A six-month telerehabilitation programme delivered via readily accessible technology is acceptable to people following stroke: a qualitative study.

OBJECTIVE: To explore the experiences of participants during a six-month, post-stroke telerehabilitation programme. DESIGN: A qualitative descriptive study to investigate participant experiences of ACTIV (Augmented Community Telerehabilitation Intervention), a six-month tailored exercise programme delivered by physiotherapists primarily using readily accessible telecommunication technology. Semi-structured, in-depth interviews were used to collect data, which were analysed using thematic analysis. SETTING: Interviews conducted in participants' homes or a community facility. PARTICIPANTS: Participants were eligible if they had a stroke in the previous 18 months and had participated in ACTIV. RESULTS: Twenty-one participants were interviewed. Four key themes were constructed from the data: 1. 'ACTIV was not what I call physio' (it differed from participants' expectations of physiotherapy, but they reported many positive aspects to the programme). 2. 'There's somebody there' (ongoing support from the physiotherapists helped participants find strategies to continue improving). 3. 'Making progress' (in the face of barriers, small improvements were valued). 4. 'What I really want' (participant goals were frequently more general than therapy goals and involved progress towards getting back to 'normal'). CONCLUSIONS: Although ACTIV was not what participants expected from physiotherapy, the majority found contact from a physiotherapist reduced the feeling of being left to struggle alone. Most participants found a programme with minimal face-to-face contact augmented by phone calls and encouraging text messages to be helpful and acceptable. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registration Number: ACTRN12612000464864 CONTRIBUTION OF THE PAPER.

What does real-world walking mean to people with stroke? An interpretive descriptive study.

PURPOSE: Understanding personal experiences of real-world walking for stroke survivors could assist clinicians to tailor interventions to their clients' specific needs. We explored the research questions: "What does real-world walking mean to people after stroke and how do they think it can be better?" METHOD: Using an Interpretive Descriptive methodology, we purposively sampled eight stroke survivors who reported difficulty walking in the real-world. We sought diversity on key participant characteristics. Participants were interviewed using a semi-structured guide. Data were analysed with thematic analysis. RESULTS: Many found real-world walking, particularly in the outdoors, created opportunities for freedom from dependence and a visible step by step progress, which generated hope for future recovery. Conversely, when participants did not experience sufficient progress, they expressed negative emotions. Participants strove to overcome challenges to their walking goals using everyday routines, planning skills, and confidence building experiences to motivate themselves. They also drew on, and extended, social resources highlighting the relational aspects of real-world walking. CONCLUSIONS: Walking in their real-world provided a meaningful, desirable, but challenging goal for participants that required significant emotional effort. Successful progress in real-world walking builds confidence and hope and can contribute to psychological wellbeing by providing opportunities for successful mastery and social connectedness.IMPLICATIONS FOR REHABILITATIONReal-world settings can be unpredictable which makes walking in the real-world after stroke demanding.Positive experiences of walking in the real-world can provide significant psychological benefits to stroke survivors.Many survivors need to carefully concentrate on the act of walking in outdoor settings.Pre-planning routes, confidence-building experiences and developing daily routines may help patients overcome these challenges.

Embedding the living well toolkit into service delivery - A complex process.

Objective: To embed the Living Well Toolkit package and to understand how it was implemented at each site and to explore the experiences of users. Methods: The toolkit package was introduced in four rehabilitation settings using a tailored implementation process negotiated with each site. The varied data sources were analysed drawing on directed content analysis. Results: Clients with neurological conditions and clinicians initially weighed the merits of the toolkit package. A positive weighing up was prerequisite for deciding to use. Clinicians described considerable thought and planning to make the toolkit package fit and flow in clinical practice. Users of the toolkit package described ways in which it shaped their thinking. Conclusion: Implementation of the toolkit package was a complex process for clinicians and services, involving ongoing work to optimise its impact relative to the client and context. Clinicians and clients who used the toolkit package described positive changes, congruent with person-centred communication. Innovation: The Living Well Toolkit is freely available for all to use. Clinicians who used reflective and responsive thinking to make the toolkit package work found it provided them with a broader perspective of the client.

