Community Stroke Rehabilitation Teams Research Articles

Using intervention mapping to develop and facilitate implementation of a multifaceted behavioural intervention targeting physical activity and sedentary behaviour in stroke survivors: Physical Activity Routines After Stroke (PARAS): intervention development study

ABSTRACT Objectives The benefits of increased physical activity for stroke survivors include improved function and mental health and wellbeing. However, less than 30% achieve recommended physical activity levels, and high levels of sedentary behaviour are reported. We developed a multifaceted behavioural intervention (and accompanying implementation plan) targeting physical activity and sedentary behaviour of stroke survivors. Design Intervention Mapping facilitated intervention development. Step 1 involved a systematic review, focus group discussions and a review of care pathways. Step 2 identified social cognitive determinants of behavioural change and behavioural outcomes. Step 3 linked determinants of behavioural outcomes with specific behaviour change techniques (BCTs) to target behaviours of interest. Step 4 involved intervention development informed by steps 1–3. Subsequently, an implementation plan was developed (Step 5) followed by an evaluation plan (Step 6). Setting Community and secondary care settings, North East England. Participants Stroke survivors and healthcare professionals (HCPs) working in stroke services. Results Systematic review findings informed selection of nine ‘promising’ BCTs (e.g. problem-solving). Focus groups with stroke survivors (n = 18) and HCPs (n = 24) identified the need for an intervention delivered throughout the rehabilitation pathway, tailored to individual needs with training for HCPs delivering the intervention. Intervention delivery was considered feasible within local stroke services. The target behaviours for the intervention were levels of physical activity and sedentary behaviour in adult stroke survivors. Assessment of acceptability and usability with 11 HCPs and 21 stroke survivors/relatives identified issues with self-monitoring tools and the need for a physical activity repository of local services’ and training for HCPs with feedback on intervention delivery. A feasibility study protocol was designed to evaluate the intervention. Conclusions A systematic development process using intervention mapping resulted in a multi-faceted evidence- and theory-informed intervention (Physical Activity Routines After Stroke – PARAS) for delivery by community stroke rehabilitation teams.

Individualized home-based rehabilitation after stroke in France: a pragmatic study of a community stroke rehabilitation team.

Community stroke rehabilitation teams (CSRT) provide an individualized home-based rehabilitation service to patients recovering from stroke. To examine whether there is an improvement in the social participation of patients who received a rehabilitation program provided by CSRT. The secondary objectives were to show if there is an improvement in the patients' quality of life and a reduction in the caregiver burden. Retrospective cohort study, pragmatic in real-care conditions. The rehabilitation program delivered by the CSRT was adapted to the needs of the patients and caregivers. The outcome questionnaires included: the Frenchay Activity Index (FAI), the Minizarit, the EuroQol EQ5D, and the Barthel Index. The primary outcome measure was the FAI. We included 206 patients followed by the CSRT over the 2018-2020 study period, for whom the primary endpoint was present. The mean age was 66.3 ± 12.7 years, the post-stroke delay was 16.4 ± 32.7 months, and the Barthel index was 66.42 ± 12.6. The duration of the rehabilitation program was on average 162 ± 109 days. We observed a significant improvement in the FAI, from 12.9 ± 10.4 to 17.85 ± 12.4 (p < 0.00001); in the EuroQol, from 57.51 ± 19.96 to 66.36 ± 18.87 (p < 0.00001); in the mini-Zarit, from 2.49 ± 1.75 to 2.06 ± 1.67 (p = 0.0002); and in the Barthel index, from 66.42 ± 12.67 to 84.81 ± 23.70 (p < 0.001). Patients who received a rehabilitation program by the CSRT have an improvement in their social participation, and their informal caregivers have a reduction in their burden.

The role of the nurse in the community stroke rehabilitation team: a personal perspective

Excellent patient care often requires the collaboration of a range of health professionals, and stroke patient rehabilitation is no exception. Brenda Townshend offers insights from her personal journey as a nurse in a London-based community stroke rehabilitation team.

