A qualitative pilot study exploring clients' and health-care professionals' experiences with aquatic therapy post-stroke in Ontario, Canada.

BACKGROUND: Aquatic therapy is beneficial for people post-stroke, as it improves their physical function, well-being, and quality of life. There is a lack of description of users' experiences and perspectives toward aquatic therapy that could elucidate contextual factors for aquatic therapy implementation. OBJECTIVES: To explore participants' experiences with aquatic therapy post-stroke as part of a participatory design project to develop an education tool-kit to address the users' needs for aquatic therapy post-stroke. METHODS: A qualitative descriptive study was employed using a purposive sampling. Letters were sent to stroke and aquatic therapy organizations. Individual interviews were conducted either by phone or Zoom with nine participants in the chronic phase of stroke and 14 health-care professionals. All transcripts were coded and analyzed independently by two researchers. Inductive thematic analysis was used to identify the main themes. RESULTS: Health-care professionals practiced aquatic therapy in rehabilitation hospitals (N = 7), community centers (N = 8) and private clinics (N = 3). From the interviews, two organizing themes were identified: (1) Importance of aquatic therapy (e.g. experiences, benefits, and program approaches); and (2) Aquatic therapy education (e.g. knowledge gaps, sources of learning and communication). CONCLUSIONS: Health-care professionals and clients reported numerous benefits of aquatic therapy post-stroke including, but not limited to, improvements in mobility, balance, wellbeing, and socialization. Lack of formal and informal education and communication as participants' transition from rehab to community were viewed as barriers to aquatic therapy use post-stroke. Developing education material and communication strategies may improve the uptake of aquatic therapy post-stroke.

The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada.

BACKGROUND: Several studies have demonstrated improved outcomes poststroke when higher intensity rehabilitation is provided. Canadian Stroke Best Practice Recommendations advise patients receive 180 min of therapy time per day; however, the exact amount required to reach benefit is unknown. AIMS: The primary aim of this study was to determine the association between rehabilitation intensity (RI) and total Functional Independence Measure (FIM) Instrument change. Secondary aims included determining the association between RI and discharge location, 90-day home time, rehabilitation effectiveness, and motor and cognitive FIM change. METHODS: A retrospective cohort study was conducted using available administrative databases of acute stroke patients discharged to inpatient rehabilitation facilities in Ontario, Canada, from January 2017 to December 2021. RI was defined as number of minutes per day of direct therapy by all providers divided by rehabilitation length of stay. The association between RI and the outcomes of interest were analyzed using regression models with restricted cubic splines. RESULTS: A total of 12,770 individuals were included. Mean age of the sample was 72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic stroke. Mean RI was 74.7 min (range: 5-162 min) per day. Increased RI was associated with an increase in mean FIM change. However, there was diminishing incremental increase after reaching 95 min/day. Increased RI was positively associated with motor and cognitive FIM change, rehabilitation effectiveness, 90-day home time, and discharge to preadmission setting. Higher RI was associated with a lower likelihood of discharge to long-term care. CONCLUSIONS: None of the patients met the recommended RI of 180 min/day based on the Canadian Stroke Best Practice Recommendations. Despite this, higher intensity was associated with better outcomes. Given that most positive associations were observed with a RI ⩾95 min/day, this may be a more feasible target.

The influence of food packaging on independent eating in individuals with hand impairments.

PURPOSE: Hand function plays a major role in the successful performance of activities of daily living (ADLs), such as eating. There is a lack of data exploring how persons with hand impairment manage food packaging and its impact on eating. METHODS: A convenience sample of 12 inpatients with hand impairments undergoing rehabilitation participated in a qualitative interview where they were asked questions about their experiences with food packaging and independent eating, and asked to open a set of commonly available hospital food packages, first without any tools/aids, and then with tools/aids if they desired to use them. Audio data were transcribed and cross-referenced with video data. Data were analyzed using codebook thematic analysis. RESULTS: An overarching theme of "Messiness" along with four major themes were identified: a) Inaccessibility of food packaging; b) Lack of control; c) Eating avoidance; and d) Preferred packaging and strategies. CONCLUSIONS: Inpatients with a hand impairment often experience several challenges with independent eating while in hospital as a result of their difficulties with hard to open food packaging. A greater consideration of universal design principles may be relevant for designers to make packaging more accessible.