Telerehabilitation After Stroke Using Readily Available Technology: A Randomized Controlled Trial.

BACKGROUND: The number of people living with stroke has increased demand for rehabilitation. A potential solution is telerehabilitation for health care delivery to promote self-management. One such approach is the Augmented Community Telerehabilitation Intervention (ACTIV). This structured 6-month program uses limited face-to-face sessions, telephone contact, and text messages to augment stroke rehabilitation. OBJECTIVE: To investigate whether ACTIV improved physical function compared with usual care. METHODS: This 2-arm, parallel randomized controlled trial was conducted in 4 New Zealand centers. Inclusion criteria were patients with first-ever stroke, age >20 years, and discharged home. A blinded assessor completed outcome measurement in participants' homes at baseline, postintervention, and 6 months postintervention. Stratified block randomization occurred after baseline assessment, with participants allocated to ACTIV or usual care control. RESULTS: A total of 95 people were recruited (ACTIV: n = 47; control: n = 48). Postintervention intention-to-treat analysis found a nonsignificant difference between the groups in scores (4·51; P = .07) for physical function (measured by the physical subcomponent of the Stroke Impact Scale). The planned per-protocol analysis (ACTIV: n = 43; control: n = 48) found a significant difference in physical function between the groups (5·28; P = .04). Improvements in physical function were not maintained at the 12-month follow-up. CONCLUSIONS: ACTIV was not effective in improving physical function in the ACTIV group compared with the usual care group. The per-protocol analysis raises the possibility that for those who receive more than 50% of the intervention, ACTIV may be effective in preventing deterioration or even improving physical function in people with stroke, in the period immediately following discharge from hospital.

Pilot trial of The Living Well Toolkit: qualitative analysis and implications for refinement and future implementation.

BACKGROUND: Following a neurological event, people's long-term health and well-being is hampered by a system that struggles to deliver person-centred communication and coordinated care and fails to harness individual and family capability to live well with the condition. We aimed to implement and evaluate a toolkit package to support these processes for people with long-term neurological conditions. METHODS: This is a multi-phased study drawing on the principles of participatory research. In this pilot phase, the toolkit package was introduced to clinicians, who introduced it to clients in four neurorehabilitation settings (inpatient and community-based). Individual and focus group interviews were carried out with clients (n = 10) and clinicians (n = 9). Data were categorised by the four components of Normalisation Process Theory (NPT), and data within each component was then coded inductively. This analysis was used to inform revisions to the toolkit package and wider implementation processes. RESULTS: There was widespread support for the principles underpinning the toolkit package from clients and clinicians. However, it was less clear how the client toolkit could support these principles in clinical practice which impacted buy-in. The flexibility of use of the client toolkit, which we encouraged, made it difficult for clinicians and clients to be clear about its purpose and for clinicians to operationalise in practice. Clinicians and clients identified a number of barriers that limited the time, energy and work users were able or prepared to invest, to the extent that uptake of the toolkit package was modest. Use of the toolkit package appeared more likely when clinicians perceived it to augment existing processes (e.g. goal setting) rather than detract from 'doing' therapy. This analysis was used to inform revisions to the toolkit package, including simplification of the client toolkit, development of videos with examples of use and a modular and reflective training package for clinical services. The refinements were intended to improve sense-making and minimise the cognitive barriers associated with implementation of a new intervention. CONCLUSION: Understanding how supporting the client toolkit could add value to the therapeutic encounter was necessary for clinicians to invest time and perceive the worth of the toolkit package. TRIAL REGISTRATION: ANZCTR: ACTRN12614000537651. Registered 21 May, 2014.

Implementation in rehabilitation: a roadmap for practitioners and researchers.

