But you don't mention getting your survivors 100% recovered, so you're still delivering failure!
A Network of Sites and Upskilled Therapists to Deliver Best-Practice Stroke Rehabilitation of the Arm: Protocol for a Knowledge Translation Study
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1
Occupational Therapy, School of Allied Health Human Services and Sport, La Trobe University, Melbourne, VIC 3086, Australia
2
Austin Campus, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3084, Australia
3
School of Allied Health (Melbourne Campus), Australian Catholic University, Fitzroy, VIC 3065, Australia
4
Austin Health, Heidelberg, VIC 3084, Australia
5
College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW 2308, Australia
6
Centre for Rehab Innovations, The University of Newcastle, Callaghan, NSW 2308, Australia
7
Department of
Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and
Health Sciences, Monash University, Melbourne, VIC 3800, Australia
8
Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
9
Allied Health and Human Performance, University of South Australia, Adelaide, SA 5001, Australia
10
Clinical
Sciences at Monash Health, Faculty of Medicine, Nursing and Health
Sciences, Monash University, Melbourne, VIC 3800, Australia
*
Author to whom correspondence should be addressed.
Healthcare 2023, 11(23), 3080; https://doi.org/10.3390/healthcare11233080
Received: 19 August 2023
/
Revised: 22 October 2023
/
Accepted: 20 November 2023
/
Published: 1 December 2023
(This article belongs to the Special Issue Stroke and Ageing)
Abstract
Implementation of evidence-informed rehabilitation
of the upper limb is variable, and outcomes for stroke survivors are
often suboptimal. We established a national partnership of clinicians,
survivors of stroke, researchers, healthcare organizations, and policy
makers to facilitate change. The objectives of this study are to
increase access to best-evidence rehabilitation of the upper limb and
improve outcomes for stroke survivors. This prospective pragmatic,
knowledge translation study involves four new specialist therapy centers
to deliver best-evidence upper-limb sensory rehabilitation (known as
SENSe therapy) for survivors of stroke in the community. A
knowledge-transfer intervention will be used to upskill therapists and
guide implementation. Specialist centers will deliver SENSe therapy, an
effective and recommended therapy, to stroke survivors in the community.
Outcomes include number of successful deliveries of SENSe therapy by
credentialled therapists; improved somatosensory function for stroke
survivors; improved performance in self-selected activities, arm use,
and quality of life; treatment fidelity and confidence to deliver
therapy; and for future implementation, expert therapist effect and
cost-effectiveness. In summary, we will determine the effect of a
national partnership to increase access to evidence-based upper-limb
sensory rehabilitation following stroke. If effective, this
knowledge-transfer intervention could be used to optimize the delivery
of other complex, evidence-based rehabilitation interventions.
1. Introduction
Implementation of evidence-based stroke rehabilitation interventions improves patient outcomes [1,2]. Evidence-based therapies for the upper limb after stroke are recommended in clinical practice guidelines [3,4] and in international best-practice guidelines [5,6].
Yet, there is inconsistent access to and delivery of quality,
evidence-based stroke rehabilitation, leading to suboptimal outcomes [3,7,8].
The need for and potential benefit of implementation interventions to
promote the uptake of best-evidence rehabilitation are highlighted [9,10,11].
There
are currently very few knowledge-transfer interventions of known
effectiveness to facilitate practice change for complex interventions in
stroke rehabilitation, and the certainty of the evidence is very low [11]. We developed an implementation intervention to drive behavior change in clinical and community settings [12]. The intervention is guided by the Theoretical Domains Framework [13,14,15], with translation strategies from the Behavior Change Wheel [16].
The intervention targets the delivery of science-based rehabilitation
that requires knowledge and skill of the rehabilitation therapist, an
application of knowledge translation that is virtually untested in the
field of stroke rehabilitation [12].
Major
evidence–practice gaps in stroke rehabilitation have been identified in
addressing the loss of body sensation after stroke nationally [17] and internationally [18], contributing to poor arm use and reduced ability to return to previous life activities after stroke [19,20,21]. Impaired sensation is experienced by one in two stroke survivors [22,23,24,25]. This loss is beyond any reduction experienced with healthy aging [22,23].
As survivors of stroke report: “It is like the hand is blind” and “…I
couldn’t really do daily stuff... I couldn’t hold anything, things were
just dropping…so I had nothing, there was nothing there” [26]. Many learn non-use of their hand, leading to secondary problems and restricting return to valued activities and work [19,20,22,27]. In addition, upper limb sensory loss is a factor contributing to inferior results in rehabilitation outcomes [19,28,29,30], and adequate sensation is a prerequisite for full motor recovery of the paretic upper limb [31].
Despite
the high prevalence and negative impact on function, it has been
highlighted that loss of body sensations is a ‘neglected’ area of stroke
rehabilitation [32]. Rehabilitation therapists often use a compensatory, rather than restorative, approach to somatosensory loss and recovery [17,18].
Yet, use of compensation potentially reinforces learned non-use of the
limb with negative long-term consequences. In our national survey, less
than half of healthcare professionals reported satisfaction with the
treatments they were using, or confidence in their ability to treat
somatosensory impairment after stroke, indicating a readiness to change
practice [17].