Assessing the impact of a home-based stroke rehabilitation programme: a cost-effectiveness study

Background: Stroke is often a severe and debilitating event that requires ongoing rehabilitation. The Community Stroke Rehabilitation Teams (CSRTs) offer home-based stroke rehabilitation to individuals for whom further therapy is unavailable or inaccessible. The objective of this study was to evaluate the cost-effectiveness of the CSRT programme compared with a “Usual Care” cohort.Methods: We collected data on CSRT clients from January 2012 to February 2013. Comparator data were derived from a study of stroke survivors with limited access to specialised stroke rehabilitation. Literature-derived values were used to inform a long-term projection. Using Markov modelling, we projected the model for 35 years in six-month cycles. One-way, two-way, and probabilistic sensitivity analyses were performed. Results were discounted at 3% per year.Results: Results demonstrated that the CSRT programme has a net monetary benefit (NMB) of $43,655 over Usual Care, and is both less costly and more effective (incremental cost = −$17,255; incremental effect = 1.65 Quality Adjusted Life Years [QALYs]). Results of the probabilistic sensitivity analysis revealed that incremental cost-effectiveness of the CSRT programme is superior in 100% of iterations when compared to Usual Care.Conclusions: The study shows that CSRT model of care is cost-effective, and should be considered when evaluating potential stroke rehabilitation delivery methods.Implications for RehabilitationOngoing rehabilitation following stroke is imperative for optimal recovery.Home-based specialised stroke rehabilitation may be an option for individuals for whom ongoing rehabilitation is unavailable or inaccessible.The results of this study demonstrated that home-based rehabilitation is a cost-effective means of providing ongoing rehabilitation to individuals who have experienced a stroke.

Depressive Symptoms in Individuals after Stroke in a Home-Based Rehabilitation Setting.

Poststroke depression has been shown to affect rehabilitation progress. This study evaluated patients after stroke who actively participated in a home-based rehabilitation program to determine variables that correlated with depressive symptoms in this population. A retrospective review of patients who were provided rehabilitation by Community Stroke Rehabilitation Team clinicians between January 1, 2009, and September 30, 2015, was completed. Logistic regression analysis was conducted to determine which demographic and outcome variables (Functional Independence Measure [FIM™] and Reintegration to Normal Living Index [RNLI]) were independently associated with depressive symptoms, as defined by Patient Health Questionnaire (PHQ-9) scores. 889 patients (53.2% male, mean age = 69.8 years) were included. Based on PHQ-9 scores, 89.7% of patients presented with no or mild depressive symptoms (PHQ-9 < 10) and 10.3% were considered to have moderate to severe depressive symptoms (PHQ-9 ≥ 10). The regression demonstrated that referral from outpatient, community care access centre, or community settings (OR = 1.89, p = 0.04), low RNLI scores (OR = 0.92; p = 0.001), and younger age (OR = 0.96; p < 0.001) predicted patients having moderate to severe depressive symptoms. Given the impact of poststroke depression on rehabilitation, clinicians should consider the potential impact of referral source, community reintegration, and age when monitoring and treating depressive symptoms.

Mapping the rehabilitation interventions of a community stroke team to the extended International Classification of Functioning, Disability and Health Core Set for Stroke

Purpose: This study aim was to evaluate whether the Extended International Classification of Functioning, Disability and Health Core Set for Stroke captured the interventions of a community stroke rehabilitation team situated in a large city in New Zealand. It was proposed that the results would identify the contribution of each discipline, and the gaps and differences in service provision to Māori and non-Māori. Applying the Extended International Classification of Functioning, Disability and Health Core Set for Stroke in this way would also inform whether this core set should be adopted in New Zealand.Method: Interventions were retrospectively extracted from 18 medical records and linked to the International Classification of Functioning, Disability and Health and the Extended International Classification of Functioning, Disability and Health Core Set for Stroke. The frequencies of linked interventions and the health discipline providing the intervention were calculated.Results: Analysis revealed that 98.8% of interventions provided by the rehabilitation team could be linked to the Extended International Classification of Functioning, Disability and Health Core Set for Stroke, with more interventions for body function and structure than for activities and participation; no interventions for emotional concerns; and limited interventions for community, social and civic life. Results support previous recommendations for additions to the EICSS.Conclusions: The results support the use of the Extended International Classification of Functioning, Disability and Health Core Set for Stroke in New Zealand and demonstrates its use as a quality assurance tool that can evaluate the scope and practice of a rehabilitation service.Implications for RehabilitationThe Extended International Classification of Functioning Disability and Health Core Set for Stroke appears to represent the stroke interventions of a community stroke rehabilitation team in New Zealand.As a result, researchers and clinicians may have increased confidence to use this core set in research and clinical practice.The Extended International Classification of Functioning Disability and Health Core Set for Stroke can be used as a quality assurance tool to establish whether a community stroke rehabilitation team is meeting the functional needs of its stroke population.

