A systematic review of discrete choice experiments in stroke rehabilitation.

OBJECTIVES: Existing research qualitatively explores consumer preferences for stroke rehabilitation interventions. However, it remains unclear which intervention characteristics are most important to consumers, and how these preferences may influence uptake and participation. Discrete choice experiments (DCE) provide a unique way to quantitatively measure preferences for health and health care. This study aims to explore how DCEs have been used in stroke rehabilitation and to identify reported consumer preferences for rehabilitation interventions. MATERIAL AND METHODS: A systematic review of published stroke rehabilitation DCEs was completed (PROSPERO registration: CRD42021282578). Six databases (including CINAHL, MEDLINE, EconLIT) were searched from January 2000-March 2023. Data extracted included topic area, sample size, aim, attributes, design process, and preference outcomes. Descriptive and thematic analyses were conducted, and two methodological checklists applied to review quality. RESULTS: Of 2,446 studies screened, five were eligible. Studies focused on exercise preference (n = 3), the structure and delivery of community services (n = 1), and self-management programs (n = 1). All had small sample sizes (range 50-146) and were of moderate quality (average score of 77%). Results indicated people have strong preferences for one-to-one therapy (over group-based), light-moderate intensity of exercise, and delivery by qualified therapists (over volunteers). CONCLUSIONS: Few DCEs have been conducted in stroke rehabilitation, suggesting consumer preferences could be more rigorously explored. Included studies were narrow in the scope of attributes included, limiting their application to practice and policy. Further research is needed to assess the impact of differing service delivery models on uptake and participation.

Consumer perspectives of allied health involvement in a public hospital setting: cross-sectional survey and electronic health record review.

Objective Consumer-centred care is fundamental to high-quality health care, with allied health professionals playing a pivotal role in hospital settings. Allied health typically operates within standard weekday working-hours. Consumer preferences for receiving allied health services are largely unexplored but could inform whether weekend and/or out-of-hours services are required. This study aims to understand consumer preferences for hospital-based inpatient and outpatient allied health services. Methods Using a cross-sectional survey and convenience sampling approach, consumers of a public health service in Melbourne, Australia were surveyed about preferences for allied health service delivery. Electronic health record reviews compared the accuracy of self-reported service delivery times. Descriptive statistics, concordance and predictive values were calculated. Responses to free-text survey items were analysed using content analysis. Results Of 120 participants (79% response rate), most (69%) received allied health services, however, almost half of inpatient responders (44%) were unsure of the specific allied health professional involved. Audit results found moderate-high concordance overall (range, 77-96%) between self-reported and audit-identified allied health services by profession. Most inpatient responders had no strong day of week preference, equally selecting weekdays and weekend days, with most preferring services between 8 am and 4 pm. Outpatient responders (81%) preferred a weekday appointment between 8 am and 12 pm or before 8 am (29%) to complete scheduled activities early in the day. Conclusion While provision of allied health services during standard working-hours was preferred by most consumers, some inpatient and outpatient consumers are receptive to receiving weekend and out-of-hours services, respectively. Decisions about offering these services should consider operational capacity and research evidence.

Staying Active with Multimorbidity In Acute hospital settings (StAMInA) trial: protocol for a feasibility randomised controlled trial of allied health assistant mobility rehabilitation for patients with multimorbidity.