Purpose: Despite growth in rehabilitation research, implementing research findings into rehabilitation practice has been slow. This creates inequities for patients and is an ethical issue. However, methods to investigate and facilitate evidence implementation are being developed. This paper aims to make these methods relevant and accessible for rehabilitation researchers and practitioners.Methods: Rehabilitation practice is varied and complex and occurs within multilevel healthcare systems. Using a "road map" analogy, we describe how implementation concepts and theories can inform implementation strategies in rehabilitation. The roadmap involves a staged journey that considers: the nature of evidence; context for implementation; navigation tools for implementation; strategies to facilitate implementation; evaluation of implementation outcomes; and sustainability of implementation. We have developed a model to illustrate the journey, and four case studies exemplify implementation stages in rehabilitation settings.Results and Conclusions: Effective implementation strategies for the complex world of rehabilitation are urgently required. The journey we describe unpacks that complexity to provide a template for effective implementation, to facilitate translation of the growing evidence base in rehabilitation into improved patient outcomes. It emphasizes the importance of understanding context and application of relevant theory, and highlights areas which should be targeted in new implementation research in rehabilitation.Implications for rehabilitationEffective implementation of research evidence into rehabilitation practice has many interconnected steps and a roadmap analogy is helpful in defining them.Understanding context for implementation is critically important and using theory can facilitate development of understanding.Research methods for implementation in rehabilitation should be carefully selected and outcomes should evaluate implementation success as well as clinical change.Sustainability requires regular revisiting of the interconnected steps.

Development of a toolkit to enhance care processes for people with a long-term neurological condition: a qualitative descriptive study.

OBJECTIVE: To (A) explore perspectives of people with a long-term neurological condition, and of their family, clinicians and other stakeholders on three key processes: two-way communication, self-management and coordination of long-term care; and (B) use these data to develop a 'Living Well Toolkit', a structural support aiming to enhance the quality of these care processes. DESIGN: This qualitative descriptive study drew on the principles of participatory research. Data from interviews and focus groups with participants (n=25) recruited from five hospital, rehabilitation and community settings in New Zealand were analysed using conventional content analysis. Consultation with a knowledge-user group (n=4) and an implementation champion group (n=4) provided additional operational knowledge important to toolkit development and its integration into clinical practice. RESULTS: Four main, and one overarching, themes were constructed: (1) tailoring care:referring to getting to know the person and their individual circumstances; (2) involving others: representing the importance of negotiating the involvement of others in the person's long-term management process; (3) exchanging knowledge: referring to acknowledging patient expertise; and (4) enabling: highlighting the importance of empowering relationships and processes. The overarching theme was: assume nothing. These themes informed the development of a toolkit comprising of two parts: one to support the person with the long-term neurological condition, and one targeted at clinicians to guide interaction and support their engagement with patients. CONCLUSION: Perspectives of healthcare users, clinicians and other stakeholders were fundamental to the development of the Living Well Toolkit. The findings were used to frame toolkit specifications and highlighted potential operational issues that could prove key to its success. Further research to evaluate its use is now underway.

Identifying an outcome measure to assess the impact of Mobility Dogs.

PURPOSE: Mobility Dogs® trains dogs to work with people with physical disabilities to increase independence, confidence, self-esteem and participation. Mobility Dogs® seeks to critically evaluate and improve its services as it grows. This study aimed to identify and implement a standardised outcome measure into practice at Mobility Dogs®. METHOD: Based on the Consolidated Framework for Implementation Research and guided by a steering group of key stakeholders, a three-phase approach was developed to identify and assess an outcome measure. The steering group highlighted the organisation's specific needs, selected participation as the assessment domain and identified core utility requirements of the measure. A comprehensive review of evidence was undertaken to identify and rank potential measures according to the specified needs. RESULTS: Of the seven participation outcome measures that met inclusion criteria, the three highest ranked measures were critically evaluated by the steering group to determine suitability against the organisation's needs. The Impact on Participation and Autonomy (IPA) was selected for implementation into practice at Mobility Dogs®. CONCLUSION: Use of the IPA is an important first step for Mobility Dogs® to test the benefits of trained service dogs. This process could be replicated by other service dog organisations to identify outcome measures to assess their own services. Implications for Rehabilitation Service dogs (such as Mobility Dogs® in New Zealand) assist people living with physical impairments by performing tasks, however there is limited evidence on outcomes. The process for selecting an appropriate outcome measure for Mobility Dogs® involving partnership between Mobility Dogs® personnel and academics was an effective way to steer the project by determining important properties of the measure, before a search of the literature was undertaken. While the IPA was selected as the most appropriate outcome measure for use at Mobility Dogs®, it was the process that is valuable to replicate if other organisations wish to select an outcome measure for use in their own practice.

