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Introduction: During the Coronavirus (Covid-19) pandemic, physiotherapists changed rapidly to working remotely. Research demonstrates the benefits of remote physiotherapy, but little is known about its implementation in practice. Purpose: Explore the take-up and delivery of remote physiotherapy during the pandemic in the United Kingdom. Methods: Sequential mixed methods evaluation with physiotherapists leading remote physiotherapy delivery. Two-stage approach included online survey (2020) and semi-structured interviews with documentary/data analysis (2021). Results: There were 1620 physiotherapists who completed the survey. The most used devices were telephone (n = 942,71.0%) and the AttendAnywhere platform (n = 511, 38.5%). Remote consultations were frequently used for initial assessment (n = 1105, 83%), screening/triage (n = 882, 67%), or to review, monitor, and progress treatment (n = 982–1004, 74%–76%). Qualitative survey responses reflected respondents' response to COVID-19 and delivery of remote physiotherapy. Twelve remote physiotherapy leads were then purposively sampled across clinical areas. Three main themes emerged from interviews: response to Covid-19, delivery of remote physiotherapy, and future of remote physiotherapy. Conclusion: Remote physiotherapy was safe, feasible, and acceptable for those who accessed it. There were patients for which it was deemed unsuitable across clinical areas. In practice, it should be combined with in-person consultation based on patients' needs/preferences. Further research should explore post-pandemic maintenance of remote delivery. [ABSTRACT FROM AUTHOR]

Objective: To develop a measure of the needs injured children and their families' needs throughout recovery; The MAnchester Needs Tool for Injured Children (MANTIC). Design: Tool development, psychometric testing. Setting: Five children's major trauma centres in England. Participants: Children aged 2 to 16 years with any type of moderate/severe injury(ies) treated in a major trauma centre within 12 months of injury, plus their parents. Methods: Stage 1a (Item generation) : Interviews with injured children and their parents to generate draft items. Stage 1b (Co-production) : Feedback about item clarity, relevance and appropriate response options was provided by parents and the patient and public involvement group. Stage 2 (Psychometric development) : Completion of the prototype MANTIC by injured children and their parents with restructuring (as necessary) to establish construct validity. Concurrent validity was assessed by correlation with quality of life (EQ-5D-Y). MANTICs were repeated 2 weeks later to assess test–retest reliability. Results: Stages 1a,b : Interviews (13 injured children, 19 parents) generated 64 items with semantic differential four-point response scale (strongly disagree, disagree, agree, strongly agree). Stage 2 : One hundred and forty-four participants completed MANTIC questionnaires (mean age 9.8 years, SD 3.8; 68.1% male). Item responses were strong requiring only minor changes to establish construct validity. Concurrent validity with quality of life was moderate (r = 0.55, P < 0.01) as was test–retest reliability (ICC = 0.46 and 0.59, P < 0.001). Uni-dimensionality was strong (Cronbach's α > 0.7) Conclusion: The MANTIC is a feasible, acceptable, valid self-report measure of the needs of injured children and their families, freely available for clinical or research purposes. [ABSTRACT FROM AUTHOR]

The study explored the acceptability of high repetition arm training as part of a randomised controlled trial, early after stroke, when fatigue levels and emotional strain are often high. 36 sub-acute stroke survivors (61 years+/-15) attended for assessment sessions at 3, 6, and 12 weeks after stroke. Individuals were randomised to receive 6 high repetition arm training sessions between 3 and 6 weeks (intervention) or the control group. Semi-structured interviews were conducted at trial completion. Interview transcripts were analysed through framework analysis conducted independently by 2 researchers. Stroke survivors participated despite high levels of fatigue because they hoped for personal benefit or to potentially benefit future patients. Benefits reported from participation included physical improvements, psychological benefit, improved understanding of their condition as well as a feeling of hope and distraction. The arm training at three weeks after stroke, aiming for 420 movement repetitions was not considered to be too intensive or too early, and most individuals felt lucky to have been, or would have preferred to be in the early training group. High repetition arm training early after stroke was acceptable to participants. Study participation was generally viewed as a positive experience, suggesting that early intervention may not only be physically beneficial but also psychologically. Stroke survivors report that high repetition arm training early after stroke is acceptable. Participation in rehabilitation research early after stroke provides stroke survivors with hope and meaning despite the high prevalence of fatigue. Complex information needs to be repeated and provided in a number of formats early after stroke. [ABSTRACT FROM AUTHOR]