INTRODUCTION: Key to improving outcomes for patients with multimorbidity is increasing mobility through prescription of a physical activity programme, but this can be difficult to achieve in acute hospital settings. One approach that would assist physiotherapists to increase levels of physical activity is delegation of rehabilitation to allied health assistants. We aim to conduct a randomised controlled trial to determine the feasibility of an allied health assistant providing daily inpatient mobility rehabilitation for patients with multimorbidity. METHODS AND ANALYSIS: Using a parallel group randomised controlled design, participants will be allocated to allied health assistant mobility rehabilitation or physiotherapist mobility rehabilitation. Adult inpatients (n=60) in an acute hospital with a diagnosis of multimorbidity who walked independently preadmission will be included. The experimental group will receive routine mobility rehabilitation, including daily mobilisation, from an allied health assistant under the supervision of a physiotherapist. The comparison group will receive routine rehabilitation from a physiotherapist. Feasibility will be determined using the following areas of focus in Bowen's feasibility framework: Acceptability (patient satisfaction); demand (proportion of patients who participate); implementation (time allied health assistant/physiotherapist spends with participant, occasions of service); and practicality (cost, adverse events). Staff involved in the implementation of allied health assistant rehabilitation will be interviewed to explore their perspectives on feasibility. Secondary outcomes include: Physical activity (daily time spent walking); daily mobilisation (Y/N); discharge destination; hospital readmission; falls; functional activity (Modified Iowa Level of Assistance Scale); and length of stay. Descriptive statistics will be used to describe feasibility. Secondary outcomes will be compared between groups using Poisson or negative binomial regression, Cox proportional hazards regression, survival analysis, linear regression or logistic regression. ETHICS AND DISSEMINATION: Ethics approval was obtained from Peninsula Health (HREC/97 431/PH-2023). Findings will be disseminated in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trial Registry ACTRN12623000584639p.

Development of an implementation strategy for routine collection of generic patient reported outcome measures: a qualitative study in multidisciplinary community rehabilitation.

PURPOSE: To explore staff perceptions of barriers and enablers towards implementing the EQ-5D-5L in community rehabilitation, and develop a theory-informed implementation approach for routine administration of generic patient-reported outcome measures (PROMs) using implementation science frameworks. MATERIALS AND METHODS: A qualitative study was conducted at three sites. Multidisciplinary rehabilitation staff completed individual semi-structured interviews, which were transcribed and coded against the Theoretical Domains Framework (TDF). We identified and selected potentially effective behaviour change techniques using the Behavior Change Wheel. Hypothetical strategies were operationalised. RESULTS: Twenty-one interviews were conducted, and four themes emerged: (1) The Impact of PROMs on patient centered-care; (2) Considerations for validity of PROMs; (3) Service-level impact of embedding PROMs; (4) Practical issues of embedding PROMs within the service. Barriers and enablers were mapped to seven of the TDF domains; relating most to clinicians' "belief about consequences", "reinforcement", and "environmental context and resources". Five hypothetical strategies were developed to overcome identified barriers and strengthen enablers. Key behaviour change techniques underpinning the strategies include: restructuring the physical environment, incentivisation, persuasion and education, enablement, and, social support. CONCLUSIONS: Our implementation approach highlights the importance of automating processes, engaging site champions, routinely reporting, and using PROM data to inform service provision.

Implementation of patient reported outcome measures within multidiscipline rehabilitation settings are likely optimised by establishing infrastructure support e.g., information technology systems to automate the process and minimise manual aspects of data collection.Engaging site champions may be an important enabler for the routine collection of patient reported outcome measuresProviding feedback to clinicians on aggregated results of patient reported outcome measures are likely to motivate and encourage routine collection.

Implementation of a leisure reintegration programme for people with acquired brain injury in a community rehabilitation programme: a feasibility study.

BACKGROUND: Participation in leisure activities is significantly impacted following acquired brain injury (ABI). Despite this being a common community rehabilitation goal, re-engagement with leisure activities following ABI is poorly addressed within Australian community rehabilitation services, which often cater to a mixed-diagnostic group of both ABI and non-ABI clients. OBJECTIVES: To evaluate the feasibility and effect of a leisure reintegration group programme within a community rehabilitation service. METHOD: A single-site, pre- and post-test feasibility study was conducted. Three cohorts of a semi-structured leisure group programme were offered, each conducted over eight sessions within 4 weeks. The Nottingham Leisure Questionnaire (NLQ) and Leisure Satisfaction Measure (LSM) were used as primary outcome measures. Measures of acceptability, including adherence, and a post-intervention participant survey were also completed. RESULTS: Of the 14 consenting participants, 9 completed all outcome measures. Mean change score for the NLQ was -3.63 (p = 0.11) and the LSM 4.25 (p = 0.46). The programme was well attended (79%), acceptable for ABI and non-ABI participants and able to be implemented within an existing community rehabilitation service. CONCLUSION: Providing a leisure reintegration group programme met an identified need, developed client and carer capacity and could be delivered within a community rehabilitation service for clients with mixed diagnoses including ABI. A larger trial is warranted to examine the effectiveness and cost-effectiveness of this intervention for people with ABI.

