Date Presented 04/04/19
For clients with spinal-cord injury (SCI), OTs commonly apply electrical stimulation (ES) to facilitate upper-extremity activities. However, ES is inconsistently implemented in the clinic. In response to this practice gap, the current study conducted focus groups with senior OTs having experience using ES for clients with SCI. The goal was to establish a detailed outline for a thorough, clinician-friendly guide for using ES with the SCI population.
Primary Author and Speaker: Timothy Dionne
Additional Authors and Speakers: James Lenker
PURPOSE: For clients with spinal cord injury (SCI), occupational therapists commonly apply electrical stimulation (ES) to facilitate upper extremity activities (Popovic et al, 2011). However, ES is inconsistently implemented in clinical practice (Dionne & Lenker 2017). The goal of this study was to establish a detailed outline for a clinical intervention guideline for occupational therapists using ES with the SCI population.
DESIGN: Focus groups were conducted with senior occupational therapists having clinical experience using ES for clients with SCI. In all, 7 geographically dispersed therapists participated in one of two 1-hour focus groups. The qualitative findings from the focus groups were member-checked via follow-up survey involving both quantitative ratings and open-ended comments. Participants received a $150 honorarium in consideration for their time.
METHODS: Four discussion questions were posed to elicit group members’ experiences with existing clinical practice guidelines, challenges using ES with spinal cord injury, and suggestions for the key features needed to create a clinically feasible intervention guide for ES. The 26-item follow-up survey examined strength of agreement with overarching focus group themes, as well as a draft outline for a clinical intervention guideline for using ES with SCI.
RESULTS: Four themes emerged from focus group discussions: (a) clinical practice guidelines are rarely used; (b) research findings are often difficult to implement; (c) outcome measures are often burdensome to administer and lack sensitivity to functional changes; and (d) guidance for ES interventions should support a variety of clinical scenarios, including activity-specific selection of parameters and problem solving in cases where ES is not having the desired effect. Based on these themes, a detailed outline for an intervention guideline document was created for participant review and comment. Notably, the outline included a background section (which would include definitions of key terms, types of equipment, parameter settings, safety issues, and summary of research evidence) followed by separate sections detailing ES intervention strategies to achieve four common functional goals: sub-motor pain management, muscle strengthening, and functional activity. Each of these four goal-specific sections would describe patient indicators, visual pad placement, suggested stimulation parameters, guidelines and rationale for changing parameters, troubleshooting scenarios, outcome measures and burden of administration, beginner FAQ guide, and a quick reference guide for experienced practitioners. Participants responded positively to this structure: 9 of 14 elements were rated “essential” or “very important”. The remaining 5 items were rated by the majority to be “essential” or “very important”, with a minority of “somewhat important” ratings.
CONCLUSION: Among senior occupational therapists using ES to facilitate upper extremity activities for clients with SCI, there was clear consensus that a clinical intervention guideline is needed to address their daily practice needs. For such a guideline to be successful, four characteristics are needed: (a) clinically approachable synthesis of evidence, (b) activity-specific guidance for setting ES parameters, (c) flexible structure to carry-out creative patient-specific interventions, and (d) time-efficient guide as an everyday clinical reference. Once developed, such a guideline would support more consistent use of ES in OT treatment sessions and provide a basis for research protocols that could fortify the evidence base for this intervention.
References
Dionne, T., & Lenker, J. (2017). Investigating Occupational Therapy Using Upper-Extremity Electrical Stimulation in Patients With Spinal Cord Injury. American Journal of Occupational Therapy, 71(4_Supplement_1), 7111515253p1-7111515253p1.
Popovic, M., Kapadia, N., Zivanovic, V., Furlan, J., Cravern, B., & McGillivray, C. (2011). Functional electrical stimulation therapy versus only conventional rehabilitation for patients with subacute incomplete tetraplegia: A randomized clinical trial. Neurorehabilitation and Neural Repair, 25, 433–442. https://doi.org/10.1177/1545968310392924
