Standardized tools for assessing balance and mobility in stroke clinical practice guidelines worldwide: A scoping review.

Background: Use of standardized tools to assess balance and mobility limitations is a recommended practice in stroke rehabilitation. The extent to which clinical practice guidelines (CPGs) for stroke rehabilitation recommend specific tools and provide resources to support their implementation is unknown. Purpose: To identify and describe standardized, performance-based tools for assessing balance and/or mobility and describe postural control components challenged, the approach used to select tools, and resources provided for clinical implementation, in CPGs for stroke. Methods: A scoping review was conducted. We included CPGs with recommendations on the delivery of stroke rehabilitation to address balance and mobility limitations. We searched seven electronic databases and grey literature. Pairs of reviewers reviewed abstracts and full texts in duplicate. We abstracted data about CPGs, standardized assessment tools, the approach for tool selection, and resources. Experts identified postural control components challenged by each tool. Results: Of the 19 CPGs included in the review, 7 (37%) and 12 (63%) were from middle- and high-income countries, respectively. Ten CPGs (53%) recommended or suggested 27 unique tools. Across 10 CPGs, the most commonly cited tools were the Berg Balance Scale (BBS) (90%), 6-Minute Walk Test (6MWT) (80%), Timed Up and Go Test (80%) and 10-Meter Walk Test (70%). The tool most frequently cited in middle- and high-income countries was the BBS (3/3 CPGs), and 6MWT (7/7 CPGs), respectively. Across 27 tools, the three components of postural control most frequently challenged were underlying motor systems (100%), anticipatory postural control (96%), and dynamic stability (85%). Five CPGs provided information in varying detail on how tools were selected; only 1 CPG provided a level of recommendation. Seven CPGs provided resources to support clinical implementation; one CPG from a middle-income country included a resource available in a CPG from a high-income country. Conclusion: CPGs for stroke rehabilitation do not consistently provide recommendations for standardized tools to assess balance and mobility or resources to facilitate clinical application. Reporting of processes for tool selection and recommendation is inadequate. Review findings can be used to inform global efforts to develop and translate recommendations and resources for using standardized tools to assess balance and mobility post-stroke. Systematic Review Registration: https://osf.io/, identifier: 10.17605/OSF.IO/6RBDV.

'We don't have to do it together': a qualitative study of physiotherapists' and patients' perceptions about collaborative goal setting in Nigeria.

BACKGROUND: The adoption of Collaborative Goal Setting (CGS) is limited in most rehabilitation settings in Nigeria despite its recommendations in clinical practice guidelines. OBJECTIVE: To explore the perceptions of physiotherapists and patients about CGS at a tertiary healthcare facility in Ibadan, Nigeria. METHODS: We conducted focus group discussions among purposively selected physiotherapists (n = 8) and patients (4 stroke survivors, 3 patients with brain injury) to qualitatively explore their perceptions. Audio-taped discussions were transcribed verbatim and thematically analyzed. RESULTS: We identified four themes around CGS which were: 1) paternalistic view of goal setting; 2) physiotherapists as goal setters; 3) perceived benefits of collaborative goal setting; and 4) barriers and facilitators to CGS. The physiotherapists articulated goals as expected outcomes from treatment and believed they were better poised and experienced to determine what patients could achieve during each phase of treatment. Patients' view of goal setting agreed with the physio-therapists', as they also opined that goal setting is the responsibility of physiotherapists. Time constraint, inadequate knowledge and the inability of patients to appropriately articulate their goals and expectations from treatment were barriers to CGS. Concerns about who to collaborate with when dealing with patients with impaired cognition and/or disorders of consciousness were raised by the physiotherapists. Participants in both groups indicated that education on how to set patient-oriented goals could facilitate CGS. CONCLUSIONS: Though rarely practiced, participants agreed that collaborative goal setting could be beneficial. Both the physiotherapists and patients require education on how to appropriately collaborate in setting goals of rehabilitation.

Expectations of individuals with neurological conditions from rehabilitation: A mixed-method study of needs.

BACKGROUND: Knowledge of the specific expectations of patients with neurological conditions (NCs) from rehabilitation helps in setting attainable goals. Such expectations may vary from situation to situation. There are no studies investigating rehabilitation expectations amongst individuals with NCs in Nigeria. OBJECTIVES: The aim of our study was to explore the rehabilitation expectations of individuals with NCs. METHOD: This convergent mixed-methods study comprised a cross-sectional survey of 105 individuals with NCs and two sessions of Focus Group Discussions (FGDS) amongst eight individuals with NCs. The modified Needs Assessment Questionnaire was used to assess rehabilitation needs as a proxy for rehabilitation expectations, whilst disability was assessed using the World Health Organization Disability Assessment Schedule 2.0. Quantitative data were summarised using descriptive statistics and analysed using inferential statistics at p < 0.05. Thematic analysis was conducted on the qualitative data. RESULTS: Sixty-one (58.1%) stroke survivors, 33 (31.4%) individuals with spinal cord injury (SCI) and 11 (10.5%) with traumatic brain injury (TBI) aged 46.48 ± 15.91 were surveyed. The need for social/recreational activity was the most expressed need (100%) amongst the participants. Mobility was reported as an important need constituting a barrier to enjoying life by 93 (88.6%) participants. Individuals with SCI expressed the greatest needs compared with the other two groups. Needs were significantly correlated with severity of disability (p < 0.05). Four overarching themes (physical health, financial, healthcare services/rehabilitation and emotional/social) representing major areas of needs emerged from the FGD data. CONCLUSION: Individuals with NCs in Nigeria have specified expectations of rehabilitation. Disability was a major driver of these expectations, irrespective of NC subtype. CLINICAL IMPLICATIONS: Rehabilitation programmes for individuals with NCs should target expressed needs or expectations of each patient cohort and minimise disabilities associated with these conditions.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review.

