35, 95% CI 0.13 to 0.56), lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48), standing balance/reach (SMD 0.27, 95% CI 0.09 to 0.45) and global motor function (SMD 0.38, 95% CI 0.11 to 0.65). Follow-up measures were significant for both upper and lower limb outcomes up to 6 months post-treatment. Conclusion: Repetitive task training resulted in improvement in upper and lower limb function; improvements were sustained up to 6 months post-treatment. Further research should focus on the type and amount of training, including measuring the number of repetitions performed.