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Background: Stroke-specific protocols for the 10-meter and 6-minute walk tests that include instructions for people with aphasia, accessible walkway lengths, and allow provision of assistance to wa...

Background: The long-term consequences of traumatic brain injury can create major barriers to community integration. Peer support represents a sustainable model of support across this transition. The objective of the current study was to determine the feasibility of conducting a randomized controlled trial on the Ontario Brain Injury Association Peer Support Program and the preliminary effectiveness of the program on community integration, mood, health-related quality of life, and self-efficacy, Methods: A pilot feasibility randomized controlled trial with an embedded qualitative component was conducted. Mentees with moderate-to-severe traumatic brain injury (n = 13) were randomized to a weekly intervention or waitlist control group. Interviews were conducted with a subset of mentees and peer mentors (n = 10). Integration of the quantitative and qualitative data was completed using a joint display approach, Results: No statistically significant results were found for community integration, mood, or self-efficacy, however, changes in these outcomes were accompanied by moderate-to-large effect sizes. Within health-related quality of life, the mean pain score of the intervention group was significantly lower than that of the control group at the two-month timepoint but not at completion. Interviews revealed proximal improvements in knowledge, skills, and goals, and identified two domains related to trial acceptability: (1) environmental context and resources, and (2) reinforcement, Conclusions: Given the conceivable importance of proximal improvements in domains such as knowledge, skills, and/or goals for the attainment of more distal outcomes, modifications to the existing Peer Support Program may be warranted. The introduction of program recommendations which promote discussion around particular domains may help facilitate long-term improvements in health outcomes.

Although there is growing utilisation of intermediate care to improve the health and well-being of older adults with complex care needs, there is no international agreement on how it is defined, limiting comparability between studies and reducing the ability to scale effective interventions. To identify and define the characteristics of intermediate care models. A scoping review, a modified two-round electronic Delphi study involving 27 multi-professional experts from 13 countries, and a virtual consensus meeting were conducted. Sixty-six records were included in the scoping review, which identified four main themes: transitions, components, benefits and interchangeability. These formed the basis of the first round of the Delphi survey. After Round 2, 16 statements were agreed, refined and collapsed further. Consensus was established for 10 statements addressing the definitions, purpose, target populations, approach to care and organisation of intermediate care models. There was agreement that intermediate care represents time-limited services which ensure continuity and quality of care, promote recovery, restore independence and confidence at the interface between home and acute services, with transitional care representing a subset of intermediate care. Models are best delivered by an interdisciplinary team within an integrated health and social care system where a single contact point optimises service access, communication and coordination. This study identified key defining features of intermediate care to improve understanding and to support comparisons between models and studies evaluating them. More research is required to develop operational definitions for use in different healthcare systems.

Background Despite the high prevalence of comorbid chronic pain and depression, this comorbidity remains understudied. Meditation has demonstrated efficacy for both chronic pain and depression independently, yet there have been few studies examining its effectiveness when both conditions are present concurrently. Furthermore, while meditation is generally accepted as a safe and effective health intervention, little is known about how to implement meditation programs within or alongside the health care system. Methods We will conduct a hybrid type 1 effectiveness–implementation evaluation. To measure effectiveness, we will conduct a randomized controlled trial comparing Sahaj Samadhi Meditation and the Health Enhancement Program in 160 people living with chronic pain, clinically significant depressive symptoms, and on long-term opioid therapy. Changes in depressive symptoms will be our primary outcome; pain severity, pain-related function, opioid use, and quality of life will be the secondary outcomes. The primary end point will be at 12 weeks with a secondary end point at 24 weeks to measure the sustainability of acute effects. Patients will be recruited from a community-based chronic pain clinic in a large urban center in Mississauga, Canada. The meditation program will be delivered in the clinical environment where patients normally receive their chronic pain care by certified meditation teachers who are not regulated health care providers. We will use a mixed-methods design using the multi-level framework to understand the implementation of this particular co-location model. Discussion Results of this hybrid evaluation will add important knowledge about the effectiveness of meditation for managing depressive symptoms in people with chronic pain. The implementation evaluation will inform both effectiveness outcomes and future program development, scalability, and sustainability. Trial registration ClinicalTrials.gov: NCT04039568. Registered on 31 July 2019.

ContextOpioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined.ObjectiveIdentify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit.Study designSystematic rapid realist review.DatasetBibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation.Results95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion.ConclusionsProviding alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.