What influences the implementation of the New Zealand stroke guidelines for physiotherapists and occupational therapists?

Purpose To explore perceived barriers and facilitators to the use of the New Zealand (NZ) stroke guidelines by occupational therapists and physiotherapists. Methods A qualitative descriptive methodology was used. Eligible physiotherapists and occupational therapists (NZ registered, working in one of two hospitals, treating at least 10 patients with stroke in the previous year) were invited to participate in semi-structured interviews to elicit their perceptions of the utility and feasibility of the NZ stroke guidelines and identify barriers and facilitators to their implementation. All interviews were audio-recorded and transcribed. Conventional content analysis with constant comparative methods was used for coding and analysis. Results The main themes influencing guideline implementation were resources and characteristics of the guidelines, the organization, the patient and family and the therapist. Insufficient resources were a major barrier that crossed many of the themes. Participants suggested a range of strategies relating to the organization to improve therapists' alignment to the guidelines. Conclusion Alignment to the guidelines in NZ is influenced both positively and negatively by a range of interacting factors, consistent with other studies. Alignment might be improved by the introduction of some relatively simple strategies, such as ring-fencing time for access to resources and training in the use of the guidelines. Many of the barriers and related interventions are likely to be more complex. Implications for rehabilitation Alignment with stroke guidelines has been shown to improve patient outcomes. Therapist alignment with the implementation of the New Zealand stroke guidelines is influenced by guideline characteristics, organizational characteristics, resources, patient and family characteristics and therapist characteristics. Frequently encountered barriers related to limited resources, particularly time. Ring-fencing regular time for access to resources and training in the use of guidelines are examples of simple strategies that may reduce barriers.

Interventions to improve real-world walking after stroke: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to determine the effectiveness of current interventions to improve real-world walking for people with stroke and specifically whether benefits are sustained. DATA SOURCES: EBSCO Megafile, AMED, Cochrane, Scopus, PEDRO, OTSeeker and Psychbite databases were searched to identify relevant studies. REVIEW METHODS: Proximity searching with keywords such as ambulat*, walk*, gait, mobility*, activit* was used. Randomized controlled trials that used measures of real-world walking were included. Two reviewers independently assessed methodological quality using the Cochrane Risk of Bias Tool and extracted the data. RESULTS: Nine studies fitting the inclusion criteria were identified, most of high quality. A positive effect overall was found indicating a small effect of interventions on real-world walking (SMD 0.29 (0.17, 0.41)). Five studies provided follow-up data at >3-6 months, which demonstrated sustained benefits (SMD 0.32 (0.16, 0.48)). Subgroup analysis revealed studies using exercise alone were not effective (SMD 0.19 (-0.11, 0.49)), but those incorporating behavioural change techniques (SMD 0.27 (0.12, 0.41)) were. CONCLUSIONS: A small but significant effect was found for current interventions and benefits can be sustained. Interventions that include behaviour change techniques appear more effective at improving real-world walking habits than exercise alone.

Ageing with cerebral palsy; what are the health experiences of adults with cerebral palsy? A qualitative study.