Inaccessible food packaging may lead to psychological distress in patients with hand impairments, which can involve avoidance of eating.Food packaging that is large, lightweight and that has clear tabs or markers for pulling or tearing are better suited for patients with functional hand impairments.The use of a non-slip mat and/or tool with a sharp end might be useful aids to help patients be more independent with opening food packages while in hospital.

Exemplary post-discharge stroke rehabilitation programs: A multiple case study.

OBJECTIVE: The objective of this study was to identify essential aspects of exemplary post-discharge stroke rehabilitation as perceived by patients, care partners, rehabilitation providers, and administrators. DESIGN: We carried out an exploratory qualitative, multiple case study. Stroke network representatives from four regions of the province of Ontario, Canada each nominated one post-discharge rehabilitation program they felt was exemplary. SETTING: The programs included: a mixed home- and clinic-based service; a home-based service; a clinic-based service with a stroke community navigator and; an out-patient clinic-based service. PARTICIPANTS: Participants included 32 patients, 16 of their care partners, 23 providers, and 5 administrators. METHODS: We carried out semi-structured qualitative interviews with patients and care partners, focus groups with providers, and semi-structured interviews with administrators. Health records of patient participants were reviewed. Using an interpretivist-informed inductive content analysis, we developed overarching categories and subcategories first for each program and then across programs. RESULTS: Across four regions with differing types of programs, exemplary care was characterized by three essential components: stroke and stroke rehabilitation knowledge, relationship built through personalized respectful care, and a commitment to high quality, person-centered care. CONCLUSION: Exemplary post-discharge care included knowledge regarding identification and treatment of stroke-related impairment, that is, information found in best practice guidelines. However, expertise related to building relationship through providing personalized respectful care, within a mutually supportive, improvement-oriented team was also essential. Additionally, administrators played a crucial role in ensuring continued ability to deliver exemplary care.

Strategy-training post-stroke via tele-rehabilitation: a pilot randomized controlled trial.

PURPOSE: Long-term limitations in social participation are common after stroke. Whether these can be attenuated through a tele-rehabilitation approach is unknown. We were particularly interested in examining transfer of learning effects which could result in broader improvements in social participation. METHODS: We adapted a strategy training rehabilitation approach (tele-CO-OP) for remote delivery. Participants with chronic stroke were randomized to receive the intervention (EXPT) or to a wait list (Control). Feasibility and acceptability were measured via attendance scores, satisfaction with the training and therapist evaluation of engagement with the training. The primary outcome measure was the Canadian Occupational Performance Measure (COPM), a standardized semi-structured interview which elicits difficulties in day-to-day life. RESULTS: Seventeen participants were randomized. Tele-CO-OP was found to be feasible and acceptable: participants reported high satisfaction and engagement, and missed few sessions. Large effect sizes for transfer of learning effects were observed in favor of receiving tele-CO-OP vs being waitlisted. Significant benefits were also conferred to the Control group following receipt of tele-CO-OP. The intervention also appeared to improve mood. CONCLUSIONS: This exploratory study demonstrates the feasibility and acceptability of tele-CO-OP and provides preliminary evidence for transfer of learning effects to untrained everyday social participation activities. Trial registration number: NCT02724813.

Stroke results in long-term limitations in social participation.The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach provides a potential avenue for ameliorating these limitations.This pilot randomized controlled trial demonstrated that it is feasible to deliver tele-CO-OP and that positive benefits may accrue to those receiving the intervention for both trained and untrained activities.Tele-CO-OP is a promising intervention for addressing long-term participation limitations in individuals with chronic stroke.

The impact of an integrated, interprofessional knowledge translation intervention on access to inpatient rehabilitation for persons with cognitive impairment.

