Virtual rehabilitation: what are the practical barriers for home-based research?

Virtual reality technologies are becoming increasingly accessible and affordable to deliver, and consequently the interest in applying virtual reality within rehabilitation is growing. This has resulted in the emergence of research exploring the utility of virtual reality and interactive video gaming interventions for home use by patients. The aim of this paper is to highlight the practical factors and difficulties that may be encountered in research in this area, and to make recommendations for addressing these. Whilst this paper focuses on examples drawn mainly from stroke rehabilitation research, many of the issues raised are relevant to other conditions where virtual reality approaches have the potential to be applied to home-based rehabilitation

Constraint induced movement therapy in hemiplegic cerebral palsy: a national survey of its use by physiotherapists in the UK

Background/aims: There is an emerging evidence base into the use of Constraint Induced Movement Therapy (CIMT) in hemiplegic Cerebral Palsy (CP). However, there is little evidence of its use in the UK. This study aimed to conduct a national survey of physiotherapists to explore their use of CIMT in hemiplegic CP and to identify barriers and facilitators to its use. Methods: An online survey was distributed to members of the Association of Paediatric Chartered Physiotherapists (APCP) within the UK. At this time, there were approximately 2300 members on the professional database. Participants were asked about their experience and views regarding CIMT use/training, including their beliefs regarding delivery of CIMT in the UK health system. Findings: Responses were from 121 therapists from 12 regions of the UK, working across the National Health Service, private sector and education; based in inpatient, outpatient, community and school settings. Fifty three percent had never used CIMT although 73.6% felt it was an appropriate treatment. Most therapists felt they did not have enough training to use CIMT. Barriers included ethical issues, resources and training. Facilitators to its use included treatment modification, support of others and outcome appraisal. The ethical and legal ramifications of restraint were a common concern which prevented therapists from using CIMT. Family compliance influenced therapists’ decision to use CIMT. Conclusions: There is evidence to suggest physiotherapists in the UK are using CIMT to some extent in this patient group and that there is established clinical interest. Further research is needed to clarify ethical and legal ramifications of restraint

An introduction to economic evaluation in occupational therapy: cost-effectiveness of pre-discharge home visits after stroke (HOVIS)

Introduction: Occupational therapy interventions, such as home visits, have been identified as being resource-intensive, but cost-effectiveness analyses are rarely, if ever, carried out. We sought to estimate the cost-effectiveness of occupational therapy home visits after stroke, as part of a feasibility study, and to demonstrate the value and methods of economic evaluation. Method: We completed a cost-effectiveness analysis of pre-discharge occupational therapy home visits after stroke compared with a hospital-based interview, carried out alongside a feasibility randomized controlled trial. Our primary outcome was quality-adjusted life years. Full cost and outcome data were available for 65 trial participants. Results: We found that the mean total cost of a home visit was £183, compared with £75 for a hospital interview. Home visits are shown to be slightly more effective, resulting in a cost per quality-adjusted life year of just over £20,000. Conclusion: Our analysis is the only economic evaluation of this intervention to date. Home visits are shown to be more expensive and more effective than a hospital-based interview, but our results are subject to a high level of uncertainty and should be treated as such. Further economic evaluations in this field are encouraged

Constraint induced movement therapy in hemiplegic cerebral palsy: a national survey of its use by physiotherapists in the UK