Effect of Time Post Stroke Onset on Ability to Make Functional Gains in Individuals Accessing a Home-Based Stroke Rehabilitation Program

To determine if time post stroke onset (TPO) affects the ability of Community Stroke Rehabilitation Team (CSRT) clients to make functional gains.

Feasibility study of an integrated stroke self-management programme: a cluster-randomised controlled trial

ObjectivesTo test the feasibility of conducting a controlled trial into the effectiveness of a self-management programme integrated into stroke rehabilitation.DesignA feasibility cluster-randomised design was utilised with stroke rehabilitation teams as...

Community stroke rehabilitation teams: providing home-based stroke rehabilitation in Ontario, Canada.

Community stroke rehabilitation teams (CSRTs) provide a community-based, interdisciplinary approach to stroke rehabilitation. Our objective was to assess the effectiveness of these teams with respect to client outcomes. Functional, psychosocial, and caregiver outcome data. were available at intake, discharge from the program, and six-month follow-up. Repeated measures analysis of covariance was performed to assess patient changes between time points for each outcome measure. A total of 794 clients met the inclusion criteria for analysis (54.4% male, mean age 68.5±13.0 years). Significant changes were found between intake and discharge on the Hospital Anxiety and Depression Scale total score (p=0.017), Hospital Anxiety and Depression Scale Anxiety subscale (p<0.001), Functional Independence Measure (p<0.001), Reintegration to Normal Living Index (p=0.01), Bakas Caregiver Outcomes Scale (p<0.001), and Caregiver Assistance and Confidence Scale assistance subscale (p=0.005). Significant gains were observed on the strength, communication, activities of daily living, social participation, memory, and physical domains of the Stroke Impact Scale (all p<0.001). These improvements were maintained at the 6-month follow-up. No significant improvements were observed upon discharge on the memory and thinking domain of the Stroke Impact Scale; however, there was a significant improvement between admission and follow-up (p=0.002). All significant improvements were maintained at the 6-month follow-up. Results indicate that the community stroke rehabilitation teams were effective at improving the functional and psychosocial recovery of patients after stroke. Importantly, these gains were maintained at 6 months postdischarge from the program. A home-based, stroke-specific multidisciplinary rehabilitation program should be considered when accessibility to outpatient services is limited.

Stroke Self-efficacy Questionnaire: A Rasch-refined measure of confidence post stroke

Measuring self-efficacy during rehabilitation provides an important insight into understanding recovery post stroke. A Rasch analysis of the Stroke Self-efficacy Questionnaire (SSEQ) was undertaken to establish its use as a clinically meaningful and scientifically rigorous measure. One hundred and eighteen stroke patients completed the SSEQ with the help of an interviewer. Participants were recruited from local acute stroke units and community stroke rehabilitation teams. Data were analysed with confirmatory factor analysis conducted using AMOS and Rasch analysis conducted using RUMM2030 software. Confirmatory factor analysis and Rasch analyses demonstrated the presence of two separate scales that measure stroke survivors' self-efficacy with: i) self-management and ii) functional activities. Guided by Rasch analyses, the response categories of these two scales were collapsed from an 11-point to a 4-point scale. Modified scales met the expectations of the Rasch model. Items satisfied the Rasch requirements (overall and individual item fit, local response independence, differential item functioning, unidimensionality). Furthermore, the two subscales showed evidence of good construct validity. The new SSEQ has good psychometric properties and is a clinically useful assessment of self-efficacy after stroke. The scale measures stroke survivors' self-efficacy with self-management and activities as two unidimensional constructs. It is recommended for use in clinical and research interventions, and in evaluating stroke self-management interventions.