INTRODUCTION: Stroke rehabilitation teams' skills and knowledge in treating persons with cognitive impairment (CI) contribute to their reduced access to inpatient rehabilitation. This study examined stroke inpatient rehabilitation referral acceptance rates for persons with CI before and after the implementation of a multi-faceted integrated knowledge translation (KT) intervention aimed at improving clinicians' skills in a cognitive-strategy based approach, Cognitive Orientation to daily Occupational Performance (CO-OP), CO-OP KT. METHODS: CO-OP KT was implemented at five inpatient rehabilitation centres, using an interrupted time series design and data from an electronic referral and database system called E-Stroke. CO-OP KT included a 2-day workshop, 4 months of implementation support, health system support, and a sustainability plan. A mixed effects model was used to model monthly acceptance rates for 12 months prior to the intervention and 6 months post. RESULTS: The dataset was comprised of 2604 pre-intervention referrals and 1354 post. In the mixed effects model, those with CI had a lower pre-intervention acceptance rate than those without. Post-intervention the model showed the acceptance rate for those with CI increased by 8.6% (p = 0.02), whereas those with no CI showed a non-significant increase of less than 1%. CONCLUSIONS: Proportionally more persons with CI gained access to inpatient stroke rehabilitation following an integrated KT intervention.

Canadian Stroke Best Practice Recommendations: Virtual Stroke Rehabilitation Interim Consensus Statement 2022.

ABSTRACT: The seventh edition of the Canadian Stroke Best Practice Recommendations for Rehabilitation and Recovery following Stroke includes a new section devoted to the provision of virtual stroke rehabilitation. This consensus statement uses Grading of Recommendations, Assessment, Development and Evaluations methodology and Appraisal of Guidelines for Research & Evaluation II principles. A literature search was conducted using PubMed, Embase, and Cochrane databases. An expert writing group reviewed all evidence and developed recommendations, as well as consensus-based clinical considerations where evidence was insufficient for a recommendation. All recommendations underwent internal and external review. These recommendations apply to hospital, ambulatory care, and community-based settings where virtual stroke rehabilitation is provided. This guidance is relevant to health professionals, people living with stroke, healthcare administrators, and funders. Recommendations address issues of access, eligibility, consent and privacy, technology and planning, training and competency (for healthcare providers, patients and their families), assessment, service delivery, and evaluation. Virtual stroke rehabilitation has been shown to safely and effectively increase access to rehabilitation therapies and care providers, and uptake of these recommendations should be a priority in rehabilitation settings. They are key drivers of access to high-quality evidence-based stroke care regardless of geographical location and personal circumstances in Canada.

Using a Virtual Community of Practice to Support Stroke Best Practice Implementation: Mixed Methods Evaluation.

BACKGROUND: Successful best practice implementation is influenced by access to peer support and knowledge exchange. The Toronto Stroke Networks Virtual Community of Practice, a secure social media platform, is a knowledge translation tool supporting dissemination and adoption of stroke best practices for interprofessional stroke stakeholders. OBJECTIVE: The aim of this study is to evaluate the use of a virtual community of practice (VCoP) in supporting regional stroke care best practice implementation in an urban context. METHODS: A mixed methods approach was used. Qualitative data were collected through focus groups and interviews with stroke care provider members of the VCoP working in acute and rehabilitation settings. Thematic analysis was completed, and the Wenger Value Creation Model and developmental evaluation were used to reflect practice change. Quantitative data were collected and analyzed using website analytics on VCoP use. RESULTS: A year after implementation, the VCoP had 379 members. Analysis of web analytics data and transcripts from focus groups and interviews conducted with 26 VCoP members indicated that the VCoP provided immediate value in supporting user networking, community activities, and interactions. Skill acquisition and changes in perspective acquired through discussion and project work on the VCoP were valued by members, with potential value for supporting practice change. Learning about new stroke best practices through the VCoP was a starting point for individuals and teams to contemplate change. CONCLUSIONS: These findings suggest that the VCoP supports the early stages of practice change and stroke best practice implementation. Future research should examine how VCoPs can support higher levels of value creation for implementing stroke best practices.

"We could be good partners if we work together": the perspectives of health and social service providers on the barriers to forming collaborative partnerships with social housing providers for older adults.