Mixed methods study to understand the experiences of adults with acquired brain injury and their family members who receive specialised rehabilitation.

BACKGROUND AND AIM: Rehabilitation therapy is a key part of the recovery pathway for people with severe acquired brain injury (ABI). The aim of this study was to explore inpatients' and their family members' experiences of a specialist ABI rehabilitation service. METHODS: A cross sectional, prospective mixed method study was undertaken at a metropolitan specialist ABI rehabilitation unit in Victoria, Australia. All inpatients and their family members of the service were invited to complete a satisfaction survey. Employing purposive sampling, semi-structured interviews were conducted with inpatients and/or their family members. RESULTS: In total, 111 people completed the satisfaction survey and 13 were interviewed. High levels of satisfaction with the specialist service were reported; the majority of inpatients (74%) and family members (81%) rated the overall quality of care received in the service as 'high' or 'very high'. Interviews revealed four main themes: (i) satisfaction with rehabilitation services, (ii) inconsistent communication, (iii) variable nursing care, and (iv) strengths and weakness of the rehabilitation environment. Overall, important components of a positive experience were being involved in decision making and discharge planning, effective communication and information processes, and being able to form therapeutic relationships with staff. Key sources of dissatisfaction for inpatients and family members related to inconsistency in care, accessing information about treatments in a format easily understood, and communication. CONCLUSION: Specialised rehabilitation is valued by inpatients and their family members alike. The findings highlight the importance of exploring inpatient experiences to optimise service delivery in a tailored, specialised rehabilitation programme.

Stroke rehabilitation research translation in Australia: a survey of clinical trialists.

PURPOSE: Translation of findings from stroke trials into clinical practice remains low. Little is known about planned translation activities from the perspective of trialists who generate the evidence. This study aims to investigate perceptions of Australian stroke clinical trialists' about implementation of their findings into practice, and what translation activities they embedded into trial protocols. MATERIALS AND METHOD: A descriptive cohort design and electronic survey was conducted. Three databases were searched to identify Australian stroke rehabilitation trials published between 2007 and 2017. Corresponding authors of the included trials were invited to complete an anonymous online survey about implementation of their trial intervention. RESULTS: Fifty-one trialists were invited to participate and 38 completed the survey (74% response rate). The majority (79%) considered their trial results to be clinically significant and 68% had pre-planned knowledge translation activities. The most common planned translation activities were publication (89%), conference presentation (87%), and feedback of results to target audiences (58%). Mixed opinions were evident regarding when and how to design knowledge translation activities for inclusion in trial protocols. Stroke rehabilitation trialists rely mostly on anecdotal reports about implementation of trial interventions, with few formally measuring uptake.Implications for rehabilitationThe most common knowledge translation activities planned for by researchers are publication of findings in academic journals, and conference presentations.Mixed opinions exist regarding when and how to design for knowledge translation activities in trial protocols.Limited formal measurement of intervention uptake is completed.Further implementation research is required to support and measure effective translation efforts when embedded into trial protocols.

Self-reported quality of life following stroke: a systematic review of instruments with a focus on their psychometric properties.

