Rehabilitation Clinical Practice Guidelines Research Articles

Should I Stay or Should I Go? Identifying Intrinsic and Extrinsic Factors in the Decision to Return to Duty Following Lower Extremity Injury.

Rehabilitation research of wounded service members (SMs) commonly focuses on physical ability to return to duty (RTD) as a measure of successful recovery. However, numerous factors or barriers may influence a SM's ability and/or desire to RTD after lower extremity musculoskeletal trauma. SMs themselves as well as the clinical care team that works with them daily, often for years at a time, both offer unique perspectives on the influential factors that weigh into decisions to RTD. The purpose of this study was to identify the intrinsic and extrinsic factors patients and clinicians recognized as influencing the decision to RTD after severe lower extremity trauma. Thirty-two SMs with severe lower extremity trauma (amputation and lower limb salvage) and 30 providers with at least 2 years' experience caring for SMs with similar injuries participated separately in either a SM or provider/clinician focus group. Open-ended questions on factors influencing RTD and other rehabilitation success were discussed. Data analysis consisted of qualitative transcription and participatory active sorting, followed by thematic coding and grouping of qualitative data. Individual (health condition, personal traits, and career consideration), interpersonal (clinician's impact, family influence, and peer influence), health care system (systems of care, transdisciplinary rehabilitation, and innovation availability), and institutional (policy, benefits, and unit/commander) themes emerged amongst SM patients and clinicians. Expected frequently occurring themes common to both groups were the influence of the team and family unit, as well as career trajectory options after a severe injury. An unexpected theme was acknowledgment of and dissatisfaction with the recent dismantling of institutional systems that support wounded SMs. Patients placed less emphasis on severity of injury and greater emphasis on system and policy barriers than did clinicians. Characterization and classification of these clinician and SM-identified factors that influence the decision to RTD after severe lower extremity trauma is expected to improve the efficacy of future rehabilitation efforts and clinical practice guidelines by providing the clinical team the knowledge necessary to recognize modifiable barriers to patient success. A better understanding of factors influencing RTD decision-making may support policies for mitigating RTD barriers, better monitoring of the changing landscape of RTD after lower extremity trauma, improving systems of health care, and/or reducing turnover and facilitating force readiness.

What Determines the Quality of Rehabilitation Clinical Practice Guidelines?: An Overview Study.

The aim of the study was to determine what factors determine the quality of rehabilitation clinical practice guidelines. Six databases were searched for articles that had applied the Appraisal of Guidelines for Research & Evaluation II quality assessment tool to rehabilitation clinical practice guidelines. The 573 deduplicated abstracts were independently screened by two authors, resulting in 81 articles, the full texts of which were independently screened by two authors for Appraisal of Guidelines for Research & Evaluation II application to rehabilitation clinical practice guidelines, resulting in a final selection of 40 reviews appraising 504 clinical practice guidelines. Data were extracted from these by one author and checked by a second. Data on each clinical practice guideline included the six Appraisal of Guidelines for Research & Evaluation II domain scores, as well as the two Appraisal of Guidelines for Research & Evaluation II global evaluations. All six Appraisal of Guidelines for Research & Evaluation II domain scores were statistically significant predictors of overall clinical practice guideline quality rating; D3 (rigor of development) was the strongest and D1 (scope and purpose) the weakest (overall model P < 0.001, R2 = 0.53). Five of the six domain scores were significant predictors of the clinical practice guideline use recommendation, with D3 the strongest predictor and D5 (applicability) the weakest (overall model P < 0.001, pseudo R2 = 0.53). Quality of rehabilitation clinical practice guidelines may be improved by addressing key domains such as rigor of development.

Narrative Review of Clinical Practice Guidelines for Rehabilitation of People With Spinal Cord Injury: 2010-2020.

Clinical practice guidelines provide reliable, vetted, and critical information to bring research to practice. Some medical specialties (e.g., physical medicine and rehabilitation) provide multidomain treatment for various conditions. This presents challenges because physical medicine and rehabilitation is a small specialty, a diverse patient base in terms sociodemographics and diagnosis, treatments are difficult to standardize, and rehabilitation research is underfunded. We wished to identify quality and applicability of clinical practice guidelines and searched "Spinal Cord Injury AND Clinical Practice Guidelines AND Rehabilitation" and vetting process.Three hundred fifty-nine articles were identified of which 58 met all criteria for full-text review of which 13 were included in the final selection. Additional publications were accessed from a nondatabase search. Five articles addressed postacute care, community treatment. Nine articles had no recorded vetting process but addressed rehabilitation as an outcome and were included separately. Many of the clinical practice guidelines were developed without evidence from randomized controlled trials, one had input from stakeholders, and some are out of date and do not address important aspects of changes in demographics of the affected population and the use of newer technologies such as sensors and robotics and devices. Identification of these gaps may help stimulate treatment that is clinically relevant, accessible, and current.