BACKGROUND: Many older adults are aging-at-home in social housing. However, the lack of integration between housing and health services makes it difficult for older tenants to access needed supports. We examined barriers and facilitators health and social service providers face providing on-site services to older tenants. METHODS: We conducted semi-structured qualitative interviews and focus groups with health and social service professionals (n = 58) in Toronto, Canada who provide community programs in support of older tenants who live in non-profit, rent-geared-to-income social housing. Interviews examined the barriers they faced in providing on-site services to older tenants. FINDINGS: Service providers strongly believed that collaboration with on-site housing staff led to better health and housing outcomes for older tenants. Despite the recognized benefits of partnering with housing staff, service providers felt that their ability to work effectively in the building was dependent on the staff (particularly the superintendent) assigned to that building. They also identified other barriers that made it difficult to work collaboratively with the housing provider, including staffing challenges such as high staff turnover and confusion about staff roles, a lack of understanding among housing staff about the link between housing and health, challenges sharing confidential information across sectors, and complex and inefficient partnership processes. CONCLUSION: Older adult tenants are increasingly vulnerable and in need of supports but the housing provider has a long history of ineffective partnerships with service providers driven by complex and inefficient staffing models, and an organizational culture that questions the role of and need for partnerships. Findings highlight the need for more effective integration of housing and health services. Simplified processes for establishing partnerships with service agencies and more opportunities for communication and collaboration with housing staff would ensure that services are reaching the most vulnerable tenants.

Lessons learned and functional outcomes following multifaceted team training in a cognitive strategy-based approach to stroke rehabilitation.

AIM: To estimate the impact of a multifaceted knowledge translation intervention on patient rehabilitation outcomes in an inpatient stroke setting. METHODS: Interprofessional stroke rehabilitation teams were trained in Cognitive Orientation to daily Occupational Performance as part of the larger knowledge translation study. This study describes a two group (historical control vs. post knowledge translation intervention) nonrandomized study. Patient participants with stroke and cognitive impairment were recruited from five rehabilitation hospitals and completed an assessment battery upon admission to and discharge from rehabilitation and at three follow-up times. Data were analyzed using a two-way ANOVA. RESULTS: Seventeen historical controls and eight postintervention participants were recruited. The effect for time was significant (P ≤ 0.05) for the majority of outcomes, but there were no significant group × time effects. Small effect sizes for the group × time interaction were noted on several indicators. CONCLUSION: Few studies report on patient outcomes following a knowledge translation intervention. Small effect sizes were detected on several patient outcomes, despite study limitations. Lessons learned for future patient-level studies within knowledge translation interventions include the importance of monitoring therapist adherence to implementation protocols and ensuring research designs consider the impact on patient recruitment and retention.

The cognitive augmented mobility program (CAMP): feasibility and preliminary efficacy.

BACKGROUND: Best evidence suggests incorporating task-specific training, aerobics, and strengthening to improve mobility and gait in persons with stroke (PWS). Related research suggests incorporating cognitive problem-solving strategy training may lead to better skill maintenance and transfer. The present study examined the feasibility and preliminary outcomes of an evidence-based cognitive augmented mobility program (CAMP) for PWS. METHODS: A single-arm pre-post and follow-up design was conducted, in two blocks (NCT03683160). Participants completed an exercise intervention with an integrated cognitive strategy component and had weekly 1:1 sessions with a physiotherapist trained in Cognitive Orientation to daily Occupational Performance (CO-OP), focusing on goal practice and cognitive strategy use. CAMP consisted of a pre-intervention education and goal-setting session and 16 90-minute sessions held in a group format, 2x/wk for 8 weeks. Assessments were conducted 1 week prior to beginning the intervention, 1 week post-intervention, and at a 4-5 week follow-up. RESULTS: CAMP was found to be feasible with 96% session attendance and strong participant satisfaction. Pre to post-CAMP intervention, a large effect was found for endurance (r = 0.53), balance (r = 0.59), mobility (r = 0.63) and goal attainment (r = 0.63) indicators, and large effects were maintained at follow-up for balance, mobility, and goal attainment. A medium effect was found for functional independence (r = 0.38), gait speed (r = 0.39), and balance confidence (r = 0.38). A small effect was found for participation (r = 0.27) and overall stroke recovery (r = 0.25). CONCLUSIONS: Preliminary results suggest CAMP is feasible; there may be a beneficial effect of combining best evidence for mobility and fitness with cognitive strategy training. The positive results for skill maintenance and transfer suggest further investigation is warranted.

Clinician perspectives on implementing a team-based metacognitive strategy training approach to stroke rehabilitation.