PURPOSE: To evaluate the psychometric properties of common health-related quality-of-life instruments used post stroke and provide recommendations for research and clinical use with this diagnostic group. METHODS: A systematic review of the psychometric properties of the five most commonly used quality-of-life measurement tools (EQ-5D, SF-36, SF-6D, AQoL, SS-QOL) was conducted. Electronic searches were performed in MEDLINE, CINAHL, and EMBASE on November 27th 2019. Two authors screened papers against the inclusion criteria and where consensus was not reached, a third author was consulted. Included papers were appraised using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist and findings synthesized to make recommendations. RESULTS: A total of n = 50,908 papers were screened and n = 45 papers reporting on 40 separate evaluations of psychometric properties met inclusion criteria (EQ-5D = 19, SF-36 = 16, SF-6D = 4, AQoL = 2, SS-QOL = 4). Studies reported varied psychometric quality of instruments, and results show that psychometric properties of quality-of-life instruments for the stroke population have not been well established. The strongest evidence was identified for the use of the EQ-5D as a quality-of-life assessment for adult stroke survivors. CONCLUSIONS: This systematic evaluation of the psychometric properties of self-reported quality-of-life instruments used with adults after stroke suggests that validity across tools should not be assumed. Clinicians and researchers alike may use findings to help identify the most valid and reliable measurement instrument for understanding the impact of stroke on patient-reported quality of life.

Timing and Dose of Upper Limb Motor Intervention After Stroke: A Systematic Review.

This systematic review aimed to investigate timing, dose, and efficacy of upper limb intervention during the first 6 months poststroke. Three online databases were searched up to July 2020. Titles/abstracts/full-text were reviewed independently by 2 authors. Randomized and nonrandomized studies that enrolled people within the first 6 months poststroke, aimed to improve upper limb recovery, and completed preintervention and postintervention assessments were included. Risk of bias was assessed using Cochrane reporting tools. Studies were examined by timing (recovery epoch), dose, and intervention type. Two hundred and sixty-one studies were included, representing 228 (n=9704 participants) unique data sets. The number of studies completed increased from one (n=37 participants) between 1980 and 1984 to 91 (n=4417 participants) between 2015 and 2019. Timing of intervention start has not changed (median 38 days, interquartile range [IQR], 22-66) and study sample size remains small (median n=30, IQR 20-48). Most studies were rated high risk of bias (62%). Study participants were enrolled at different recovery epochs: 1 hyperacute (<24 hours), 13 acute (1-7 days), 176 early subacute (8-90 days), 34 late subacute (91-180 days), and 4 were unable to be classified to an epoch. For both the intervention and control groups, the median dose was 45 (IQR, 600-1430) min/session, 1 (IQR, 1-1) session/d, 5 (IQR, 5-5) d/wk for 4 (IQR, 3-5) weeks. The most common interventions tested were electromechanical (n=55 studies), electrical stimulation (n=38 studies), and constraint-induced movement (n=28 studies) therapies. Despite a large and growing body of research, intervention dose and sample size of included studies were often too small to detect clinically important effects. Furthermore, interventions remain focused on subacute stroke recovery with little change in recent decades. A united research agenda that establishes a clear biological understanding of timing, dose, and intervention type is needed to progress stroke recovery research. Prospective Register of Systematic Reviews ID: CRD42018019367/CRD42018111629.

Effect of occupational therapy home visit discharge planning on participation after stroke: protocol for the HOME Rehab trial.

