Tailored GuideLine Implementation in STrokE Rehabilitation (GLISTER) in Germany. Protocol of a Mixed Methods Study Using the Behavior Change Wheel and the Theoretical Domains Framework

 I wish they would get rid of the useless word, 'guideline', and just focus on creating EXACT PROTOCOLS. An objective damage diagnosis should lead directly to EXACT  stroke rehab protocols that directly lead to 100% recovery. If you can't accomplish that, get the hell out of stroke!

Tailored GuideLine Implementation in STrokE Rehabilitation (GLISTER) in Germany. Protocol of a Mixed Methods Study Using the Behavior Change Wheel and the Theoretical Domains Framework

Bettina Scheffler^1*, Florian Schimböck², Almut Schöler¹, Katrin Rösner³, Jacob Spallek⁴ and Christian Kopkow¹

• ¹Department of Therapy Sciences I, Brandenburg University of Technology Cottbus—Senftenberg, Senftenberg, Germany
• ²Department of Nursing Sciences and Clinical Nursing, Brandenburg University of Technology Cottbus—Senftenberg, Senftenberg, Germany
• ³Department of Health Sciences, University of Lübeck, Lübeck, Germany
• ⁴Department of Public Health, Brandenburg University of Technology Cottbus—Senftenberg, Senftenberg, Germany

Objective: Evidence-based guidelines are important for informing clinical decision-making and improving patient outcomes. There is inconsistent usage of guidelines among physical therapists involved in stroke rehabilitation, suggesting the existence of a gap between theory and practice. Addressing the German guideline “evidence-based rehabilitation of mobility after stroke (ReMoS),” the aims of this project are (1) to describe the current physical therapy practice within the context of stroke rehabilitation in Germany, (2) to evaluate barriers and facilitators of guideline usage, (3) to develop, and (4) to pilot test a theory-based, tailored implementation intervention for the benefit of guideline recommendations.

Materials and Methods: This study uses a stepwise mixed methods approach for implementing a local guideline. A self-reported online questionnaire will be used to survey the current physical therapy practice in stroke rehabilitation. The same survey and systematic-mixed methods review will be used to evaluate the barriers and facilitators of guideline usage quantitatively. Semi-structured interviews will add a qualitative perspective on factors that influence ReMoS guideline implementation. The Behavior Change Wheel and Theoretical Domains Framework will be used to support the development of a tailored implementation intervention which will be pilot tested in a controlled study. Patient and physical therapy-related outcomes, as well as the appropriateness, such as acceptance and feasibility of the tailored implementation intervention, will be analyzed.

Conclusion: This will be the first endeavor to implement a guideline in German stroke rehabilitation with a focus on changing care provider behavior based on the knowledge of current practice and determining factors using a tailored and theory-based intervention.

Introduction

In comparison with other diseases, mortality among people after stroke is the second highest of all causes in Europe and the world (1). Stroke typically occurs among older people, but its prevalence among younger adults is also rising (2–4). In the German population, about 2.5% of all adults have already suffered a stroke, and about 200,000 new cases occur every year (5–7). Among neurological disorders, stroke causes 41.2% of the global burden of diseases and is among the most common causes of long-term disability worldwide (8, 9). At about 28 billion euros, Germany contributes 63% of the total disease-related costs of stroke in Europe (10). For the affected individuals, stroke can result in multifaceted dysfunctions (11, 12) and can lead to an impaired physical and mental quality of life over the long term (13). In particular, limitations of motor skills often follow a stroke, and these are crucial for a dependent living with the disease (14, 15). Restoring mobility after stroke is a relevant rehabilitation goal for affected individuals, but only 53% of patients will be able to walk independently outdoors after a stroke (16–20).

Clinical guidelines are defined as “statements that include recommendations intended to optimize patient care. These statements are informed by a systematic review of evidence and an assessment of the benefits and costs of alternative care options” (21). Although guideline-based motor rehabilitation after stroke has been shown to be effective and important for those affected, physiotherapy has been found to deviate from the recommended practice (22–27). Possible reasons for non-adherence to guidelines in acute stroke rehabilitation may be related to healthcare professionals', patients', and healthcare institutions' characteristics, the complexity of some recommended therapies, or complexities in the guidelines themselves (28). In terms of the mobility of patients with stroke, Donnellan et al. noted that guidelines were not specific enough with regard to the performance of the recommended intervention (29). For the purposes of stroke rehabilitation, several guidelines have become available (30). Neurologists and physical therapists of the German Society of Neurorehabilitation (Deutsche Gesellschaft für Neurorehabilitation—DGNR) developed the interdisciplinary “rehabilitation of mobility after stroke (ReMoS)” guideline, which was first published in 2015 by the “Working Group of Scientific Medical Societies” (Arbeitsgemeinschaft Wissenschaftlicher Medizinischer Fachgesellschaften—AWMF) (31). According to the AWMF classification, the ReMoS guideline is considered an “S2e guideline” which implies that the guideline development process is based on a systematic literature search and a systematic selection and appraisal of the evidence. Considering the adverse events and the clinical applicability, the authors recommend therapy goal-directed interventions for improving walking ability, walking speed, walking distance, and the balance of individuals with sub-acute and chronic stroke (31). As the greatest potential for functional recovery in patients with stroke can be expected during the 1st months after disease onset (32), only recommendations for the sub-acute phase during the first 6 months are focused upon here (Supplementary Material 1).

Since the ReMoS guideline was disseminated via passive dissemination strategies, and as its publication was not supported by a specific implementation strategy, a gap between theory and practice is to be expected (33, 34). As such, the aims are (1) to describe the current physical therapy practice for stroke rehabilitation in Germany, (2) to evaluate barriers and facilitators of guideline usage, (3) to develop, and (4) to pilot test a theory-based implementation intervention for the benefit of ReMoS guideline recommendations.

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