INTRODUCTION: The objective of this research study was to explore site and clinician specific experiences, successes and challenges in implementing a complex intervention (cognitive orientation to daily occupational performance approach) to enhance stroke team's ability to address cognitive impairments as part of comprehensive stroke rehabilitation. METHODS: A focus group was held with clinicians from five study sites, all rehabilitation stroke hospitals in a large urban setting, to discuss implementation experiences. Participants were clinicians (site champions) from each of the five participating stroke program study sites and included four occupational therapists, three physiotherapists and one speech-language pathologist. Thematic analysis was used to identify themes that represented clinicians' perspectives. RESULTS: Implementing this complex team-based intervention was influenced by three themes-organizational support, experiential evidence, and clinicians' perspectives. Continued implementation of the intervention following the withdrawal of study support was represented on a continuum that ranged from not using the approach at all to implementing it with all patients. Sites where managers encouraged and supported use of the intervention within teams (organization support), continued to use it after the study support period as did clinicians who were willing to try new interventions (clinicians' perspectives). Development of iterative conclusions through implementation or attempts to implement the intervention had both positive and negative effects on continued implementation (experiential evidence). CONCLUSIONS: Strategies that reinforce development of positive experiential evidence and building organizational support for innovative practice were found to be useful adjuncts in facilitating implementation of complex interprofessional interventions.

Diabetes Mellitus Is Associated With Poor In-Hospital and Long-Term Outcomes in Young and Midlife Stroke Survivors.

Background The incidence of ischemic stroke has increased among adults aged 18 to 64 years, yet little is known about relationships between specific risk factors and outcomes. This study investigates in-hospital and long-term outcomes in patients with stroke aged <65 years with preexisting diabetes mellitus. Methods and Results Consecutive patients aged <65 years admitted to comprehensive stroke centers for acute ischemic stroke between 2003 and 2013 were identified from the Ontario Stroke Registry. Multinomial logistic regression was used to estimate adjusted odds ratio (OR [95% CI]) of in-hospital mortality or direct discharge to long-term or continuing care. Cox proportional hazards regression was used to estimate the adjusted hazards ratio (aHR [95% CI]) of long-term mortality, readmission for stroke/transient ischemic attack, admission to long-term care, and incident dementia. Predefined sensitivity analyses examined stroke outcomes among young (aged 18-49 years) and midlife (aged 50-65 years) subgroups. Among 8293 stroke survivors (mean age, 53.6±8.9 years), preexisting diabetes mellitus was associated with a higher likelihood of in-hospital death (adjusted OR, 1.46 [95% CI, 1.14-1.87]) or direct discharge to long-term care (adjusted OR, 1.65 [95% CI, 1.07-2.54]). Among stroke survivors discharged (N=7847) and followed up over a median of 6.3 years, preexisting diabetes mellitus was associated with increased hazards of death (aHR, 1.68 [95% CI, 1.50-1.88]), admission to long-term care (aHR, 1.57 [95% CI, 1.35-1.82]), readmission for stroke/transient ischemic attack (aHR, 1.37 [95% CI, 0.21-1.54]), and incident dementia (aHR, 1.44 [95% CI, 1.17-1.77]). Only incident dementia was not increased for young stroke survivors. Conclusions Focused secondary prevention and risk factor management may be needed to address poor long-term outcomes for patients with stroke aged <65 years with preexisting diabetes mellitus.

Depression and Diabetes Mellitus Multimorbidity Is Associated With Loss of Independence and Dementia Poststroke.

