You can see how godawful this is. They aren't using efficacy ratings of protocols based upon the objective damage diagnosis. So this is just guessing in the dark. Hope you are OK with such crapola.
A day in the life: a qualitative study of clinical decision-making and uptake of neurorehabilitation technology
Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 121 (2021)
Abstract
Background
Neurorehabilitation engineering faces numerous challenges to translating new technologies, but it is unclear which of these challenges are most limiting. Our aim is to improve understanding of rehabilitation therapists’ real-time decision-making processes on the use of rehabilitation technology (RT) in clinical treatment.
Methods
We used a phenomenological qualitative approach, in which three OTs and two PTs employed at a major, technology-encouraging rehabilitation hospital wrote vignettes from a written prompt describing their RT use decisions during treatment sessions with nine patients (4 with stroke, 2 traumatic brain injury, 1 spinal cord injury, 1 with multiple sclerosis). We then coded the vignettes using deductive qualitative analysis from 17 constructs derived from the RT literature and the Consolidated Framework for Implementation Research (CFIR). Data were synthesized using summative content analysis.
Results
Of the constructs recorded, the five most prominent are from CFIR determinants of: (i) relative advantage, (ii) personal attributes of the patients, (iii) clinician knowledge and beliefs of the device/intervention, (iv) complexity of the devices including time and setup, and (v) organizational readiness to implement. Therapists characterized candidate RT as having a relative disadvantage compared to conventional treatment due to lack of relevance to functional training. RT design also often failed to consider the multi-faceted personal attributes of the patients, including diagnoses, goals, and physical and cognitive limitations. Clinicians’ comfort with RT was increased by their previous training but was decreased by the perceived complexity of RT. Finally, therapists have limited time to gather, setup, and use RT.
Conclusions
Despite decades of design work aimed at creating clinically useful RT, many lack compatibility with clinical translation needs in inpatient neurologic rehabilitation. New RT continue to impede the immediacy, versatility, and functionality of hands-on therapy mediated treatment with simple everyday objects.
Background
Rehabilitation technology (RT) is defined by the Rehabilitation Act of 1973 as “the systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of and address the barriers confronted by individuals with disabilities…” [1]. Occupational and physical therapists (OTs and PTs) use a variety of measurement and therapeutic RTs to aide in their delivery of evidence-based rehabilitation. The field of neurorehabilitation engineering faces numerous challenges with translating new RT into everyday practice at all stages of development and implementation. Successful application of therapeutic RT requires development, testing, validation, clinician uptake, and patient acceptance.
There are several benefits of incorporating RT into therapy. RT can enable therapists to achieve tasks that are difficult or impossible to do without RT, such as lifting a heavy patient or measuring physiological variables [2]. RT can enable patients to achieve a higher number of movement practice repetitions, a necessary element of neuroplasticity during recovery [3, 4]. RT can increase motivation for therapy by providing physical assistance that allows patients to attempt and complete movements [5,6,7] or by incorporating gaming environments and quantitative feedback [8]. Finally, it can also reduce the need for providing continuous physical assistance or supervision to a patient, which can increase productivity or can increase patient access to therapeutic training [9].
Despite the observed benefits of RT, clinicians report barriers to their practical application. Barriers can arise from multiple domains such as the patient, the clinician, or the rehabilitation context [10]. Patients themselves can reject RT in favor of conventional therapy or have cognitive deficits which inhibit their participation [4]. Clinicians question the effectiveness strength and clinical necessity of the device [4]. Within the clinical setting, devices sometimes are too large and bulky to adapt use within an organization [11]. Clinician use is also influenced by institution facilitation of use, organizational culture and intention of use [2]. Outside clinical setting barriers also exist when a device is unavailable to the patient post-discharge [10].
Research suggests that clinicians function as gatekeepers to promote the implementation of new interventions [12]. The process for adopting RT into the clinic must undergo intense scrutiny before uptake including the clinical applicability, cost–benefit analysis, and safety of the device [13]. Therefore, it is vital to determine the gaps between the theoretical benefits and the practical application of such RT that would enable clinician uptake. Several previous studies have used survey methods [10, 14] or focus groups [4] to identify these gaps, but such approaches may not fully capture the real-time, pragmatic decision making that therapists must engage in during treatment sessions. Our approach here combined implementation science methodology to help make research more generalizable. Our premise is that integrating implementation science with neurorehabilitation engineering can accelerate the future integration of novel RT.
Our purpose is to describe clinician decision-making around incorporating RT into treatment sessions to improve understanding of clinician uptake, the critical step to device implementation. To provide a window into a day-in-the-life of clinician and the decision-making during a typical treatment session, we had OTs and PTs write vignettes describing a treatment session, along with their thought processes. Then we synthesized the vignette data using an implementation science framework, the Consolidated Framework for Implementation Research (CFIR), a common implementation framework used to classify the determinants (barriers and facilitators) of successful implementation [15]. From our qualitative data analysis, we were able to pinpoint several constructs mentioned in the vignettes to highlight the hurdles encountered by therapists in treatment sessions. Presenting and synthesizing vignettes will help engineering audiences to understand the practical application of the devices they develop and how to improve the success of future RT.
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