The Management of Stroke Rehabilitation: A Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

In June 2019, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved an update of the joint clinical practice guideline for rehabilitation after stroke. This synopsis summarizes the key recommendations from this guideline. In February 2018, the VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included clinical stakeholders and stroke survivors and conformed to the National Academy of Medicine (formerly the Institute of Medicine) tenets for trustworthy clinical practice guidelines. The guideline panel identified key questions, systematically searched and evaluated the literature, and developed 2 algorithms and 42 key recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Stroke survivors and their family members were invited to share their perspectives to further inform guideline development. The guideline recommendations provide evidence-based guidance for the rehabilitation care of patients after stroke. The recommendations are applicable to health care providers in both primary care and rehabilitation. Key features of the guideline are recommendations in 6 areas: timing and approach; motor therapy; dysphagia; cognitive, speech, and sensory therapy; mental health therapy; and other functions, such as returning to work and driving.

A South African experience in applying the Adopt\u2013Contextualise\u2013Adapt framework to stroke rehabilitation clinical practice guidelines

BackgroundClinical practice guideline (CPG) activity has escalated internationally in the last 20 years, leading to increasingly sophisticated methods for CPG developers and implementers. Despite this, there remains a lack of practical support for end-users in terms of effectively and efficiently implementing CPG recommendations into local practice. This paper describes South African experiences in implementing international CPG recommendations for best practice stroke rehabilitation into local contexts, using a purpose-build approach.MethodsComposite recommendations were synthesised from 16 international CPGs to address end-user questions about best practice rehabilitation for South African stroke survivors. End-user representatives on the project team included methodologists, policy-makers, clinicians, managers, educators, researchers and stroke survivors. The Adopt–Contextualise–Adapt model was applied as a decision-guide to streamline discussions on endorsement and development of implementation strategies. Where recommendations required contextualisation to address local barriers before they could be effectively implemented, prompts were provided to identify barriers and possible solutions. Where recommendations could not be implemented without additional local evidence (adaptation), options were identified to establish new evidence.FindingsThe structured implementation process was efficient in terms of time, effort, resources and problem solving. The process empowered the project team to make practical decisions about local uptake of international recommendations, develop local implementation strategies, and determine who was responsible, for what and when. Different implementation strategies for the same recommendation were identified for different settings, to address different barriers.ConclusionThe South African evidence translation experience could be useful for evidence implementers in other countries, when translating CPG recommendations developed elsewhere, into local practice.

Clinical Practice Guidelines for the Rehabilitation of Lower Limb Amputation

Between 2015 and 2017, the US Department of Veterans Affairs and the US Department of Defense developed a clinical practice guideline for rehabilitation of lower limb amputation to address key clinical questions. A multidisciplinary workgroup of US Department of Veterans Affairs and US Department of Defense amputation care subject matter experts was formed, and an extensive literature search was performed which identified 3685 citations published from January 2007 to July 2016. Articles were excluded based on established review criteria resulting in 74 studies being considered as evidence addressing one or more of the identified key issues. The identified literature was evaluated and graded using the National Academies of Science GRADE criteria. Recommendations were formulated after extensive review. Eighteen recommendations were confirmed with four having strong evidence and workgroup confidence in the recommendation. Key recommendations address patient and caregiver education, consideration for the use of rigid and semirigid dressings, consideration for the use of microprocessor knees, and managed lifetime care that includes annual transdisciplinary assessments. In conclusion, this clinical practice guideline used the best available evidence from the past 10 yrs to provide key management recommendations to enhance the quality and consistency of rehabilitation care for persons with lower limb amputation.