BACKGROUND AND PURPOSE: Many patients with ischemic stroke present with multiple comorbidities that threaten survival and recovery. This study sought to determine the risks of adverse long-term stroke outcomes associated with multimorbid diabetes mellitus and depression. METHODS: Retrospective analysis of prospectively collected data on consecutive patients without premorbid dementia admitted from the community for a first-ever acute ischemic stroke to comprehensive stroke centers across Ontario, Canada (2003-2013). Premorbid histories of diabetes mellitus and depression were ascertained within 5 years before stroke admission. Adjusted hazard ratios (aHR [95% CI]) of admission to long-term care, incident dementia, readmission for stroke or transient ischemic attack and all-cause mortality, over time among those discharged back into the community poststroke. RESULTS: Among 23 579 stroke admissions, n=20 201 were discharged back into the community. Diabetes mellitus and depression were associated with synergistic hazards of admission to long-term care (X2=5.4; P=0.02) over a median follow-up of 5.6 years. This interaction was observed among women specifically; depression multimorbidity showed particularly high hazards of admission to long-term care (aHRDepression=1.57 [1.24-1.98]) and incident dementia (aHRDepression=1.85 [1.40-2.44]) among women with diabetes mellitus. In the whole cohort, diabetes mellitus and depression were associated individually with long-term care admission (aHRDiabetes=1.20 [1.12-1.29]; aHRDepression=1.19 [1.04-1.37]), incident dementia (aHRDiabetes=1.14 [1.06-1.23]; aHRDepression=1.27 [1.08-1.49]), stroke/transient ischemic attack readmission (aHRDiabetes=1.18 [1.10-1.26]; aHRDepression=1.24 [1.07-1.42]), and all-cause mortality (aHRDiabetes=1.29 [1.23-1.36]; aHRDepression=1.16 [1.05-1.29]). CONCLUSIONS: The risks of dementia and needing long-term care in the years after surviving a stroke were particularly elevated among women when premorbid diabetes mellitus and depression occurred together. Long-term stroke recovery strategies might target high-risk patients with mood and metabolic multimorbidity.

Participation-focused interventions for stroke rehabilitation: a scoping review protocol.

OBJECTIVE: The objectives of this scoping review are to i) identify adaptive stroke rehabilitation interventions using metacognitive or self-management approaches targeting participation as an outcome; ii) determine the explicit and implicit theories underlying these interventions; and iii) ascertain the elements in each intervention. This review will develop a catalogue of these interventions, improving the understanding of how these interventions work, thereby facilitating efficient development and testing of participation-focused interventions. INTRODUCTION: Stroke rehabilitation interventions can be categorized as those aiming to correct impairment and those seeking participation improvement despite impairment. Impairment-focused interventions include a relatively small number of well-defined elements, generally based on motor learning or other types of learning theory. Participation-focused interventions span a large group of diverse interventions. The underlying theory is typically varied and often implicit, but many of these interventions are based on metacognitive or self-management approaches. An examination of the underlying theory and elements of participation-focused interventions would allow researchers to more effectively advance the science of these approaches. INCLUSION CRITERIA: The review will include published papers describing rehabilitation interventions using metacognitive or self-management approaches to improve participation among adults who have experienced a stroke. METHODS: The search will include JBI Evidence-Based Practice Database, MEDLINE, Embase, CINAHL, PsycINFO, OTSeeker, and PEDro databases. Studies will be selected according to a three-step process, including i) managing search results and removing duplicates, ii) title and abstract screening, and iii) full text screening. The extracted data will be presented in table form and narrative summary, aligning with the objectives and scope of this review.

Delayed Thrombectomy Center Arrival is Associated with Decreased Treatment Probability.

BACKGROUND: Endovascular thrombectomy (EVT) is effective in reducing disability in selected patients with stroke and large vessel occlusion (LVO), but access to this treatment is suboptimal. AIM: We examined the proportion of patients with LVO who did not receive EVT, the reasons for non-treatment, and the association between time from onset and probability of treatment. METHODS: We conducted a retrospective cohort study of consecutive patients with acute stroke and LVO presenting between January 2017 and June 2018. We used multivariable log-binomial models to determine the association between time and probability of treatment with and without adjustment for age, sex, dementia, active cancer, baseline disability, stroke severity, and evidence of ischemia on computerized tomography. RESULTS: We identified 256 patients (51% female, median age 74 [interquartile range, IQR 63.5, 82.5]), of whom 59% did not receive EVT. The main reasons for not treating with EVT were related to occlusion characteristics or infarct size. The median time from onset to EVT center arrival was longer among non-treated patients (218 minutes [142, 302]) than those who were treated (180 minutes [104, 265], p = 0.03). Among patients presenting within 6 hours of onset, the relative risk (RR) of receiving EVT decreased by 3% with every 10-minute delay in arrival to EVT center (adjusted RR 0.97 CI95 [0.95, 0.99]). This association was not found in the overall cohort. CONCLUSIONS: The proportion of patients with acute stroke and confirmed LVO who do not undergo EVT is substantial. Minimizing delays in arrival to EVT center may optimize the delivery of this treatment.

Does training in a top-down approach influence recorded goals and treatment plans?