INTRODUCTION: After first stroke, the transition from rehabilitation to home can be confronting and fraught with challenges. Although stroke clinical practice guidelines recommend predischarge occupational therapy home visits to ensure safe discharge and provision of appropriate equipment, there is currently limited evidence to support this recommendation. METHODS AND ANALYSIS: The HOME Rehab trial is a national, multicentre, phase III randomised controlled trial with concealed allocation, blinded assessment and intention-to-treat analysis being conducted in Australia. The trial aim is to determine the effect and potential cost-effectiveness of an enhanced occupational therapy discharge planning intervention that involves pre and postdischarge home visits, goal setting and occupational therapy in the home (the HOME programme) in comparison to an in-hospital predischarge planning intervention. Stroke survivors aged ≥45 years, admitted to a rehabilitation ward, expected to return to a community (private) dwelling after discharge, with no significant prestroke disability will be randomly allocated 1:1 to receive a standardised discharge planning intervention and the HOME programme or the standardised discharge planning intervention alone. The primary outcome is participation measured using the Nottingham Extended Activities of Daily Living. Secondary outcome areas include hospital readmission, disability, performance of instrumental activities of daily living, health-related quality of life, quality of care transition and carer burden. Resources used/costs will be collected for the cost-effectiveness analysis and hospital readmission. Recruitment commenced in 2019. Allowing for potential attrition, 360 participants will be recruited to detect a clinically important treatment difference with 80% power at a two-tailed significance level of 0.05. ETHICS AND DISSEMINATION: This study is approved by the Alfred Health Human Research Ethics Committee and site-specific ethics approval has been obtained at all participating sites. Results of the main trial and the secondary endpoint of cost-effectiveness will be submitted for publication in peer-reviewed journalsTrial registration numberACTRN12618001360202.

Feasibility of modifying the hospital environment to reduce the length of amnesia after traumatic brain injury: a pilot randomized controlled trial.

BACKGROUND: Reorientation programmes have been an important component of neurotrauma rehabilitation for adults who suffer from post-traumatic amnesia (PTA) after traumatic brain injury (TBI); however, research testing the efficacy of acute programmes is limited. OBJECTIVE: This study aimed to determine if it is feasible to provide a standardized environmental reorientation programme to adults suffering from PTA after TBI in an acute care hospital setting, and whether it is likely to be beneficial. METHODS: We conducted a randomized controlled trial with concealed allocation and intention-to-treat analysis. A total of 40 participants suffering from PTA after TBI were included. The control group received usual care; the experimental group received usual care plus a standardized orientation programme inclusive of environmental cues. The primary outcome measure was time to emergence from PTA measured by the Westmead PTA Scale, assessed daily from hospital admission or on regaining consciousness. RESULTS: Adherence to the orientation programme was high, and there were no study-related adverse responses to the environmental orientation programme. Although there were no statistically significant between-group differences in time to emergence, the median time to emergence was shorter for those who received the standardized reorientation programme (9.0 (6.4-11.6) versus 13.0 (4.5-21.5) days). Multivariate analysis showed that the Glasgow Coma Scale (GCS) at scene (P = 0.041) and GCS at arrival at hospital (P = 0.0001) were significant factors contributing to the longer length of PTA. CONCLUSION: Providing an orientation programme in acute care is feasible for adults suffering from PTA after TBI. A future efficacy trial would require 216 participants to detect a between-group difference of 5 days with an alpha of 0.05 and a power of 80%.

A Brief Intervention to Support Implementation of Telerehabilitation by Community Rehabilitation Services During COVID-19: A Feasibility Study.

The coronavirus disease 2019 (COVID-19) pandemic has necessitated adoption of telerehabilitation in services where face-to-face consultations were previously standard. We aimed to understand barriers to implementing a telerehabilitation clinical service and design a behavior support strategy for clinicians to implement telerehabilitation. A hybrid implementation study design included pre- and post-intervention questionnaires, identification of key barriers to implementation using the theoretical domains framework, and development of a targeted intervention. Thirty-one clinicians completed baseline questionnaires identifying key barriers to the implementation of telerehabilitation. Barriers were associated with behavior domains of knowledge, environment, social influences, and beliefs. A 6-week brief intervention focused on remote clinician support, and education was well received but achieved little change in perceived barriers to implementation. The brief intervention to support implementation of telerehabilitation during COVID-19 achieved clinical practice change, but barriers remain. Longer follow-up may determine the sustainability of a brief implementation strategy, but needs to consider pandemic-related stressors.

Effectiveness of health consumer representative involvement in implementation of interventions to change health professional behaviour.