Building capacity in primary care rehabilitation clinical practice guidelines: a South African initiative

BackgroundThe large number of South Africans with disability who cannot access good quality rehabilitation presents a public health and human rights challenge. A cost-effective, efficient approach is required to address this. Implementation of high-quality, contextually relevant clinical practice guidelines (CPGs) could be a solution; however, this requires significant investment in innovative capacity-building.MethodsA qualitative descriptive national study was conducted to explore the perspectives of South African stakeholders in rehabilitation, regarding CPG capacity-building. Twenty rehabilitation professionals (physiotherapists, occupational therapists, speech language therapists, podiatrists, rehabilitation managers or directors) were interviewed. Transcribed interview data were analysed using a deductive content analysis approach, mapping findings to an international capacity-building framework to produce new knowledge.ResultsCapacity-building is required in content, purpose and construction of locally relevant CPGs, as well as personal, workforce and systems capacity. Principles and strategies were derived to underpin implementation of CPGs that are user friendly, context specific, relevant to the needs of end-users, and achievable within available resources. Collaboration, networks and communication are required at national, provincial and regional level, within and between sectors. A central agency for CPG methods, writing, implementation and evaluation is indicated.ConclusionSouth African rehabilitation can benefit from a multi-level CPG capacity-building focusing on performance, personal, workforce and systems issues.

Applicability of clinical practice guidelines for rehabilitation in traumatic brain injury in disaster settings: A critical appraisal

To provide an overview of recommendations and quality of existing clinical practice guidelines (CPGs) for management of traumatic brain injury (TBI) focusing on rehabilitation medicine; and synthesise recommendations from these for applicability in disaster settings. Comprehensive literature search including health databases, CPG clearinghouse/developer websites, and grey literature using Internet search engines to September 2017. All TBI CPGs published in the last decade were selected if their scope included: management of TBI, systematic methods for evidence search, clear defined recommendations and supporting evidence for rehabilitation interventions. Three authors independently critically appraised the quality of included CPGs using the Appraisal of Guidelines, Research and Evaluation (AGREE) Instrument. All recommendations were extracted, compared and categorized for applicability in disaster settings. Only 4 of the 14 potential identified CPGs met the inclusion criteria. Despite variation in scope, target population, size, and guideline development processes, all four CPGs were assessed as of good quality (AGREE Global score of 5–7 out of 7). The recommendations included: patient/carer education, general physical therapy, practice in daily living activities and safe equipment use, direct cognitive/behavioural feedback, basic compensatory memory/visual strategies, basic swallowing/communication and psychological input for TBI survivors in disaster settings. More advanced interventions are generally not applicable following disasters due to limited access to services, trained staff/resources, equipment, funding and operational issues. Although CPGs in this study were of high quality, many recommendations for TBI care are challenging to implement in disaster settings and need further research to identify and address barriers for implementation.

Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015.

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

Locomotor Training in the Pediatric Spinal Cord Injury Population: A Systematic Review of the Literature.

Background: The restoration of walking ability in the spinal cord injury (SCI) population is an increasingly important goal in physical therapy. Locomotor training (LT) is often implemented with the aim to restore ambulation. At this point, there are no guidelines for LT in the pediatric SCI population. Objectives: The aim of this review is to further narrow the effects of LT to the pediatric SCI population and develop recommendations for pediatric LT. Methods: A thorough search was performed using the following databases: Scopus, CINAHL, PubMed, and Ovid. Studies were selected based on the following inclusion criteria: pediatric SCI population, articles published within last 10 years, human subjects, and LT. Studies looking at other neurological disorders and subjects who were not previously ambulatory were excluded. Five students and one Faculty Research Advisor from the university's Doctor of Physical Therapy Program evaluated the inclusion criteria, conducted a risk of bias assessment using the Downs and Black checklist, and extracted the results. Results: Six studies were selected for this review. They showed gains in distance, gait speed, walking independence, and participation. There were variations in results when comparing gains in injury level based on the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Conclusions: Currently there is insufficient evidence to determine the best clinical practice guidelines for rehabilitation using LT within the pediatric SCI population.