Background/aims: There is an emerging evidence base into the use of Constraint Induced Movement Therapy (CIMT) in hemiplegic Cerebral Palsy (CP). However, there is little evidence of its use in the UK. This study aimed to conduct a national survey of physiotherapists to explore their use of CIMT in hemiplegic CP and to identify barriers and facilitators to its use.Methods: An online survey was distributed to members of the Association of Paediatric Chartered Physiotherapists (APCP) within the UK. At this time, there were approximately 2300 members on the professional database. Participants were asked about their experience and views regarding CIMT use/training, including their beliefs regarding delivery of CIMT in the UK health system.Findings: Responses were from 121 therapists from 12 regions of the UK, working across the National Health Service, private sector and education; based in inpatient, outpatient, community and school settings. Fifty three percent had never used CIMT although 73.6% felt it was an appropriate treatment. Most therapists felt they did not have enough training to use CIMT. Barriers included ethical issues, resources and training. Facilitators to its use included treatment modification, support of others and outcome appraisal. The ethical and legal ramifications of restraint were a common concern which prevented therapists from using CIMT. Family compliance influenced therapists’ decision to use CIMT.Conclusions: There is evidence to suggest physiotherapists in the UK are using CIMT to some extent in this patient group and that there is established clinical interest. Further research is needed to clarify ethical and legal ramifications of restraint

Virtually home: feasibility study and pilot randomised controlled trial of a virtual reality intervention to support patient discharge after stroke

Introduction: Virtual reality has the potential to assist occupational therapists in preparing patients for discharge by facilitating discussions and providing education about relevant practical issues and safety concerns. This study aimed to explore the feasibility of using a virtual reality intervention to support patient discharge after stroke and pilot its use. Method: Practical aspects of delivering a virtual reality intervention prior to discharge were explored by means of a non-randomised feasibility study and a subsequent pilot randomised controlled trial. Factors considered included eligibility, recruitment, intervention delivery, attrition and suitability of outcome measures. Outcome measures included standardised assessments of stroke severity, mobility, health-related quality of life, functional ability, satisfaction with services and concerns about falling. Results: Thirty-three participants were recruited in total: 17 to the feasibility study and 16 to the pilot trial. At 1-month follow-up, 14 participants (82%) were re-assessed in the feasibility study and 12 (75%) in the pilot trial. The main difficulties encountered related to recruitment, particularly regarding post-stroke cognitive impairments, the presence of mild deficits or illness. Conclusion: It was feasible to recruit and retain participants, deliver the intervention and collect outcome measures, despite slow recruitment rates. These findings could inform the design of a definitive trial

Systematic review of the epidemiology of non-collision injuries occurring to older people during use of public buses in high income countries

Each year more than 6,000 people are injured on public buses in the UK, approximately half of whom are aged 65 or over. This review synthesises the published literature on the epidemiology of non-collision injuries occurring in older people using public buses, to enable understanding of the size and nature of the problem of injuries, and to explore strategies for improving the safety of public transport for older people. We searched PubMed, Embase, CINAHL, Web of Science, and Transport International Research Documentation (TRID). Studies were included if they were cross-sectional, case-control or cohort studies. Pairs of reviewers independently screened studies for inclusion, assessed risk of bias, and extracted data. Ten studies were included in the review. Older people and women were found to be over-represented in non-collision injuries. Most injuries occurred during daytime hours and on weekdays. Injuries most commonly occurred whilst passengers were standing and either moving around the bus, boarding, or alighting, and whilst the bus was accelerating or decelerating. Bruising was the most common injury amongst emergency department attenders, although between 18% and 33% suffered more serious injuries such as fractures or dislocations. Many injuries to older public transport users are potentially preventable. Public transport needs to be safe and accessible, and to be perceived as such by older people to ensure independence in outdoor mobility

The identification of research priorities for UK occupational therapists in work rehabilitation

Background/Aims: UK occupational therapists are recognised as having key skills in work rehabilitation, but there is limited evidence to underpin this. In order to use research resources to best effect, it is vital to identify the research priorities of occupational therapists in work rehabilitation. This study aims to gather the views of those with a special interest in the field in order to identify their research priorities. Methods: An online survey was developed and administered electronically to members (n=173) of the College of Occupational Therapists Specialist Section-Work (COTSS-Work). Respondents were asked to: i) prioritise and comment on research areas; ii) propose research questions. A final sample of 42 surveys was collected and analysed thematically Results: Responses reflected the diversity and complexity of work rehabilitation. Identifying a rank order of research priorities proved challenging as the majority (≥62%) of respondents considered all of the topic areas listed a high priority. Research into the following areas were included in the survey: interventions; outcome measurements; assessments; management and/or service delivery; planning and/or commissioning; and education. However, 'interventions' was rated highest overall. Conclusions: Occupational therapists in the UK need more evidence to justify their role in the work and health arena. Greater opportunities are required for occupational therapists in clinical practice, as well as those involved in research, to address areas in which evidence-based practice is lacking and the mechanisms to disseminate this knowledge base