Evidence suggests that a stroke occurs in isolation (no comorbid conditions) in less than 6% of patients. Multimorbidity, compounded by psychosocial issues, makes treatment and recovery for stroke increasingly complex. Recent research and health policy documents called for a better understanding of the needs of this patient population, and for the development and testing of models of care that meet their needs. A research agenda specific to complexity is required. The primary objective of the think tank was to identify and prioritize research questions that meet the information needs of stakeholders, and to develop a research agenda specific to stroke rehabilitation and patient complexity. A modified Delphi and World Café approach underpinned the think tank meeting, approaches well recognized to foster interaction, dialogue, and collaboration between stakeholders. Forty-three researchers, clinicians, and policymakers attended a 2-day meeting. Initial question-generating activities resulted in 120 potential research questions. Sixteen high-priority research questions were identified, focusing on predetermined complexity characteristics-multimorbidity, social determinants, patient characteristics, social supports, and system factors. The final questions are presented as a prioritized research framework. An emergent result of this activity is the development of a complexity and stroke rehabilitation research network. The research agenda reflects topics of importance to stakeholders working with stroke patients with increasingly complex care needs. This robust process resulted in a preliminary research agenda that could provide policymakers with the evidence needed to make improvements toward better-organized services, better coordination between settings, improved patient outcomes, and lower system costs.

How does participating in a peer support group impact an adult's psychosocial adjustment following brain injury? This question was investigated using a qualitative approach, interviewing patients recruited from an ambulatory care program. Data analysis guided by Bury's sociological framework, biographical disruption and biographical repair, revealed participants' pregroup disrupted sense of self, including subthemes related to intrinsic losses and uncertainty. Enhanced psychosocial adjustment including subthemes described participants' reorientation through shared experience. Finally, a postgroup adapted sense of self including subthemes was characterized by heightened purpose, self-awareness, and acceptance. Findings lend weight to using tailored peer interventions to optimize psychosocial adjustment for this population.

Purpose: The purpose of this systematic review was to synthesize and appraise the evidence regarding the impact of quality improvement strategies on quality of life as well as physical and psychological well-being of individuals with stroke.Materials and methods: Studies were identified by searching MEDLINE (OVID interface, 2000 onwards), CINAHL (EBSCO interface, 2000 onwards), EMBASE (OVID interface, 2000 to present), and PsycINFO (OVID interface, 2000 onwards). The Effective Practice and Organization of Care Risk of Bias Tool was applied. Extracted data from the publications included: study characteristics, participant characteristics, the strategy characteristics, the outcomes, and quality appraisal.Results: Our review identified 12 trials that utilized only 4 of the 10 quality improvement strategies included in this review. The most common quality improvement strategy was self-management. Other studies included patient education, team changes, and case management. Only 5 of the 12 studies reported statistically significant improvements in some component of quality of life.Conclusions: There is a lack of evidence to demonstrate efficacy/effectiveness of patient education, self-management, team changes, and case management approaches on improving the quality of life of stroke survivors. Identifying the essential features of effective and ineffective strategies, especially in the area of self-management strategies would be beneficial.Implications for rehabilitationThere is a lack of evidence to demonstrate efficacy/effectiveness of patient education, self-management, team changes, and case management approaches on improving the quality of life of stroke survivors.To improve these outcomes, there may be a need to co-create/tailor quality improvement interventions with patients, their caregivers, and providers.The impact of a broader range of quality improvement interventions, including clinician education and patient reminder systems, on quality of life post-stroke should be considered.

Background While many outcomes post-stroke (e.g., depression) have been previously investigated, there is no complete data on the impact of a variety of quality improvement strategies on the quality of life and physical and psychological well-being of individuals post-stroke. The current paper outlines a systematic review protocol on the impact of quality improvement strategies on quality of life as well as physical and psychological well-being of individuals with stroke. Methods MEDLINE, CINAHL, EMBASE, and PsycINFO databases will be searched. Two independent reviewers will conduct all levels of screening, data abstraction, and quality appraisal. Only randomized controlled trials that report on the impact of quality improvement strategies on quality of life outcomes in people with stroke will be included. The secondary outcomes will be physical and psychological well-being. Quality improvement strategies include audit and feedback, case management, team changes, electronic patient registries, clinician education, clinical reminders, facilitated relay of clinical information to clinicians, patient education, (promotion of) self-management, patient reminder systems, and continuous quality improvement. Studies published since 2000 will be included to increase the relevancy of findings. Results will be grouped according to the target group of the varying quality improvement strategies (i.e., health system, health care professionals, or patients) and/or by any other noteworthy grouping variables, such as etiology of stroke or by sex. Discussion This systematic review will identify those quality improvement strategies aimed at the health system, health care professionals, and patients that impact the quality of life of individuals with stroke. Improving awareness and utilization of such strategies may enhance uptake of stroke best practices and reduce inappropriate health care utilization costs. Systematic review registration PROSPERO, CRD42017064141 Electronic supplementary material The online version of this article (10.1186/s13643-017-0579-3) contains supplementary material, which is available to authorized users.

