Why do stroke patients not receive the recommended amount of therapy? (ReAcT)

Objectives and brief methodology

Stroke is the commonest cause of disability in England with more than 110,000 people having a new stroke each year. Stroke can result in impairments affecting upper and lower limb function, cognition, vision, swallowing and speech and language.  Assessment and treatment by multidisciplinary teams in a stroke unit improves patient outcomes. A fundamental element of stroke unit care is assessment and patient specific therapy provided by physiotherapists (PTs), occupational therapists (OTs) and speech and language therapists (SALTs). There is increasing evidence demonstrating the effectiveness of a range of interventions and that increased intensity of therapy leads to better outcomes.

The National Clinical Guideline for Stroke recommends that up to forty-five minutes of each active therapy be provided on at least five days a week to patients if the therapy is appropriate and the patient can tolerate it. However, data from the 2013 Stroke Sentinel National Audit Programme (SSNAP) identified that this standard was not achieved for most patients.

The ReAcT study sought to  develop an in-depth understanding of post-stroke therapy provision, including how the recommendation of forty-five minutes of each relevant therapy (physiotherapy, occupational therapy and/or speech therapy) a day, was interpreted and implemented by therapists and experienced by patients and their carers in stroke units.

The programme of work involved in-depth qualitative case studies in eight stroke units in England. These included two units in each of the following regions North East, the North West, one un it on London and three Yorkshire.  Recruitment progressed to target in each site. We completed over 1000 hours of non-participant observations, including 433 therapy sessions. One hundred and ninety-seven staff, 77 patients and 53 carers were observed; we interviewed 131 staff, 49 patients and 50 carers. We completed documentary analysis of therapy records of 75 patients.

Meetings to discuss interim findings and develop recommendations for practice and for policy makers were held between March and October 2016. The findings of the study have enabled understanding of the contexts, facilitators, and barriers to providing and receiving therapy in in-patient stroke units from the perspective of therapists, patients, carers and stroke service managers.

Summary of findings

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 re-organisation of therapists’ working practices, enabling them to provide therapy consistent with guideline recommendations.

Research Outputs

This NIHR funded study exploring the provision of post-stroke therapy led by David Clarke has been used as a case-study by the Royal College of Physicians. Also cited in the Sentinel Stroke National Audit Programme (SSNAP) report in 2018, the team have showcased the research findings at several national and international conferences, including presentations at the Greater Manchester Stroke Operational Delivery Network and dissemination in Ireland and Australia.

Journal article:
Clarke, D. J., Tyson, S., Rodgers, H., Drummond, A., Palmer, R., Tyrrell, P., Prescott,M. Burton,L.Brkic,L.,Grenfell,K. Forster, A. (2015). Why do stroke patients not receive the recommended amount of active therapy (ReAcT)? Study protocol for a multi-site case study investigation. BMJ Open. 5(8) e008443  doi:10.1136/bmjopen-2015-008443

Clarke DJ, Burton L, Tyson SF, Rodgers H, Drummond A, Palmer R, Hoffman A, Prescott M, Tyrrell P, Brkic L, Grenfell K, Forster A. Why do stroke survivors not receive recommended amounts of active therapy? Findings from the ReAcT study, a mixed-methods case-study evaluation in eight stroke units. Clinical Rehabilitation 2018; 1-14. doi: 10.1177/0269215518765329 PDF

Invited conference presentations:

What factors influence the frequency and intensity of therapy provision in stroke units? Findings from the ReAcT study. Scottish Stroke Allied Health Professional Forum, Dundee. June 13 2018

Findings from the ReAcT study. Royal College of Speech and Language Therapists, London. Making Sense of SSNAP and Therapy Provision in Stroke Services Conference. 26 April 2018.

Findings from the ReAcT study. Greater Manchester Organisational Development Network (Stroke Services). Productive Therapy Conference, Ashton Under Lyne, Manchester. 25 April 2018.

What factors influence the frequency and intensity of therapy provision in stroke units? Findings from the ReAcT study. UK Stroke Forum Conference. Allied Health Professionals and Nursing Training Day Workshop. November

How to achieve 45 minutes of therapy: Findings from the ReAcT study.  Welsh Stroke Conference. Cardiff. 5th July 2017.

Better multidisciplinary communication for better stroke care. UK Stroke Forum Conference. Liverpool, November 30th 2016.

What factors influence the frequency and intensity of therapy provision in stroke units? Findings from the ReAcT study. UK Stroke Forum Conference. Allied Health Professionals and Nursing Training Day Workshop. November 28th 2016.

Conference presentations:

Why do some inpatient stroke survivors not receive the recommended frequency and intensity of active therapy? The ReAcT study. The European Forum for research in Rehabilitation (EFRR) and Society for Research in Rehabilitation Conference, Glasgow, 24-27 May 2017

What factors inform therapists’ decision making:  Selected findings from an ethnographic case- study series in eight English stroke units (the ReAcT study). The European Forum for research in Rehabilitation (EFRR) and Society for Research in Rehabilitation Conference, Glasgow, 24-27 May 2017.

World Stroke Congress 2016. What factors influence the provision of therapy to stroke survivors? Findings from an in-depth qualitative case study series in eight stroke units.

Conference Poster:
Clarke,D.J. Burton,L. Grenfell,K. Brkic,L.  Rodgers,H. Tyson,H. Drummond,A. Palmer, R. Prescott, M. Forster,A. Tyrrell.P. Why do stroke patients not receive the recommended amount of active therapy? Preliminary findings from a qualitative, case-study investigation in English stroke units. European Stroke Organisation Conference, Glasgow, April 17-19  2015

Conference abstract:
Clarke,D.J. Burton,L. Grenfell,K. Brkic,L.  Rodgers,H. Tyson,H. Drummond,A. Palmer, R. Prescott, M. Forster,A. Tyrrell.P. Why do stroke patients not receive the recommended amount of active therapy? Preliminary findings from a qualitative, case-study investigation in English stroke units. International Journal of Stroke. 10 (Suppl. 2); 2015; 77–438

Timescales

01/09/2014 – 28/02/2017

Further information

Grant applicants:

Professor Anne Forster, Professor Sarah Tyson, Professor Avril Drummond, Professor Helen Rodgers, Dr Rebecca Palmer, Mr Matt Prescott

Collaborators:

University of Manchester
University of Newcastle
University of Nottingham

For further information contact Professor Anne Forster  (a.forster@leeds.ac.uk ) 01274383441.

This summary presents independent research funded by the National Institute for Health and Care Research (NIHR) under its Research for Patient Benefit Programme: PB-PG-0213-30019 Why do stroke patients not receive the recommended amount of therapy? The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.