BACKGROUND: The adoption of research evidence to improve client outcomes may be enhanced using the principles of implementation science. This systematic review aimed to understand the effect of involving consumers to change health professional behaviours and practices. The barriers and enablers to consumer engagement will also be examined. METHODS: We searched Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials and PDQ-Evidence from 2004 to February 2019. Implementation studies involving consumers in at least one phase (development, intervention or facilitation) of an intervention that aimed to change health professional behaviour to align with evidence-based practice were included. Studies in the areas of paediatrics and primary care were excluded. Two review authors independently screened studies for inclusion, and one author extracted data and conducted quality assessments with review of a second author. Knowledge translation interventions were categorized using the Effective Practice and Organisation of Care taxonomy. The primary outcome was measures of change in health professional behaviour. RESULTS: Sixteen articles met the inclusion criteria. Meta-analysis of three studies found support for consumer involvement in changing healthcare professionals' behaviour (Hedges' g = 0.41, 95% CI [0.27, 0.57], P < 0.001). Most knowledge translation studies involved consumers during the development phase only (n = 12). Most studies (n = 9) included one type of knowledge translation intervention. Professional interventions (including education of health professionals, educational outreach, and audit and feedback) were described in 13 studies. CONCLUSIONS: Consumer involvement rarely moves beyond the design phase of knowledge translation research in healthcare settings. Further research of the barriers to and effect of increased consumer engagement across all stages of knowledge translation interventions is needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019119179.

Activity, Participation, and Goal Awareness After Acquired Brain Injury: A Prospective Observational Study of Inpatient Rehabilitation.

OBJECTIVE: To examine the frequency and timing of inpatient engagement in meaningful activities within rehabilitation (within and outside of structured therapy times) and determine the associations between activity type, goal awareness, and patient affect. METHODS: This prospective observational study performed behavioral mapping in a 42-bed inpatient brain injury rehabilitation unit by recording patient activity every 15 minutes (total 42 hours). The participants were randomly selected rehabilitation inpatients with acquired brain injury; all completed the study. The main outcome measures included patient demographics, observation of activity, participation, goal awareness, and affect. RESULTS: The inpatients spent 61% of the therapeutic day (8:30 to 16:30) in their single room and were alone 49% of the time. They were physically socially inactive for 76% and 74% of their awake time, respectively, with neutral affect observed for about half of this time. Goal-related activities were recorded for only 25% of the inpatients' awake time. The odds of physical activity were 10.3-fold higher among in patients receiving support to address their goals within their rehabilitation program (odds ratio=10.3; 95% confidence interval, 5.02-21.16). CONCLUSION: Inpatients in a mixed brain injury rehabilitation unit spent a large amount of their awake hours inactive and only participated in goal-related activities for a quarter of their awake time. Rehabilitation models that increase opportunities for physical, cognitive, and social activities outside of allied health sessions are recommended to increase overall activity levels during inpatient rehabilitation.

Patient functional independence and occupational therapist time-use in inpatient services: Patient demographic and clinical correlates.

INTRODUCTION: Health care expenditure has rapidly increased in Australia. Effective management of occupational therapy services is required to meet clinical demand. Improving our understanding of factors which influence occupational therapy service delivery is a vital step to manage workload distribution and optimise service efficiency. This study aims to examine the influence of patient sociodemographic characteristics, diagnosis and functional independence on the utilisation of occupational therapy resources in hospital inpatients over 18 years old. METHODS: Prospective, cross-sectional, observational cohort study of 4549 inpatients from three hospital sites in Melbourne, Australia. Data extracted from organisational databases and included in this study were: patient demographics, diagnosis, functional level assessed using the SMAF (Functional Autonomy Measurement System) and occupational therapy time-use. Data were analysed using univariable and multivariable modelling. RESULTS: Occupational therapy time-use was significantly associated with all variables included in analysis (p < 0.05). For each variable the amount and direction of effect differed between hospital sites. The SMAF was the only variable consistently associated with occupational therapy time-use. Higher occupational therapy time-use was associated with lower functional independence (leading to a 3.5 min increase in median occupational therapy time for every unit decrease in SMAF score). CONCLUSIONS: Management of resources within busy hospitals require knowledge of factors associated with occupational therapist time-use. This study identified that time-use could in part be predicted by functional independence, diagnosis and sociodemographic characteristics. Occupational therapy managers can use this information to support decision making while acknowledging other patient and therapist level factors also influence time-use.