Hip precautions after hip operation (HippityHop): protocol for a before and after study evaluating hip precautions following total hip replacement

Introduction Hip precautions are routinely used despite inconclusive evidence that they reduce dislocations, and concern that they impede activities of daily living. HippityHop compares a change in practice locally from implementing routine hip precautions to no routine precautions, in order to: 1. Compare patient outcomes in quality of life, functional performance, pain, sleep, mood and satisfaction. 2. Ascertain staff and patient perceptions of the two regimes. 3. Determine the cost of precautions. Methods Before and after study: phase one patients will receive hip precautions, while phase two patients will receive no routine precautions. We propose to collect data from 342 participants at baseline, and at one week, six weeks, and three months postoperatively. Interviews will be conducted with 20 staff and 20 patients, and data collected relating to costs. Results Statistical analysis will be conducted to compare the two groups to determine any differences in patient outcomes. Thematic analysis will be used to identify and report themes within the interview data. Conclusion If there are no additional advantages to hip precautions, patients could resume everyday activities more quickly, potentially improving their quality of life. Conversely, if withdrawing hip precautions is detrimental, evidence for precautions will be provided

Who should have a pre–discharge home assessment visit after a stroke? A qualitative study of occupational therapists' views

Introduction: The number of patients who have a pre-discharge home assessment visit following a stroke has been reported to vary nationally. The purpose of this research was to explore the factors influencing occupational therapists' decisions to complete such visits. Method: Semi-structured interviews were completed with 20 senior occupational therapists working with stroke in-patients, from a range of urban and rural locations in the United Kingdom. The interviews explored their views about those patients for whom a pre-discharge home assessment visit would and would not be required. The interviews were analysed using thematic analysis. Findings: Three themes were identified: the patient's level of physical, cognitive, or perceptual impairment and its impact on performance in activities of daily living; factors relating to the patient's home environment, including the availability of support within the home environment; and other influences on occupational therapists. The presence of a cognitive impairment was a particularly important factor. Conclusions: Occupational therapists balanced aspects from each of these themes in order to determine whether a visit was needed or not. Although the level of impairment was important, the most dependent patients were not necessarily those believed to be the most likely to need a visit

Effectiveness of cognitive rehabilitation for people with multiple sclerosis: a meta-synthesis of patient perspectives

While previous randomised controlled trials and meta-analyses offer only limited evidence for the effectiveness of cognitive rehabilitation, qualitative studies examining patient perspectives report more positive outcomes. This meta-synthesis of qualitative studies examined patient perspectives of cognitive rehabilitation for memory, attention, and executive function problems in people with multiple sclerosis. Using set eligibility criteria, we screened electronic databases, reference lists, and academic networks for relevant papers. Seven papers (195 participants) were selected. Two independent researchers conducted quality appraisals of papers. Data analysis, guided by the thematic synthesis approach, yielded six main themes. These suggested that patients benefitted from the group environment in rehabilitation. Cognitive rehabilitation facilitated the participants’ reflection and awareness of their cognitive deficits, and was associated with increased knowledge and understanding of their illness. Increased strategy use was reported and associated with improvements in cognitive functioning and greater confidence and perseverance. Participants reported emotional and social improvements, and felt more optimistic. Overall, these changes had a positive impact on participants’ quality of life. This synthesis of qualitative studies indicates that people with multiple sclerosis who experience cognitive deficits benefit from cognitive rehabilitation programmes. This finding must, however, be viewed in light of the limitations of this meta-synthesis. The meta-synthesis was registered in the PROSPERO database under CRD42017040148