Barriers to implementation of best-practice sensory rehabilitation
identified by therapists include low therapist confidence; lack of
skills; inconsistent access to resources; and reduced quality of therapy
delivery [17,33].
The
purpose of this study is to increase access to best-evidence
rehabilitation of the upper limb and improve outcomes for stroke
survivors. Our focus is on delivery of best-evidence somatosensory
rehabilitation, given the evidence–practice gap identified nationally
and internationally [17,18].
Specifically, we will use a knowledge transfer intervention to upskill
therapists and deliver recommended best-evidence somatosensory
rehabilitation to more survivors of stroke.
A
neuroscience-based approach to rehabilitation of somatosensory
impairment, known as SENSe (Study of the Effectiveness of
Neurorehabilitation on Sensation) [34] (http://youtu.be/G9V3I30pn68;
accessed on 2 October 2023), has been systematically developed and
tested, consistent with the Medical Research Council Framework for the
development and evaluation of complex interventions [35]. SENSe therapy has demonstrated efficacy across a series of studies [36,37], including a double-blinded randomized controlled trial [34], with reported improvements in somatosensory capacity [34] and performance of valued occupations [26].
Survivors of stroke report the positive experience and benefits of
being involved in SENSe therapy, demonstrating acceptability of this
therapy for this population [26]. SENSe therapy is recommended in clinical practice guidelines for stroke [3] and in best-practice International Standards for Arm Rehabilitation Post-stroke [5].
Skill
and experience of the therapist may impact implementation and delivery
of evidence-based complex interventions. This is particularly evident
when service delivery requires a high level of skill from therapists [11,38].
Investigation of the impact of therapist experience on therapy outcomes
is therefore warranted. Further, while evidence is growing about health
outcomes from implementation interventions across various settings and
health professional groups [11,39],
there is a paucity of data on their cost-effectiveness to inform
whether the investment of resources justifies the additional benefits
that might be achieved. Therefore, this study will also investigate
cost-effectiveness of the intervention.
We have
created a partnership of survivors of stroke, clinicians, researchers,
healthcare organizations, and policy makers to (i) increase access to
evidence-based SENSe therapy delivered by therapists via a network of
clinical practice settings and specialist SENSe therapy centers, and
(ii) improve outcomes for survivors of stroke with somatosensory
impairment of the arm/hand. The partnership is supported with a National
Health and Medical Research Council Partnership grant from Australia
(GNT 1134495), which has allowed us to create a centralized
knowledge-translation hub and four specialist therapy centers.
Two complementary studies, SENSe Implement [12]
and SENSe CONNECT (ACTRN12618001389291), are being undertaken to
address the identified gap and achieve our overall aims. Together, the
studies will permit investigation across different modes of delivery and
skill levels of therapists and will involve approximately 100
therapists and 250 stroke survivors. The first study, SENSe Implement [12]
(ACTRN12615000933550), focuses on testing the effectiveness of our
knowledge-transfer intervention to change clinician behavior in existing
rehabilitation services. Specifically, the aim is to determine whether
evidence-based knowledge-translation strategies change the practice of
occupational therapists and physiotherapists in the assessment and
treatment of sensory loss of the upper limb after stroke to improve
patient outcomes. This study is being conducted as a pragmatic,
before–after study involving eight Australian healthcare networks and
existing sub-acute and community rehabilitation services (see [12] for further details).
The
second study detailed here is known as SENSe CONNECT
(ACTRN12618001389291). The SENSe CONNECT study is designed to increase
access to evidence-based SENSe therapy via specialist SENSe therapy
centers and skilled therapists. Four new specialist SENSe therapy
centers, across three states in Australia, are planned to complement and
extend current services. This model of service delivery differs from
the current practice model being tested in the SENSe Implement study.
The focus for SENSe CONNECT is on increased access for survivors of
stroke living in the community. We will create a centralized hub to lead
the knowledge-translation intervention and provide upskilling of
therapists. A network of specialist SENSe therapy centers and community
of therapists will be linked with the hub to facilitate implementation
and sustainability. Web-based resources will be developed to further
support therapists and help sustain practice change. Some of the broader
contextual aspects of implementation [40,41]
will also be investigated in the SENSe CONNECT study, including impact
of therapist expertise on outcomes and cost-effectiveness. The specific
aims of the current SENSe CONNECT study are to
- Increase access to evidence-based SENSe therapy delivered via a network of specialist SENSe therapy centers and skilled therapists.
- Improve outcomes for survivors of stroke with somatosensory impairment of the arm/hand (primary outcome—somatosensory function; secondary outcomes—performance of self-selected valued activities, arm use, and quality of life).
- Achieve high treatment fidelity for therapists in the delivery of upper-limb sensory rehabilitation following a tailored, evidence-informed knowledge-transfer intervention.
- Explore the association of the amount of therapist experience in SENSe delivery with outcomes for stroke survivors.
- Evaluate the cost-effectiveness of the knowledge-translation intervention in terms of the amount of improvement in SENSe therapy outcomes, i.e., somatosensory function, performance in valued activities, arm use, and quality of life
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