OBJECTIVE: To enhance understanding of the experiences of ageing with cerebral palsy (CP) in adulthood with a particular focus on experiences with health services. DESIGN: A qualitative descriptive methodology was applied to capture adults' views of ageing with CP and related interactions with health services. Semistructured interviews were undertaken with data systematically coded and interpreted by grouping information into categories. Themes that encompassed the categories were identified through thematic analysis. SETTING: All healthcare settings. PARTICIPANTS: 28 adults (14 women) with CP, aged 37-70 years. RESULTS: 5 themes covered the breadth of participants' experiences: (1) acceptance of change; (2) exploring identity: cerebral palsy as only one part of self; (3) taking charge of help; (4) rethinking the future and (5) interacting with health professionals. Being seen and being heard were the features described in positive healthcare interactions. Participants also valued health professionals who reflected on who holds the knowledge?; demonstrated a willingness to learn and respected participants' knowledge and experience. CONCLUSIONS: Our findings could, and arguably should, inform more responsive strategies for disabled people in health services and, indeed, all health consumers. Our study supports other findings that impairments related to CP change and, for many, severity of disabling impact increases with age. Increased interactions with health and rehabilitation professionals, as a consequence of these changes, have the potential to impact the person's healthcare experience either positively or negatively. A 'listening health professional' may bridge their knowledge gap and, in recognising the person's own expertise, may achieve three things: a more contextualised healthcare intervention; a better healthcare experience for the person with CP and positive impact on the person's sense of autonomy and identity by recognising their expertise. Future research should identify whether this approach improves the healthcare experience for adults living with CP.

What influences acceptability and engagement with a high intensity exercise programme for people with stroke? A qualitative descriptive study.

BACKGROUND: Intensity refers to the amount of effort or rate of work undertaken during exercise. People receiving rehabilitation after stroke frequently do not reach the moderate to high intensity exercise recommended to maximise gains. OBJECTIVE: To explore the factors that influence the acceptability of, and engagement with, a high intensity group-based exercise programme for people with stroke. METHODS: This qualitative descriptive study included 14 people with stroke who had completed a 12-week, high intensity group-based exercise rehabilitation programme. Semi-structured interviews were used to explore the acceptability of high intensity exercise and the barriers and facilitators to engagement. Interviews were recorded, transcribed and analysed using qualitative content analysis. RESULTS: The participants found high intensity exercise rehabilitation acceptable despite describing the exercise intensity as hard and reporting post-exercise fatigue. Participants accepted the fatigue as a normal response to exercise, and it did not appear to negatively influence engagement. The ease with which an individual engaged in high intensity exercise rehabilitation appeared to be mediated by inter-related factors, including: seeing progress, sourcing motivation, working hard, the people involved and the fit with the person and their life. Participants directly related the intensity of their effort to the gains that they made. CONCLUSIONS: In this study, people with stroke viewed training at higher intensities as a facilitator, not a barrier, to engagement in exercise rehabilitation. The findings may challenge assumptions about the influence of exercise intensity on engagement.

Variability of total step activity in children with cerebral palsy: influence of definition of a day on participant retention within the study.

BACKGROUND: Activity monitoring is important to establish accurate daily physical activity levels in children with cerebral palsy (CP). However, few studies address issues around inclusion or exclusion of step count data; in particular, how a valid day should be defined and what impact different lengths of monitoring have on retention of participant data within a study. This study assessed how different 'valid day' definitions influenced inclusion of participant data in final analyses and the subsequent variability of the data. RESULTS: Sixty-nine children with CP were fitted with a StepWatch™ Activity Monitor and instructed to wear it for a week. Data analysis used two broad definitions of a day, based on either number of steps in a 24 h monitoring period or the number of hours of recorded activity in a 24 h monitoring period. Eight children either did not use the monitor, or used it for only 1 day. The remaining 61 children provided 2 valid days of monitoring defined as >100 recorded steps per 24 h period and 55 (90 %) completed 2 valid days of monitoring with ≥10 h recorded activity per 24 h period. Performance variability in daily step count was lower across 2 days of monitoring when a valid day was defined as ≥10 h recorded activity per 24 h period (ICC = 0.765) and, higher when the definition >100 recorded steps per 24 h period (ICC = 0.62). Only 46 participants (75 %) completed 5 days of monitoring with >100 recorded steps per 24 h period and only 23 (38 %) achieved 5 days of monitoring with ≥10 h recorded activity per 24 h period. Datasets of participants who functioned at GMFCS level II were differentially excluded when the criteria for inclusion in final analysis was 5 valid days of ≥10 h recorded activity per 24 h period, leaving datasets available for only 8 of 32 participant datasets retained in the study. CONCLUSION: We conclude that changes in definition of a valid day have significant impacts on both inclusion of participant data in final analysis and measured variability of total step count.