Patients with functional stroke can present with functional speech, language or swallowing symptoms, which are managed by speech and language therapists (SLTs). The aim of this study was to explore SLTs' views and experiences of working with patients with functional stroke. Constructivist grounded theory approach was used. Semi-structured interviews were the method of data collection. Constant comparative analysis was used to analyse data. Participants were eligible if they were SLTs who thought they had experience of working with functional stroke. 12 participants were interviewed. Patients with functional stroke were a common occurrence on participants' caseloads; yet they felt patients do not receive optimum care. All participants wanted to help their patients, yet felt they were working within a multitude of barriers to effective input. These included: stigma about the diagnosis, lack of pre-qualification training, quick discharge from inpatient settings, lack of access to mental health services and lack of clinical guidelines and care pathways. As healthcare professionals, participants were keen to help their patients. However, they felt they did not have the skills or knowledge to help which caused professional turmoil. Reducing stigma and increasing awareness and knowledge of functional stroke are required to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: To explore the experiences of children and families after a child's traumatic injury (Injury Severity Score >8). Design: Qualitative interview study. Setting: Two children's major trauma centres in England. Participants: 32 participants: 13 children with traumatic injuries, their parents/guardians (n = 14) and five parents whose injured child did not participate. Methods: Semi-structured interviews exploring the emotional, social, practical and physical impacts of children's injuries, analysed by thematic analysis. Results: Interviews were conducted a median of 8.5 months (IQR 9.3) post-injury. Injuries affected the head, chest, abdomen, spine, limbs or multiple body parts. Injured children struggled with changes to their appearance, physical activity restrictions and late onset physical symptoms, which developed after hospital discharge when activity levels increased. Social participation was affected by activity restrictions, concerns about their appearance and interruptions to friendships. Psychological impacts, particularly post-traumatic stress type symptoms often affected both children and parents. Parents' responsibilities suddenly increased, which affected family relationships and roles, their ability to work and carry out daily tasks. Rapid hospital discharge was wanted, but participants often felt vulnerable on return home. They valued continued contact with a healthcare professional and practical supports from family and friends, which enabled resumption of their usual lives. Conclusions: Injured children experience changes to their appearance, friendships, physical activity levels and develop new physical and mental health symptoms after hospital discharge. Such challenges can be addressed by the provision of advice about potential symptoms, alternative activities during recovery, strategies to build resilience and how to access services after hospital discharge. [ABSTRACT FROM AUTHOR]

Purpose: To assess the feasibility and acceptability of the Howz smart home system for stroke survivors. Materials: Howz uses smart home technology to monitor users' activity in the home and machine learning algorithms to detect when their activity changes. This information made available to the user and a named contact (usually a family member) via the Howz app. If activity changes, an alert is then sent to the user and the named contact. Methods: Howz was installed in the homes of 19 stroke survivors who lived alone. The sensors installed; the number and nature of alerts; adverse events; any technical difficulties and how Howz was used were recorded. We also interviewed participants and their named contacts about their views and experiences of using Howz eight weeks after installation. Results: Installation was effective; no technological problems or adverse events were reported. All participants chose alerts regarding "getting up" and activity during the day and at night. There was a mean of 1.1 (sd 1.2) alerts/person. Participants found the system unobtrusive and were positive about it. They found it easy to use and would recommend it to others with stroke. The most frequently reported benefit was that Howz gave peace of mind for the users and/or the family/named contact that help would be at hand if needed. Conclusions: The Howz system was feasible and acceptable for stroke survivors. It gave users and their family an enhanced sense of security and peace of mind that help would be at hand if needed. Although most stroke survivors are elderly and often suffer physical, visual and cognitive disabilities which are often considered as barriers to using smart home technology, this project has demonstrated the well-developed smart home technology is feasible and acceptable. Users were able and willing to engage with the technology (to varying degrees) and had no concerns about invasion of privacy. The main benefit of the Howz system is an enhanced sense of security for the user and their family that help is at hand if needed. [ABSTRACT FROM AUTHOR]

Objective: To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units. Design: Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews. Setting: Eight stroke units in four English regions. Subjects: Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed. Results: Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists' decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists' working practices, enabling them to provide therapy consistent with guideline recommendations. Conclusion: Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists' work improved alignment with guidelines. [ABSTRACT FROM AUTHOR]