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Satisfaction of Nigerian stroke survivors with outpatient physiotherapy care.

OBJECTIVE: To investigate the satisfaction of stroke survivors with outpatient physiotherapy care. METHODS: Sixty stroke survivors were surveyed using the European Physiotherapy Treatment Outpatient Satisfaction Survey (EPTOPS). Focus group discussion (FGD) was also conducted with four stroke survivors from the same sample. Data were analyzed using the Kruskal Wallis test and Spearman's correlation coefficients at p = 0.05. FGD was transcribed and thematically analyzed. RESULTS: Nearly all the participants (98.3%) indicated one of good, very good, and excellent improvement in their clinical conditions with physiotherapy. Majority expressed satisfaction with their physiotherapy care, the modal response being very good (59.3%). Patients' satisfaction and socio-demographics were not significantly correlated (p > 0.05). Overarching themes from FGD were physiotherapy in stroke rehabilitation, satisfaction with physiotherapy care, cost, and lack of continuity of care as sources of dissatisfaction. Physiotherapists' demeanor was a facilitator of satisfaction. CONCLUSION: The stroke survivors were generally satisfied with outpatient physiotherapy care. However, lack of continuity and cost of care were sources of dissatisfaction among patients. Delivery of physiotherapy to stroke survivors in Nigeria should be structured to allow for continuity of care as this may enhance satisfaction. Implementation of inexpensive rehabilitation strategies may help reduce cost of physiotherapy.

Perceived quality of physiotherapy services among informal caregivers of children with cerebral palsy in Ibadan, Nigeria.

OBJECTIVE: Effective physiotherapy intervention for children with cerebral palsy (CP) requires that expectations of their caregivers be incorporated into treatment plans and strategies. This study explored the perceived Quality of Physiotherapy (QoP) for children with CP in Ibadan, Nigeria METHODS: This cross-sectional survey explored the perceived QoP using the SERVQUAL instrument among informal caregivers of children with CP from two different healthcare facilities. Data was analysed using Mann Whiney U and Wilcoxon Signed Rank tests at p ≤ 0.05. RESULTS: Fifty-three informal caregivers (50 females, 3 males) of children with CP (32 males, 21 females) were surveyed. Fourth-fifths (81.13%) of the caregivers perceived the QoP service for their children as poor. The highest negative and positive ranks were in the tangible and responsiveness dimensions of the SERVQUAL respectively. CONCLUSIONS: The study demonstrated that caregivers of children with CP perceived the quality of physiotherapy provided for their children as poor. This poor perception is related more to the tangible dimension of care. Strategies to improve care environment for children with CP and their informal caregivers should be implemented to engender satisfaction with care.

Stroke rehabilitation: should physiotherapy intervention be provided at a primary health care centre or the patients' place of domicile?

PURPOSE: This randomized controlled trial compared the outcomes of physiotherapy intervention on selected indices of recovery for stroke survivors treated at a primary health centre group (PHCG) with those treated in their respective places of domicile group (DG). METHODS: Participants were 52 individuals comprising 24 males and 28 females who had suffered a stroke and were recently discharged from two inpatient health facilities in Ibadan, Nigeria. They were randomly assigned into either the PHCG (n = 25) or DG (n = 27) and treated twice weekly for 10 consecutive weeks using a physiotherapy intervention protocol comprising a battery of task-specific exercises. The outcomes measured were motor function, balance and handicap assessed using the modified motor assessment scale (MMAS), short-form postural assessment scale for stroke (SF-PASS) and reintegration to normal living index (RNLI), respectively, as well as walking speed which was assessed using a standard technique. RESULTS: Between-group comparison using the General Linear Model revealed no statistically significant difference in both the pre- and post-intervention scores of the two groups on the MMAS, SF-PASS, RNLI and walking speed in both PHCG and DG (p > 0.05). However, within-group comparison yielded a statistically significant difference in each of the indices of stroke recovery measured across the 10-week period in both groups. CONCLUSION: Physiotherapy intervention at the primary health care centre and respective homes of stroke survivors similarly improved clinical outcomes. Treatment at any of these locations may enhance access to physiotherapy after stroke in a low-income community like Nigeria. IMPLICATIONS FOR REHABILITATION: Physiotherapy protocol comprising 10-week task-specific battery of exercises produced significant improvement in walking speed, balance, motor function and community reintegration of stroke survivors. Physiotherapy post-stroke can be provided at either a primary health centre or the domicile of the individual. In a low-income country like Nigeria, this will enhance access to this important service.