Who is in control? Clinicians' view on their role in self-management approaches: a qualitative metasynthesis.

OBJECTIVE: To explore clinician perceptions of involvement in delivery of self-management approaches. SETTING: All healthcare settings. DESIGN: EBSCO, Scopus and AMED databases were searched, in July 2013, for peer-reviewed studies in English reporting original qualitative data concerning perceptions of clinicians regarding their involvement in or integration of a self-management approach. Of 1930 studies identified, 1889 did not meet the inclusion criteria. Full text of 41 studies were reviewed by two independent reviewers; 14 papers were included for metasynthesis. Findings and discussion sections were imported into Nvivo-10 and coded line-by-line. Codes were organised into descriptive themes and cross-checked against original sources to check interpretation, and refined iteratively until findings represented an agreed understanding. Studies were appraised for quality. RESULTS: Delivering self-management in practice appeared to be a complex process for many clinicians. The issue of 'control' arose in all studies, both in the qualitative data and authors' interpretations. The first theme: Who is in control?--represented ways clinicians talked of exercising control over patients and the control they expected patients to have over their condition. The second theme: Changing clinician views--reflected what appeared to be an essential transformation of practice experienced by some clinicians in the process of integrating self-management approaches into the practice. A range of challenges associated with shifting towards a self-management approach were reflected in the third theme, Overcoming challenges to change. Tensions appeared to exist around forming partnerships with patients. Strategies found helpful in the process of change included: dedicating time to practice reciprocity in communication style, peer support and self-reflection. CONCLUSIONS: A consistent finding across studies is that 'control' is a key feature of how self-management is viewed by clinicians. They described challenges associated with the paradigm shift required to share or let go of control. Future research should identify whether strategies described by clinicians are key to successful self-management.

Are physiotherapists comfortable with person-centred practice? An autoethnographic insight.

PURPOSE: This study aimed to understand our shared conflicting response and discomfort to person-centred rehabilitation within the context of our physiotherapy rehabilitation culture by reflecting on our own experiences as research physiotherapists and clinicians. METHOD: This study used autoethnographical methods to explore the personal and professional experiences of two physiotherapists in neurological rehabilitation. Data were collected through ten written reflections and five joint discussions. The data were analysed collaboratively through focused conversations and writing. We looked for patterns in our data and the literature to triangulate our findings. Joint narratives were structured based on three headings: Where we have come from, Challenges to our position and Where we are now. RESULTS: The four main topics of discussion were goal setting, hope, the physiotherapy paradigm and person-centred practice. Physiotherapy practice is typically underpinned by a biomechanical discourse, which separates the mind and the body. This paradigm limits our ability to manage aspects of person-centred practice, such as valuing patient preferences, fostering hope, managing expectation and building a positive therapeutic relationship. CONCLUSION: Awareness of existing influences on theory and practice is necessary to move the physiotherapy profession towards a greater degree of understanding and application of the principles of person-centred practice. Implications for Rehabilitation Physiotherapists need to recognise that our clinical practice is currently dominated by a biomechanical perspective, which limits our adoption of person-centred practice. Our usual way of working as an expert focuses on our own perspective that makes it difficult to work in a person-centred way. Strategies to incorporate a more person-centred approach include using communication strategies that help us actively seek patients' perspectives.