Purpose:We investigated stroke rehabilitation clinician’s perceptions of the patient as an active partner in setting goals within stroke rehabilitation and factors that influence patient engagement. Methods:Semi-structured interviews, subject to general inductive analysis with 20 Clinicians’ working in three UK based stroke rehabilitation teams (one in-patient ward and two community based rehabilitation teams). Results:There were three key themes that impacted on the patients active involvement in setting goals for rehabilitation after stroke: Patient barriers to goal setting (knowledge of the patient and family, who is the patient and the stroke’s impact); How we work as a team (the role of the patient in setting goals, the effect of clinician attributes on goal setting); and How systems impact goal setting (goal-setting practice, home versus hospital, and professional/funder expectations of clinicians’). Conclusions:Goal setting served a range of different, sometimes conflicting, functions within rehabilitation. Clinicians’ identified the integral nature of goals to engage and motivate patients and to provide direction and purpose for rehabilitation. Further, there was an identified need to consider the impact of prioritizing clinician-derived goals at the expense of patient-identified goals. Lastly the reliance on the SMART goal format requires further consideration, both in terms of the proposed benefits and whether they disempower the patient during rehabilitation.Implications for rehabilitationGoal setting is often promoted as a relatively simple, straightforward way to structure interactions with patientsPatient-related factors together with resourcing constraints are significant barriers to patient-centered goal setting, particularly during inpatient rehabilitationClinicians need to have pragmatic tools that can be integrated into practice to ensure that goal-setting practice can be maximized for patients with different intrinsic characteristics [ABSTRACT FROM PUBLISHER]

Background and Purpose. Current approaches to Upper limb rehabilitation are not sufficient to drive neural reorganization and maximize recovery after stroke. To address this evidence-practice gap, a knowledge translation intervention using the Behaviour Change Wheel was developed. The intervention involves collaboratively working with stroke therapy teams to change their practice and increase therapy intensity by therapists prescribing supplementary self-directed arm exercise. The purposes of this case series are: (1) to provide an illustrative example of how a research-informed process changed clinical practice and (2) to report on staff members' and patients' perceptions of the utility of the developed intervention. Case Descriptions. A participatory action research approach was used in 3 stroke rehabilitation units in the United Kingdom. The intervention aimed to change 4 therapist-level behaviors: (1) screening patients for suitability for supplementary self-directed arm exercise, (2) provision of exercises, (3) involving family and caregivers in assisting with exercises, and (4) monitoring and progressing exercises. Data on changes in practice were collected by therapy teams using a bespoke audit tool. Utility of the intervention was explored in qualitative interviews with patients and staff. Outcomes. Components of the intervention were successfully embedded in 2 of the 3 stroke units. At these sites, almost all admitted patients were screened for suitability for supplementary self-directed exercise. Exercises were provided to 77%, 70%, and 88% of suitable patients across the 3 sites. Involving family and caregivers and monitoring and progressing exercises were not performed consistently. Conclusions. This case series is an example of how a rigorous research-informed knowledge translation process resulted in practice change. Research is needed to demonstrate that these changes can translate into increased intensity of upper limb exercise and affect patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Effective recruitment is an essential element of successful research but notoriously difficult to achieve. This article examines health care professionals' views on the factors influencing decision-making regarding referral to a stroke rehabilitation trial.Methods: Semi-structured interviews and a card-sorting task were undertaken with stroke service staff in acute and community hospital trusts. Data analysis used a thematic framework approach.Results: Twenty-seven qualified health care professionals from 12 (6 acute and 6 community) hospital trusts and one charity participated. Four main factors emerged: patient-related, professional views, the organisation and research logistics, which all contributed to staff's decision about whether to refer patients to a trial. Clinicians identified patient-related factors as the most frequent influence and considered themselves the patients' advocate. They used their knowledge of the patient to anticipate the patients' reaction to possible participation and tended to only refer those whom they perceived would respond positively. Participants also identified experience of research, a sense of ownership of the project and a positive view of the intervention being evaluated as factors influencing referral. The need to prioritise clinical matters, meet managerial demands and cope with constant change were organisational factors impacting negatively on referral. Staff often simply forgot about recruitment in the face of other higher priorities. Quick, simple, flexible research processes that were closely aligned with existing ways of working were felt to facilitate recruitment.Conclusions: Patient- and professional-related factors were the most frequent influence on clinicians' recruitment decisions, which often had a 'gate-keeping' effect. Managerial and clinical responsibility to juggle multiple (often higher) priorities was also an important factor. To facilitate recruitment, researchers need to develop strategies to approach potential participants as directly as possible to enable them to make their own decisions about participation; ensure that research processes are as quick and simple as possible; align with existing clinical pathways and systems; and give regular reminders and ongoing support to promote recruitment.Trial Registration: ISRCTN, 98287938 . Registered 6 May 2015. [ABSTRACT FROM AUTHOR]