The role of the community stroke rehabilitation nurse

There is strong evidence for early supported discharge (ESD) following stroke, but there is no evidence on how these services should be organized or the best models of care. ESD teams rarely include a community stroke rehabilitation nurse. A service development project was undertaken in Portsmouth Hospitals NHS Trust's community stroke rehabilitation team to identify and explore the unique contributions of community stroke rehabilitation nurses in an established ESD team. When the team was set up, the nurses had inpatient stroke rehabilitation skills, but no community experience. This novel approach, which involved taking specialist hospital nurses into the community, meant there was a steep learning curve and, unfortunately, there were no role models to support their development. During these early days, it became apparent that intensive stroke rehabilitation within an interdisciplinary ESD team required effective and timely nursing intervention, the development of skills to support interdisciplinary working and a greater understanding of the roles of all team members. Locally and nationally, questions were being asked pertaining to the nurses' role, which precipitated this project. Through a series of journal club sessions, the interdisciplinary team reviewed the evidence base of the nurse role in stroke rehabilitation. The team were able to evaluate findings against current practice. The project confirmed that the community stroke rehabilitation nurse provides a unique and fundamental role to the team that strengthens the model of interdisciplinary teamworking.

Stepping Out: A programme focusing on self-management after stroke

A person having a stroke in the UK now has a good chance of receiving some care in an acute stroke unit, which is a vast improvement on 10 years ago. However, stroke survivors can rarely access any specialist rehabilitation beyond the fi rst few months after stroke and many still believe they are ill-equipped to manage in the longer term (Department of Health, 2005). The last national stroke audit found that the number of specialist community stroke rehabilitation teams had actually declined over the last 5 years (Intercollegiate Working Party for Stroke, 2004). It seems that the attention of the stroke world has chiefl y focused on primary prevention and acute care, possibly to the detriment of developing better programmes to support individuals living with the consequences of stroke.

Ask the experts: person-centred care

My work covers four domains: Expert clinical practice Working within a critical companionship model has enabled me to challenge practice at the bedside. Reflective sessions within stroke care areas allow me to hear about difficulties staff face and, in turn, for me to challenge practice. Professional leadership and consultancy As a member of the professional executive committee and board of my primary care trust I have an insight into policy development and decision making. This knowledge has enabled me to forge ahead with service developments. Education, training and development Following years of holding formal training and education sessions, I have adopted a practice-based learning approach to education. Ascertaining what clinicians know, what they believe they need to know, and demonstrating how best to build on clinical skills is a very effective method of learning. I am also able to access older people across a range of settings. Primary and secondary prevention of stroke in residential care is vital and I have undertaken work in partnership with both statutory and non-statutory providers. Practice and service development My duty is to be flexible and adaptable, facilitating innovation and service redesign from the patient’s perspective. I have developed a community stroke rehabilitation team based on a study that gathered the views of older stroke survivors and their carers. Listening to and being able to represent their needs provided the stimulus to modernise local services. Research I have undertaken has affected clinical care by ensuring that ethical, sensitive decision making regarding feeding after stroke is person and family-centred. The use of audit and evaluative data ensures that stroke care remains a high priority on each local organisation’s agenda. The role of consultant nurse in stroke care is dynamic and innovative. Eighty per cent of strokes occur in people over the age of 65 and keeping abreast of the needs of older individuals is crucial. It is imperative to be politically aware at local and national levels, and to have the courage to speak out and be innovative. Retaining clinical credibility and having sound leadership skills will ensure that other clinicians learn by example and aspire to consultant practitioner roles. Jane Williams

The development of a community stroke rehabilitation team

Following a successful Health of the Nation bid in 1994, a new community-based stroke team was formed in south-west London (Merton and Sutton). The team has evolved considerably over the last 5 years and is now a baseline service accepting over 170 new referrals every year. This paper evaluates the lessons learnt from this project.