Delivering intensive rehabilitation in stroke: factors influencing implementation

Abstract

Background
The evidence-base for stroke rehabilitation recommends intensive and repetitive task-specific practice, as well as aerobic exercise. However, translating these evidence-based interventions from research into clinical practice remains a major challenge.

Objective
To investigate factors influencing implementation of higher intensity activity in stroke rehabilitation settings

Design
A cross-sectional qualitative study.

Methods
Semi-structured interviews with rehabilitation therapists who had experience of delivering a higher intensity intervention as part of a clinical trial (DOSE), from four sites, across two provinces, in Canada. An interview guide was developed and data analysed using implementation frameworks.

Results
Fifteen therapists were interviewed before data saturation was reached. Therapists and patients generally had positive experiences regarding high intensity interventions. However, therapists felt they would adapt the protocol to accommodate their beliefs about ensuring movement quality. The requirement for all patients to have a graded exercise test, and the use of sensors, e.g. heart rate monitors, gave therapists confidence to push patients harder than they normally would. Paradoxically, a system that enables routine graded exercise testing, and the availability of staff and equipment contribute challenges for implementation in everyday practice.
Conclusions
Even therapists involved in delivering a high intensity intervention as part of a trial wanted to adapt it for clinical practice. Hence it is imperative that researchers are explicit regarding key intervention components and what can be adapted to help ensure implementation fidelity.

Changes in therapist’s beliefs and system level changes (staffing and resources) are likely to be required to facilitate higher intensity rehabilitation in practice.