BACKGROUND.: Five stroke rehabilitation teams were supported in the implementation of Cognitive Orientation to daily Occupational Performance (CO-OP) as part of a knowledge translation (KT) project called CO-OP KT. Medical record auditors noted there was occasionally a disconnect between client goals and treatment plans, revealing a need to better understand the characteristics of each and their relationship to each other. PURPOSE.: This study aimed to examine the characteristics of goals and treatment plans in occupational therapy before and after CO-OP KT. METHOD.: A descriptive secondary analysis of medical record data was employed. FINDINGS.: Post intervention, there was a change in goal specificity (p = .04) and therapist-client goal alignment (p = .05). Occupation-based goals were often paired with a bottom-up, impairment-based treatment. Top-down treatments, when present, lacked the same detail given to bottom-up plans. IMPLICATIONS.: CO-OP KT seemed to lead to more specific goals, but matching top-down treatment plans were not found.

The implications of the Canadian Stroke Best Practice Recommendations for design and allocation of rehabilitation after hospital discharge: a problematization.

Introduction: Implementation of the Canadian Stroke Best Practice Recommendations has improved inpatient rehabilitation. As attention is turned to the design and allocation of rehabilitation after hospitalization, examination of their implications for post-discharge rehabilitation could help optimize service planningMethods: Critical discourse analysis modeled on Alvesson and Sandberg's method of problematization was conducted to determine how the Canadian Stroke Best Practice Recommendations envision and shape post-discharge rehabilitation, and identify any tensions and potential ways to resolve them.Results: Within the Canadian Stroke Best Practice Recommendations post-discharge rehabilitation is implicitly viewed as a continuation of inpatient rehabilitation. Rehabilitation is largely envisioned as a set of biomedical procedures aimed at normalization through correction of impairment. There is potential tension between this implicit goal and the explicit goal of providing patient and family-centered care and promoting reengagement in valued activities and roles.Conclusion: An alternate vision of post-discharge rehabilitation could help resolve this tension. Post-discharge rehabilitation could be envisioned as a self-management intervention. Rather than primarily an expert-driven process of measuring impairment and applying procedures aimed at normalization, rehabilitation would be considered facilitation of self-management with the goal of reengaging in forms of participation that comprise a satisfying life.Implications for RehabilitationImplicit assumptions within best practice guidelines powerfully influence recommendations. These ideas are difficult to examine because they seem self-evident.Implicit assumptions in the Canadian Stroke Best Practice Guidelines envision post-discharge stroke rehabilitation as an expert-driven, impairment-focused biomedical procedure.This biomedical image makes it difficult to provide care that meets the guideline's explicit goals of client- and family-centeredness.Reimagining post-discharge stroke rehabilitation as a chronic self-care management intervention aimed at developing a satisfying life after stroke could improve patient care.

Implementing a shared decision-making and cognitive strategy-based intervention: Knowledge user perspectives and recommendations.

The aim of this study was to employ knowledge user perspectives to develop recommendations that facilitate implementation of a complex, shared decision-making (SDM)-based intervention in an interprofessional setting. This study was part of a larger knowledge translation (KT) study in which interprofessional teams from five freestanding, academically affiliated, rehabilitation hospitals were tasked with implementing a cognitive strategy-based intervention approach that incorporates SDM known as Cognitive Orientation to daily Occupational Performance (CO-OP) to treat survivors of stroke. At the end of the 4-month CO-OP KT implementation support period, 10 clinicians, two from each site, volunteered as CO-OP site champions. A semi-structured focus group was conducted with 10 site champions 3 months following the implementation support period. To meet the study objective, an exploratory qualitative research design was used. The focus group session was audio-recorded, transcribed verbatim and analyzed through the lens of the integrated promoting action on research implementation in health services (iPARIHS) framework. The focus group participants (n = 8) consisted of occupational therapists, physical therapists, and speech language pathologists. Ten recommendations for CO-OP implementation were extracted and co-constructed from the focus group transcript. The recommendations reflected all four iPARHIS constructs: Facilitation, Context, Innovation, and Recipients. Implementation recommendations, from the knowledge user perspective, highlight that context-specific facilitation is key to integrating a novel, complex intervention into interprofessional practice. Facilitators should lay out a framework for training, communication and implementation that is structured but still provides flexibility for iterative learning and active problem-solving within the relevant practice context.