Living well with disability: needs, values and competing factors.

BACKGROUND: Obesity is more prevalent for disabled people (estimated as being between 27-62%) compared to the general population (17-22%). Disabled people are more likely to report poorer general health and acquire a range of obesity-related secondary conditions. Although there are many physical activity and nutrition initiatives aimed at obesity prevention, little is known about whether these options are relevant and accessible for disabled people. The Living Well Study aimed to better understand the issues faced by disabled people when engaging in physical activity and healthy eating. METHODS: The study drew on a participatory action research design involving key stakeholders. There were two core cyclical phases (A and B), in which data collection was followed by a period of analysis, reflection and refinement. Focus groups and interviews were held with individuals who experience a range of disabilities, family members, service providers and representatives from disability advocacy groups. We sought to explore the importance and meaning of physical activity and healthy eating and factors that influenced engagement in these. Data in phase A were analysed using conventional content analysis drawing on constant comparative methods to identify themes of importance. In phase B, data analysis occurred alongside data collection, using a structured template to summarise participants' agreement or disagreement with the draft themes and recommendations, until the themes and recommendations were refined based on participants' corroboration. RESULTS: 146 participants aged between 10-69 years, from both rural and urban areas and of different cultural backgrounds participated. Seven interconnecting themes that related to engagement in living well behaviours emerged with a wide range of external factors (such as people, knowledge, time, cost, identity and the environment) impacting on living well options. The central theme - It depends: needs, values and competing factors - emphasised the complexity faced by a disabled person when balancing the external factors with their own personal values and needs in order to arrive at a decision to engage in healthy living behaviours. CONCLUSIONS: Although disabled people experience similar issues when participating in healthy living behaviours as those living without disability, additional factors need to be addressed in order to improve opportunities for 'living well' in these populations. This information has implications for health professionals to target the relevance and content of interventions.

Activity coaching to improve walking is liked by rehabilitation patients but physiotherapists have concerns: a qualitative study.

QUESTION: Does activity coaching add value to physiotherapy from the perspective of physiotherapists and patients in neurological rehabilitation? Is the use of activity coaching to promote walking and physical activity considered feasible by these physiotherapists and patients? DESIGN: Qualitative study using interviews. PARTICIPANTS: Five pairs of physiotherapists and their patients with neurological conditions. INTERVENTION: A research physiotherapist trained in health coaching delivered an activity coaching intervention. This was provided in addition to standard physiotherapy. The treating physiotherapists observed the activity coaching session undertaken by their patients. RESULTS: Observing the coaching interview was valuable for the treating physiotherapists in that it provided a way to refocus, step back, gain insight, and facilitate more active involvement for their patients in the rehabilitation process. Similarly patients valued the opportunity to focus on what was important and put into action their rehabilitation goals. Contrasting perceptions were evident, which limits the practical usefulness of this intervention due to the concerns voiced by some of the physiotherapists. CONCLUSION: The activity coaching was perceived as providing a valuable addition to standard practice and was acceptable to patients but the mixed responses of physiotherapists limit the feasibility of this approach. Use of strategies and specific training for physiotherapists may be needed before approaches like activity coaching can be adopted successfully.

Telerehabilitation to improve outcomes for people with stroke: study protocol for a randomised controlled trial.