IntroductionThe objective of this study is to conduct a pilot randomised controlled trial (RCT) of the Ontario Brain Injury Association (OBIA) Peer Support Program. The RCT is designed to evaluate the effectiveness and dose–response of the Peer Support Program in improving participation and mood for people with moderate-to-severe traumatic brain injury compared with a wait-list control group.Methods and analysisThe proposed research is a three-phase, mixed methods pilot RCT. Consistent with an integrated knowledge translation approach, the study design has been informed in consultation with the knowledge user (ie, OBIA). It will include an initial qualitative examination of barriers and enablers to the trial implementation (phase 1), a pilot RCT (phase 2) and conclude with a qualitative component (phase 3). A qualitative descriptive approach will be adopted for both qualitative phases of the study (n=20–25) and thematic analysis will be used. The 6 months phase-2 trial will be conducted with 60 participants. These participants will be randomised to one of three groups: a twice a week programme (n=20), a once a week programme (n=20) or the wait-list control group (n=20). The feasibility of participant recruitment and retention, data collection, as well as participant adherence to the OBIA Peer Support Program will be evaluated. The primary outcome measure will be participation, as measured by the Participation Assessment with Recombined Tools–Objective. Other proposed outcomes of interest will include mood, health-related quality of life and self-efficacy.Ethics and disseminationEthics approval will be obtained from the principal author’s institution (University Health Network Research Ethics Board). The results of this study will inform the development of a larger scale RCT and will inform future iterations of the OBIA Peer Support Program including a revised programme curriculum.Trial registration numberNCT03450460; Pre-results.

In Canada, policy makers are working to align services with the Stroke Rehabilitation Best Practice Recommendations (SRBPR). Complicating the application of clinical practice guidelines (CPGs) is the fact that most strokes occur in the context of other diagnoses. We sought to understand clinicians' use of the CPGs and ascertain how much guidance regarding multimorbidity was available in the SRBPR. Study results indicated that using the recommendations was problematic due to a perceived lack of guidance regarding comorbidities and multimorbidity, and concerns regarding the applicability to "real-life patients." Comorbidities were mentioned in less than half of the recommendations, but no explicit guidance was provided regarding the management of comorbidities. Given the prevalence of multimorbidity in stroke rehabilitation, this clinical context is ideal for development and testing of CPGs that account for multimorbidity and other complexity factors. Results may also suggest limitations to using CPGs in the development of activity-based funding models.

Background Approximately 80% of people who survive a stroke have on average five other conditions and a wide range of psychosocial issues. Attention to biopsychosocial issues has led to the identification of ‘complex patients’. No single definition of ‘patient complexity’ exists; therefore, applied health researchers seek to understand ‘patient complexity’ as it relates to a specific clinical context. Objective To understand how ‘patient complexity’ is conceptualized by clinicians, and to position the findings within the existing literature on patient complexity. Methods A qualitative descriptive approach was utilized. Twenty-three stroke rehabilitation clinicians participated in four focus groups. Results Five elements of patient complexity were identified: medical/functional issues, social determinant factors, social/family support, personal characteristics, and health system factors. Using biopsychosocial factors to identify complexity results in all patients being complex; operationalization of the definition led to the identification of systemic elements. A disconnect between acute, inpatient rehabilitation and community services was identified as a trigger for increased complexity. Conclusions Patient complexity is not a dichotomous state. If applying existing complexity definitions, all patients are complex. This study extends the understanding by suggesting a structural element of complexity from manageable to less manageable complexity based on ability to discharge.

Stroke care presents unique challenges for clinicians, as most strokes occur in the context of other medical diagnoses. An assessment of capacity for implementing “best practice” stroke care found clinicians reporting a strong need for training specific to patient/system complexity and multimorbidity. With mounting patient complexity, there is pressure to implement new models of healthcare delivery for both quality and financial sustainability. Policy makers and administrators are turning to clinical practice guidelines to support decision-making and resource allocation. Stroke rehabilitation programs across Canada are being transformed to better align with the Canadian Stroke Strategy's Stroke Best Practice Recommendations. The recommendations provide a framework to facilitate the adoption of evidence-based best practices in stroke across the continuum of care. However, given the increasing and emerging complexity of patients with stroke in terms of multimorbidity, the evidence supporting clinical practice guidelines may not align with the current patient population. To evaluate this, electronic databases and gray literature will be searched, including published or unpublished studies of quantitative, qualitative or mixed-methods research designs. Team members will screen the literature and abstract the data. Results will present a numerical account of the amount, type, and distribution of the studies included and a thematic analysis and concept map of the results. This review represents the first attempt to map the available literature on stroke rehabilitation and multimorbidity, and identify gaps in the existing research. The results will be relevant for knowledge users concerned with stroke rehabilitation by expanding the understanding of the current evidence.