Upper Limb Rehabilitation following Brain Injury: Complex,Multifaceted and Challenging

Abstract

Neurological upper limb rehabilitation is influenced by a diverse range of factors within the practice environment. Clinical reasoning is the means by which occupational therapists make sense of such factors in order to make decisions that promote individual occupational goals. However, changes in neurological knowledge, the limited availability of research evidence and the need to maintain a focus on client-centred practice in rehabilitation settings are factors that contribute to clinical reasoning uncertainty. A protocol that aims to structure clinical decision making in the light of such diversity has been developed to guide upper limb rehabilitation after brain injury.

As part of a larger study designed to determine the conceptual usefulness of the protocol, 11 expert occupational therapists were asked to describe the challenges that they faced in their practice. Four themes emerged from the focus group data, described in terms of (a) the complexity of domain-specific knowledge and the paucity of evidence for practice; (b) the diversity of upper limb presentation; (c) the need to balance client-centred practice and professional duty of care; and (d) uncertainty regarding clinical decision making.

Although the data supported the participants' expertise, they nevertheless articulated a need for guidance in structuring the clinical reasoning and decision making underlying neurological upper limb rehabilitation. Various strategies are described that can be used to guide clinical reasoning, including research evidence, the differentiation of situations requiring the application of artistic or scientific knowledge, reflective and reflexive practice, and the application of system aids such as decision-making protocols.