Abstract
Background: Stroke is a major cause of global disability which is largely managed by rehabilitation. Survivors of severely disabling stroke experience poorer outcomes compared to less disabled stroke survivors. One possible explanation for poor outcomes is that rehabilitation of physical function, which involves physiotherapy and occupational therapy, does not fully address the sequelae of severely disabling stroke. However, there is a paucity of research to identify what current therapy practice involves, how rehabilitation interventions are decided upon, and their effectiveness in managing the consequences of severely disabling stroke.Aim: To investigate therapy in the rehabilitation of physical function after severely disabling stroke. Method: Using the theoretical framework of evidence-based practice and its use in clinical decision making, mixed methods research was undertaken involving three studies: a national survey of physiotherapy and occupational therapy practice, comprising an on-line questionnaire and follow-up interviews; a systematic review examining the effectiveness of rehabilitation interventions on improving physical function and reducing immobility-related complications; and an ethnographic exploration of therapy practice, involving participant observation and interviews, in five stroke services.
Results: 440 therapists completed the survey questionnaire, including 18 therapists who participated in follow-up interviews. The survey found that interventions were delivered to achieve identified aims as part of goal-directed therapy and differed according to professional role and type of stroke service. The systematic review included 28 randomised controlled trials and found a lack of high-quality evidence supporting the use of rehabilitation interventions to improve physical function and reduce immobility-related complications after severely disabling stroke. The ethnographic exploration of therapy practice involved over 400 hours of participant observation conducted over an 18-month period, as well as 52 in-depth semi-structured interviews. Findings demonstrated that clinical expertise and the stroke survivor’s clinical presentation were two of the most influential factors guiding therapist decision making. Research evidence and the stroke survivor’s treatment preferences were less influential factors guiding decision making. Other factors guiding therapist decision making included professional role, the therapist’s beliefs and attitudes about post-stroke recovery, organisational function, and the stroke pathway design. Integrating findings across the studies demonstrated that current therapy practice for survivors of severely disabling stroke is infrequently based upon a limited and low-quality research evidence base. Findings also demonstrated that current therapy practice is guided by a variety of factors, some of which may negatively influence how therapists select interventions in the rehabilitation of severely disabling stroke.
Conclusions: Current therapy practice does not always address the needs of severely disabled stroke survivors, which may contribute to the poor outcomes experienced by this cohort of the stroke population. Alternative aims and models of stroke rehabilitation, as well as ways of therapist working, should be considered to address the needs of severely disabled stroke survivors more fully.
| Date of Award | 1 Apr 2021 |
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| Original language | English |
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| Supervisor | Catherine Sackley (Supervisor), Christopher McKevitt (Supervisor) & Rachel Faulkner Gurstein (Supervisor) |