Guideline Recommendations for Oral Care After Acquired Brain Injury: Protocol for a Systematic Review.

BACKGROUND: Oral care is important to prevent buccal and systemic infections after an acquired brain injury (ABI). Despite recent advancements in the development of ABI clinical practice guidelines, recommendations for specific clinical processes and actions to attain adequate oral care often lack information. OBJECTIVE: This systematic review will (1) identify relevant ABI clinical practice guidelines and (2) appraise the oral care recommendations existing in the selected guidelines. METHODS: A search strategy was developed based on a recent systematic review of clinical practice guidelines for ABI. The protocol includes a search of MEDLINE, EMBASE, and DynaMed Plus databases, as well as organizational and best-practice websites and reference lists of accepted guidelines. Search terms will include medical subject headings and user-defined terms. Guideline appraisal will involve the Appraisal of Guidelines for Research and Evaluation II ratings, followed by a descriptive synopsis for oral care recommendations according to the National Health and Medical Research Council evidence levels. RESULTS: This project started in April 2019, when we developed the search strategy. The preliminary search of databases and websites yielded 863 and 787 citations, respectively, for a total of 1650 citations. Data collection will start in August 2020 and we expect to begin disseminating the results in May 2021. CONCLUSIONS: Nursing staff may not have detailed recommendations on how to provide oral care for neurologically impaired patients. The findings of this review will explore the evidence for oral care in existing guidelines and improve outcomes for patients with ABI. We expect to provide adequate orientations to clinicians, inform policy and guidelines for best practices, and contribute to future directions for research in the ABI realm. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/17249.

What is the feasibility and observed effect of two implementation packages for stroke rehabilitation therapists implementing upper limb guidelines? A cluster controlled feasibility study.

BACKGROUND: Hand and arm activity after stroke improves with evidence-based rehabilitation. Therapists face known barriers when providing evidence-based rehabilitation and require support to implement guidelines. The aim of this study was to investigate the feasibility of two implementation packages on guideline adherence by occupational therapists and physiotherapists, and explore effect on patient upper limb outcomes. METHOD: This was a non-randomised clustered feasibility study of occupational and physiotherapy rehabilitation services (n=3 inpatient and n=3 outpatient services). Services were allocated to one of three groups: (group A) facilitator-mediated implementation package, (group B) self-directed implementation package or (group C) usual care (control); we recruited n=1 inpatient and n=1 outpatient service per group. Outcomes of feasibility, adherence to guidelines (medical file audits) and patient upper limb impairment (Fugl-Meyer Upper Extremity Assessment), activity (Box and Block Test) and practice (minutes/week) were collected at baseline and after 3 months of intervention. RESULTS: 29 therapists (8 in group A, 13 in groups B and 8 in group C) and 55 patients participated. Both the facilitator-mediated and the self-directed implementation packages were feasible to deliver in the rehabilitation setting. Therapists in group A improved with respect to guideline adherence (medical file audits; median within-group proportion difference of 0.29 (95% CI 0.22 to 0.36, p<0.0001) preintervention to postintervention). No significant within-group differences from baseline to postintervention were found in group B or group C, and no between-group differences were found for upper limb outcomes. CONCLUSION: A facilitator-mediated package was acceptable to therapists working in stroke rehabilitation, and feasibility data suggest increased guideline uptake following implementation. An adequately powered study is planned to understand how to support therapists to provide evidence-based upper limb rehabilitation after stroke. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12619000596101).

Interventions supporting caregiver readiness when caring for patients with dementia following discharge home: A mixed-methods systematic review.