Intention toward Implementation of Stroke Rehabilitation Clinical Practice Guidelines: An Application of the Theory of Planned Behavior

Intention toward Implementation of Stroke Rehabilitation Clinical Practice Guidelines: An Application of the Theory of Planned Behavior

Quality of stroke rehabilitation clinical practice guidelines

Clinical practice guidelines (CPGs) are systematically developed statements that assist practitioners to provide appropriate evidence-based care. The purpose of this study was to evaluate the quality of currently published CPGs for stroke care and to examine the reliability and validity of the appraisal of guidelines, research and evaluation (AGREE) instrument. Multiple databases and Internet resources were searched for stroke care CPGs. Guidelines included were published in English or French from 1998 to 2004 and developed by a group process. Four appraisers evaluated each CPG using the AGREE instrument. The AGREE consists of 23 items, ranked on a 4-point Likert scale, that is organized into six domains. A standardized score is calculated separately for each domain and ranges from 0 to 100. Eight guidelines were identified. The AGREE quality scores were high for the 'scope and purpose' domain (mean +/- SE = 71.2 +/- 5.48, intra-class correlation (ICC) = 0.66), and 'clarity and presentation' (mean +/- SE = 70.6 +/- 4.43, ICC = 0.66). There was wide variation in ratings of 'rigour of development' (mean +/- SE = 60.7 +/- 7.1, ICC = 0.75) and 'stakeholder involvement' (mean +/- SE = 52.6 +/- 7.14, ICC = 0.89). The 'editorial independence' (mean +/- SE = 38.1 +/- 8.72, ICC = 0.88) and 'applicability' (mean +/- SE = 35.1 +/- 4.93, ICC = 0.75) had the lowest scores. There is considerable variability in quality of stroke care guidelines but stroke guidelines score higher on the AGREE rigour of development domain than CPGs from other medical fields. The Scottish Intercollegiate Guideline Network, Veterans Affairs/Department of Defence, Royal College of Physicians, and the New Zealand Guidelines Group consistently scored the highest across the domains. Stroke rehabilitation clinicians should consider these results in selecting a guideline. CPG development groups can improve their AGREE scores by considering the cost of implementing their CPGs, pilot testing their CPGs, recording conflict of interest of development panel members and providing tools supporting application of their CPGs.

Effektivität psychosozialer Behandlungsmethoden zur medizinischen Rehabilitation alkoholabhängiger Patienten

Treatment approaches which are used in the context of inpatient alcoholism treatment are frequently neither theoretically justified nor empirically examined. In view of the enormous method variety the necessity exists for the development of treatment guidelines in order to offer indicators of promising treatment achievement for practitioners and pension funds. In a first step, it must be examined which treatments are effective, which are ineffective and which are possibly even counter-productive. This article aims to give a comprehensive review of randomized-controlled studies/meta-analysis on the efficacy of different treatment approaches. This article reporting the literature review is part of a larger programme to develop clinical practice guidelines for rehabilitation which is supported in form, content and finance by the German Pension Institute for Salaried Employees (Bundesversicherungsanstalt für Angestellte, BfA). Summing up, treatment is effective compared to no treatment. Cognitive behavioural therapy included in a multimodal treatment program is effective. There are a number of treatment protocols for which controlled research has consistently found positive results like social skills training, community reinforcement approaches, behaviour contracting, motivation-enhancing treatment, and family/marital therapy. There is also a number of commonly used treatment approaches that brought neither a positive result or were counter productive like relapse prevention, non-behavioural marital therapy, and insight psychotherapy, confrontational counseling, education, relaxation training, and milieu therapy. Support for matching to a specific treatment is weak, but interventions against alcohol problems should be differentiated according to the severity of the alcohol problem. Since treatment evaluation is mainly accomplished in the US and supplying structures with respect to the US and Germany are substantially different, a generalized transmission of US-American research results on Germany is to be evaluated carefully. Randomized-controlled studies are needed in Germany.

Development of a guideline for rehabilitation of patients with low back pain-- phase 2: analysis of data of the classification of therapeutic procedures