BACKGROUND: In New Zealand, around 45,000 people live with stroke and many studies have reported that benefits gained during initial rehabilitation are not sustained. Evidence indicates that participation in physical interventions can prevent the functional decline that frequently occurs after discharge from acute care facilities. However, on-going stroke services provision following discharge from acute care is often related to non-medical factors such as availability of resources and geographical location. Currently most people receive no treatment beyond three months post stroke. The study aims to determine if the Augmented Community Telerehabilitation Intervention (ACTIV) results in better physical function for people with stroke than usual care, as measured by the Stroke Impact Scale, physical subcomponent. METHODS/DESIGN: This study will use a multi-site, two-arm, assessor blinded, parallel randomised controlled trial design. People will be eligible if they have had their first ever stroke, are over 20 and have some physical impairment in either arm or leg, or both. Following discharge from formal physiotherapy services (inpatient, outpatient or community), participants will be randomised into ACTIV or usual care. ACTIV uses readily available technology, telephone and mobile phones, combined with face-to-face visits from a physiotherapist over a six-month period, to help people with stroke resume activities they enjoyed before the stroke. The impact of stroke on physical function and quality of life will be assessed, measures of cost will be collected and a discrete choice survey will be used to measure preferences for rehabilitation options. These outcomes will be collected at baseline, six months and 12 months. In-depth interviews will be used to explore the experiences of people participating in the intervention arm of the study. DISCUSSION: The lack of on-going rehabilitation for people with stroke diminishes the chance of their best possible outcome and may contribute to a functional decline following discharge from formal rehabilitation. Best practice guidelines recommend a prolonged period of rehabilitation, however this is expensive and therefore not undertaken in most publicly funded centres. An effective, cost-effective, and preference-sensitive therapy using basic technology to assist programme delivery may improve patient autonomy as they leave formal rehabilitation and return home. TRIAL REGISTRATION: ACTRN12612000464864.

Test-retest reliability of the StepWatch Activity Monitor outputs in healthy adults.

BACKGROUND: Activity Monitors give an objective measure of usual walking performance. This study aimed to examine the test-retest reliability of the StepWatch Activity Monitor outputs (mean steps/day; peak activity index; sustained activity indices of 1, 5, 20, 30, 60 minutes; steps at high, medium, and low stepping rates). METHODS: Thirty healthy adults age 18 to 49 years wore the StepWatch for 2 3-day periods at least 1 week apart. RESULTS: The intraclass correlation coefficients of the StepWatch outputs ranged from 0.44 to 0.91 over 3 days. The coefficient of variation ranged from 3.0% to 51.3% over the monitoring periods, with higher variation shown for shorter monitoring periods. The most reliable 5 outputs had 95% limits of agreement between 3-day periods that were less than 40%. These were mean steps/day ( ± 39.1%), highest step rate in 1 ( ± 17.3%) and 5 ( ± 37.4%) minutes, peak activity index ( ± 25.6%), and percentage of inactive time ( ± 9.52%). CONCLUSIONS: Mean steps/day, highest step rate in 1 and 5 minutes, peak activity index, and percentage of inactive time have good test-retest reliability over a 3-day monitoring period, with lower reliability shown by the other StepWatch outputs. Monitoring over 1 or 2 days is less reliable.

Enabling self-directed computer use for individuals with cerebral palsy: a systematic review of assistive devices and technologies.

AIM: The purpose of this study was to systematically review published evidence on the development, use, and effectiveness of devices and technologies that enable or enhance self-directed computer access by individuals with cerebral palsy (CP). METHODS: Nine electronic databases were searched using keywords 'computer', 'software', 'spastic', 'athetoid', and 'cerebral palsy'; the reference lists of articles thus identified were also searched. Thirty articles were selected for review, with 23 reports of development and usability testing of devices and seven evaluations of algorithms to increase computer recognition of input and cursor movements. RESULTS: Twenty-four studies had fewer than 10 participants with CP, with a wide age range of 5 to 77 years. Computer task performance was usually tested, but only three groups sought participant feedback on ease and comfort of use. International standards exist to evaluate effectiveness of non-keyboard devices, but only one group undertook this testing. None of the study designs were higher than American Academy for Cerebral Palsy and Developmental Medicine level IV. INTERPRETATION: Access solutions for individuals with CP are in the early stages of development. Future work should include assessment of end-user comfort, effort, and performance as well as design features. Engaging users and therapists when designing and evaluating technologies to enhance computer access may increase acceptance and improve performance.