OBJECTIVE: To explore programs and information provided to caregivers of inpatients with dementia to assist with readiness to provide care following discharge. METHODS: A mixed-methods systematic review with meta-analysis was conducted. Search terms included dementia, inpatient, caregiver, anxiety, discharge and counselling. RESULTS: The search yielded 1938 studies (six databases), 13 met the inclusion criteria. Meta-analysis showed no statistically significant changes in anxiety, depression, burden or quality of life 3 months postintervention. Three emergent qualitative themes for staff consideration are as follows: understanding personal characteristics of both patient and caregiver; presenting an inclusive organisational culture; and providing appropriate information at all stages of admission. A Model of Caregiver Readiness was created from the qualitative results. CONCLUSION: The programs did not significantly decrease the outcomes measured. However, caregivers identified that inclusion at all stages during hospital admission was a vital factor to reduce stress and increase caregiver readiness.

Increasing the uptake of stroke upper limb guideline recommendations with occupational therapists and physiotherapists. A qualitative study using the Theoretical Domains Framework.

INTRODUCTION: Despite the availability of stroke clinical practice guidelines and acceptance by therapists that guidelines contain 'best practice' recommendations, compliance remains low. While previous studies have explored barriers associated with implementing rehabilitation guidelines in general, it remains unknown if these barriers are applicable to upper limb rehabilitation specifically. To plan effective implementation activities, key motivators and barriers to use should be identified. METHOD: To investigate occupational and physiotherapists' perceptions of motivators and barriers to using upper limb clinical practice guideline recommendations in stroke rehabilitation, a mixed-method study was conducted. Using an online survey and semi-structured focus groups, physiotherapists and occupational therapists working in one of six stroke rehabilitation teams in Melbourne, Australia were invited to participate. Survey data were analysed using descriptive statistics, and thematic coding of free-text responses. Focus groups were transcribed, thematically coded and mapped against the Theoretical Domains Framework. RESULTS: Forty-six participants completed the survey and 29 participated in the focus groups. Key motivators to use guideline recommendations included past experience with specific interventions, availability of required resources and an enabling workplace culture. Barriers included: limited training/skills in specific interventions, the complexity of intervention protocols, and beliefs about intervention effectiveness. Lack of accountability was highlighted and therapists perceived they are rarely checked for quality assurance purposes regarding guideline adherence. CONCLUSION: Therapists identified that both motivators and barriers to implementing best-practice upper limb rehabilitation occur largely at the levels of the individual and the environment. As such, intervention efforts should focus at both these levels to facilitate change.

A systematic review protocol of timing, efficacy and cost effectiveness of upper limb therapy for motor recovery post-stroke.

BACKGROUND: Improving upper limb (UL) motor recovery after stroke represents a major clinical and scientific goal. We aim to complete three systematic reviews to estimate the (1) association between time to start of UL therapy and motor recovery, (2) relative efficacy of different UL therapy approaches post-stroke and (3) cost-effectiveness of UL therapy interventions. METHODS: We have designed a systematic review protocol to address three systematic review questions that were each registered with PROSPERO. The search will be conducted in MEDLINE, EMBASE, and Cochrane Controlled Register of Trials. We will include randomised controlled trials, non-randomised clinical trials, before-after studies and observational studies of adult stroke survivors with an average stroke onset < 6 months, undergoing hospital-based therapy to improve UL function. Eligible interventions will aim to promote UL functional recovery. Two reviewers will independently screen, select and extract data. Study risk of bias will be appraised using appropriate tools. Clinical measures of motor recovery will be investigated (primary measure Fugl Meyer UL assessment), as well as measures of health-related quality of life (primary measure EQ-5D) and all cost-effectiveness analyses completed. Secondary outcomes include therapy dose (minutes, weeks, repetitions as available) and safety (i.e. adverse events, serious adverse events). A narrative synthesis will describe quality and content of the evidence. If feasible, we will conduct random effects meta-analyses where appropriate. DISCUSSION: We anticipate the findings of this review will increase our understanding of UL therapy and inform the generation of novel, data-driven hypotheses for future UL therapy research post-stroke. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018019367, http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018111629, http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018111628.