Initiated by the Federal Insurance Institute for Salaried Employees (BfA, Bundesversicherungsanstalt für Angestellte), the project is aimed at developing an evidence-based guideline for rehabilitation of patients with low back pain (LBP). Guideline development will be based on a systematic review of the literature, an analysis of the treatment procedures currently employed in rehabilitation, inclusion of the patients' perspectives as well as consultation of experts' panels of clinically experienced physicians and therapists. Formulation of the guideline will then be carried out in a structured consensus building process. This article is focused on analysing the present situation with regard to the treatments received by patients insured by the BfA, using data from routine documentation according to the Classification of Therapeutic Procedures (KTL, Klassifikation Therapeutischer Leistungen). The analysis is intended to provide indications of a basic need to implement a common guideline as well as, simultaneously, to explore possible deficits in present treatment practices, hence to define priorities requiring special attention in the framework of guideline development. As a result of a systematic literature review, the KTL-defined therapeutic procedures that had emerged as relevant in the rehabilitation of LBP patients were aggregated into so-called therapeutic modules which then formed the basis of the analysis. In all, more than 46,000 KTL-data of 2438 patients with a diagnosis of "low back pain" (M54.5 ICD-10) were included. In the rehab centres investigated, rehabilitation of patients with LBP follows a multidimensional, multiprofessional therapeutic strategy. More than 90 % of all patients receive treatments from the modules "medical training therapy", "health education", "physiotherapy", and "physical therapy". Treatments provided to a majority of the patients are massage (78 %), electrotherapy (67 %) as well as psychotherapy (68 %). Women more frequently than men receive therapies belonging to the "psychological treatments" and "occupational therapies" modules; younger patients receive more of the "training therapies", and more often. When treatments are compared across centres, a large variability in the therapeutic procedures provided becomes apparent. This high degree of variability suggests that development and implementation of a common clinical practice guideline for rehabilitation of patients with chronic low back pain should receive priority attention.

Transforming exercise-based cardiac rehabilitation programs into secondary prevention centers: a national imperative.

Transforming exercise-based cardiac rehabilitation programs into secondary prevention centers: a national imperative.

Stroke care: a method for measuring compliance with AHCPR guidelines.

The purpose of this article is to describe a method for converting practice guidelines to measurement criteria. To evaluate the processes of care received by patients with stroke at 11 Veteran's Administration hospital sites, we developed a measurement system based on Agency for Health Care Policy and Research (AHCPR) Post-Stroke Rehabilitation Clinical Practice Guidelines. Guideline recommendations were used as the framework for identifying important dimensions of care, and for developing chart abstraction instruments for both the acute and postacute settings. Using a modified Delphi technique to solicit opinions from an expert panel, a method was developed for aggregation of item-level chart abstraction components to overall guideline compliance scores. The measurement system was shown to have good-to-excellent intrarater and interrater reliability at the item, dimension, and overall compliance score levels. Abstraction of a sample of 100 medical records demonstrated the ability of the instruments to detect variability in processes of post-stroke care. This study provides the foundation for future research, which will evaluate associations between processes of post-stroke care, as measured by this medical chart abstraction system, and patient outcomes. (All abstraction instruments, criteria, and scoring algorithms described in this article are available for download at http://www2.kumc.edu/coa.)

Cardiac rehabilitation in the elderly.

Rehabilitation for patients with heart disease consists of exercise training, behavioral interventions, counseling, and education with the goal of improving physiologic and psychosocial status. The Cardiac Rehabilitation Clinical Practice Guidelines, recently published in the United States, list the most substantial benefits of cardiac rehabilitation as an improvement in exercise tolerance, symptoms, blood lipid levels, and psychosocial well-being, and a reduction in cigarette smoking, stress, and mortality. With the evidence-base on the elderly in the Guidelines derived from 1 non-randomized controlled trial and 7 observational studies, the efficacy and effectiveness of cardiac rehabilitation is based almost exclusively on data generated on young and middle-aged males. We have located an additional 10 randomized and 2 non-randomized controlled trials published since the Guidelines, but only one provided age-specific data. The elderly are the fastest growing segment of the population, and may be more responsive to the effects of cardiac rehabilitation as they often have greater initial disability and less independence than younger patients. While referral of elderly persons to cardiac rehabilitation services appears safe and warranted in the secondary prevention of heart disease, the lack of rigorous scientific evidence has created an important clinical research and clinical policy vacuum which urgently needs to be filled.

Introduction

The WHO Rehabilitation 2030 agenda recognises the importance of rehabilitation in the value chain of quality health care. Developing and delivering cost-effective, equitable-access rehabilitation services to the right people at the right time is a challenge for health services globally. These challenges are amplified in low-income and middle-income countries (LMICs), in which the unmet need for rehabilitation and recovery treatments is high. In this Series paper, we outline what is happening more broadly as part of the WHO Rehabilitation 2030 agenda, then focus on the specific challenges to development and implementation of effective stroke rehabilitation services in LMICs. We use stroke rehabilitation clinical practice guidelines from both high-income countries and LMICs to highlight opportunities for rapid uptake of evidence-based practice. Finally, we call on educators and the stroke rehabilitation clinical, research, and not-for-profit communities to work in partnership for greater effect and to accelerate progress.