If you want to increase activity post stroke there are two possibilities I see:
1. Have your doctor stop the 5 causes of the neuronal cascade of death in the first week. That would save billions of neurons. I only lost 5.4 billion neurons that first week because my doctor did nothing that first week. At $1000 a neuron that should have cost the hospital 5.4 trillion dollars. That would concentrate the hospital leadership.
2. Have EXACT STROKE PROTOCOLS WITH EXACT REPETITIONS THAT DELIVERS 100% RECOVERY. With that motivation to exercise would not be a problem. Survivors would be too busy counting and exercising to sit on their butts.
Your solution is incorrect because it is just a guideline NOT a protocol. So NO DEFINED OUTCOME.
Addressing inactivity after stroke: The Collaborative Rehabilitation in Acute Stroke (CREATE) studyj
Abstract
Background
Stroke patients are often inactive outside of structured therapy sessions – an enduring international challenge despite large scale organizational changes, national guidelines and performance targets. We examined whether experienced-based co-design (EBCD) – an improvement methodology – could address inactivity in stroke units.
Aims
To evaluate the feasibility and impact of patients, carers, and staff co-designing and implementing improvements to increase supervised and independent therapeutic patient activity in stroke units and to compare use of full and accelerated EBCD cycles.
Results
Interviews were held with 156 patients, staff, and carers in total; ethnographic observations for 364 hours, behavioral mapping of 68 patients, and self-report surveys from 179 patients, pre- and post-implementation of EBCD improvement cycles.
Three priority areas emerged: (1) ‘Space’ (environment); (2) ‘Activity opportunities’ and (3) ‘Communication’. More than 40 improvements were co-designed and implemented to address these priorities across participating units. Post-implementation interview and ethnographic observational data confirmed use of new social spaces and increased activity opportunities. However, staff interactions remained largely task-driven with limited focus on enabling patient activity. Behavioral mapping indicated some increases in social, cognitive, and physical activity post-implementation, but was variable across sites. Survey responses rates were low at 12–38% and inconclusive.
Conclusion
It was feasible to implement EBCD in stroke units. This resulted in multiple improvements in stroke unit environments and increased activity opportunities but minimal change in recorded activity levels. There was no discernible difference in experience or outcome between full and accelerated EBCD; this methodology could be used across hospital stroke units to assist staff and other stakeholders to co-design and implement improvement plans.
Introduction
Evidence that increasing the frequency and intensity of stroke rehabilitation can improve outcomes has driven numerous international guidelines and other major developments in hospital-based stroke care to achieve larger doses of therapy provided over seven days.1,2 However, outside of the scheduled therapy, inactivity is common and observational studies show stroke patients can be inactive and alone for more than 60% of waking hours, an issue largely unchanged for decades.3,4
There is now more understanding that rehabilitation intensity and outcomes cannot be improved by national targets alone – the stroke unit environment and how time is spent outside of scheduled face-to-face therapy are of critical consideration. Attempts to address inactivity have had mixed results. Dose-driven interventions including circuit class therapy and seven-day therapy have increased therapy provision but not patient activity outside of sessions.5 Some progress has been made by applying environmental enrichment evidence from animal models.6 Studies conducted in Australia have utilized controlled pre- and post-designs and evaluated the impact of more stimulating environments on inpatient activity.3,7 Behavior mapping showed an increase in activity levels across all domains and some changes were sustained at six months post intervention. However, the environmental enrichment was driven by the perspectives of researchers and professionals without patient and carer involvement and no specific quality improvement (QI) methodology. Improvement research is now recognized to be critical to ‘cumulate, synthesize and scale learning’ to expedite the translation of evidence into practice.8 We believed that a robust QI methodology could address the intractable issue of patient inactivity.
Across healthcare internationally, there is increasing evidence of improvement methodologies which involve patients and staff working collaboratively to help co-design solutions and deliver healthcare services.9 Experience-based co-design (EBCD) is an approach which enables staff and patients to co-design services in partnership. Experiences are gathered from patients and staff through in-depth interviewing, observations and group discussions, to identify key ‘touch points’ or emotionally positive or negative issues. An edited ‘trigger’ film is created from patient interviews to convey experiences of the service. Staff and patients are then brought together to explore the findings and to work in small groups to identify, co-design and implement activities that will improve the service or the care pathway.10,11 EBCD now has widespread use and led to improvements across multiple healthcare settings, including acute hospitals – but can lack detailed evaluation of feasibility and impact.12 To date EBCD has not been used as an improvement method in stroke units to address inactivity.
Aims
The Collaborative Rehabilitation in Acute Stroke study (CREATE) aimed to (1) evaluate the feasibility of patients, carers and staff collaborating to develop and implement changes to increase supervised and independent therapeutic patient activity in acute stroke units; and (2) understand if improvements developed by two initial stroke units could be transferred to two further units and implemented within a shortened time frame using an accelerated form of EBCD (AEBCD).
Figure 1 provides an overview of the stages of EBCD and AEBCD, data collected, and cohorts included pre- and post-implementation of improvements. Full EBCD and AEBCD took nine and six months to complete, respectively.
Figure 1. Showing accelerated and full experienced-based co-design with pre- and post-implementation data collection.
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