Purpose: Patient-led therapy, in which patients work outside therapy sessions without direct supervision, is a possible way to increase the amount of therapy stroke patients’ receive without increasing staff demands. Here, we report patients’ views of patient-led mirror therapy and lower limb exercises.Method: 94 stroke survivors with upper and lower limb limitations at least 1-week post-stroke undertook 4 weeks of daily patient-led mirror therapy or lower limb exercise, then completed questionnaires regarding their experience and satisfaction. A convenience random sample of 20 participants also completed a semi-structured telephone interview to consider their experience in more detail and to capture their longer term impressions.Results: Participants were generally positive about patient-led therapy. About 71% found it useful; 68% enjoyed it; 59% felt it “worked” and 88% would recommend it to other patients. Exercise was viewed more positively than the mirror therapy. Difficulties included arranging the equipment and their position, particularly for more severe strokes, loss of motivation and concerns about working unsupervised.Conclusions: Patient-led mirror therapy and lower limb exercises during in-patient rehabilitation is generally feasible and acceptable to patients but “light touch” supervision to deal with any problems, and strategies to maintain focus and motivation are needed.Implications for RehabilitationMost stroke patients receive insufficient therapy to maximize recovery during rehabilitation. As increases in staffing are unlikely there is an imperative to find ways for patients to increase the amount of exercise and practice of functional tasks they undertake without increasing demands on staff.Patient-led therapy (also known as patient-directed therapy or independent practice), in which patients undertake exercises or functional tasks practice prescribed by a professional outside formal therapy sessions is one way of achieving this. It is widely used in community-based rehabilitation but is uncommon in hospital-based stroke care.We explored the feasibility and acceptability of two types of patient-led therapy during hospital-based stroke care; mirror therapy for the upper limb and exercises (without a mirror) for the lower limb. Here, we report patients’ experiences of undertaking patient-led therapy.Patient-led mirror therapy and lower limb exercises during in-patient stroke rehabilitation is generally feasible and acceptable to patients but “light touch” supervision to deal with any problems, and strategies to maintain focus and motivation are needed. [ABSTRACT FROM AUTHOR]

Background The initiation of end of life care in an acute stroke context should be focused on those patients and families with greatest need. This requires clinicians to synthesise information on prognosis, patterns (trajectories) of dying and patient and family preferences. Within acute stroke, prognostic models are available to identify risks of dying, but variability in dying trajectories makes it difficult for clinicians to know when to commence palliative interventions. This study aims to investigate clinicians' use of different types of evidence in decisions to initiate end of life care within trajectories typical of the acute stroke population. Methods/design This two-phase, mixed methods study comprises investigation of dying trajectories in acute stroke (Phase 1), and the use of clinical scenarios to investigate clinical decision-making in the initiation of palliative care (Phase 2). It will be conducted in four acute stroke services in North Wales and North West England. Patient and public involvement is integral to this research, with service users involved at each stage. Discussion This study will be the first to examine whether patterns of dying reported in other diagnostic groups are transferable to acute stroke care. The strengths and limitations of the study will be considered. This research will produce comprehensive understanding of the nature of clinical decision-making around end of life care in an acute stroke context, which in turn will inform the development of interventions to further build staff knowledge, skills and confidence in this challenging aspect of acute stroke care. [ABSTRACT FROM AUTHOR]

Rationale Routine collection of outcome measures is advocated to improve quality of care. However, there has been scant investigation of how measurement tools are used in clinical practice and what impact they may have. This paper compares two neuro-rehabilitation teams, one which routinely used standardized measurement tools and the other which did not. We explore differences in communication and clinical decision making within multidisciplinary team (MDT) meetings to illuminate the influence measurement tools could have on clinical practice. Method Non-participant observation of MDT meetings in two neurological rehabilitation units in England. Semi-structured interviews were also carried out with at least one member of each profession in each team. Grounded theory techniques were used to analyse the data. Results Differences in team members' communication within MDT meetings underscored differences in the process of clinical decision making within the teams. Using measurement tools provided a shared understanding to facilitate communication by focusing discussion on the patient's abilities rather than individual professionals' contributions. This led to differences in the way team members identified the nature and cause of patients' problems, monitored their progress and planned for discharge. They provided a 'neutral ground' to reach a shared perspective between professionals, thereby avoiding conflict. Externally, use of the tools enabled objective discussion with patients and their families about their progress and was a vehicle to facilitate giving bad news. Conclusion Using standardized measurement tools can promote a patient-focused approach to care, thus facilitating treatment planning and clinical decision making. [ABSTRACT FROM AUTHOR]