Abstract
Evidence-based approaches to upper extremity motor recovery emphasize the use of repetitive-task practice strategies incorporating motor learning principles. These approaches, however, are not consistently implemented in practice. Understanding factors related to the practitioner, the client, the practice setting, and the therapeutic interaction that influence a practitioners' clinical decision making reveals strategies that may help decrease this research-to-practice gap.
Primary Author and Speaker: Shannon L. Scott
Additional Authors and Speakers: Morgan Sanei
Contributing Authors: Leora Comis, Rafael Jimenez Silva, and Smita Jha
Approximately 70% of individuals who experience a stroke sustain upper extremity (UE) hemiparesis (Nakayama et al., 1994); 66% experience continued loss of functional use of the affected side even after rehabilitation (Broeks et al., 1999). Contemporary evidence based approaches to UE motor recovery include interventions such as constraint induced movement therapy and modified versions, mirror therapy, mental practice, and action observation (Nilsen et al., 2015). However, studies of occupational therapy (OT) practice reveal that evidence-based approaches are not consistently used (Juckett et al., 2020) and therefore survivors are not receiving services based on best practice. It is therefore important to understand what factors influence practitioners' clinical reasoning and choice of intervention(s) when addressing UE recovery after stroke as this may provide insight into strategies to decrease the research to practice gap. The purpose of this study was to explore practitioners' practice and reasoning when addressing UE recovery with stroke survivors to 1) understand the factors that guide their clinical decisions and 2) understand how decisions are informed by theory and evidence. This was a phenomenological qualitative study conducted with a convenience sample of six occupational therapists. Participants held a variety of terminal OT degrees and had varying levels of experience working with stroke survivors across different practice settings. Participants were recruited through professional contacts, AOTA CommunOT, and professional Facebook groups. Participants were required to have worked at least one year within the last five years with stroke survivors in any practice setting. Audio-recorded semi-structured interviews were completed with follow-up interviews conducted after 3-4 weeks with all participants. Questions were developed based on literature review, expert input, and piloting. Interview transcripts were descriptively coded and categorized in an iterative process until themes and sub-themes emerged. Researcher triangulation, member checking, and peer debriefing were conducted to enhance trustworthiness of the results. Four themes, each with 3-4 subthemes, emerged as factors that contribute to practitioners' reasoning when addressing UE recovery after stroke. These factors, consistent with the Ecological Model of Professional Reasoning (Boyt Schell, 2018), relate to the practitioner, the client, the practice environment and context, and the therapeutic interaction. Within each theme, factors that appear to have the strongest influence include the practitioners' acquired knowledge and skills, the clients' functional status, the practice culture, and the application of knowledge and skills respectively. Use of theory and evidence to guide reasoning seemed to be influenced by practitioners' years of experience, personal beliefs and skills, and type of terminal OT degree. Of significance, the practice culture appeared to have a significant influence in either supporting or creating barriers to practitioners' use of contemporary evidence based approaches. The results of this study suggest that in order to lessen the research to practice gap in use of best practice when addressing UE recovery after stroke, strategies at multiple levels are needed. There are implications for; entry level education, as novice practitioners rely heavily on recent learning and resources; personal responsibility and professional development; mentoring; survivor empowerment; non-traditional practice patterns; and advocacy. Implementing strategies to address this research to practice gap will enable practitioners to demonstrate the value of their services while also ensuring survivors have the best chance of UE recovery after stroke
Nakayama, H., Jergensen, H.S., Raaschou, H. O., & Olsen, T. S. (1994). Recovery of upper extremity function in stroke patients: The Copenhagen Stroke Study. Archives of Physical Medicine and Rehabilitation, 75, 394-398. https://doi.org/10.1016/0003-9993(94)90161-9
Broeks, J. G., Lankhorst, G. J., Rumping, K., & Prevo, A. J. (1999). The longterm outcome of arm function after stroke: Results of a followup study. Disability and Rehabilitation. 21, 357-364. https://doi.org/10.1080/096382899297459
Nilsen, D. M., Gillen, G., Geller, D., Hreha, K., Osei, E., & Saleem, G. T. (2015). Effectiveness of interventions to improve occupational performance of people with motor impairments after stroke: An evidence-based review. American Journal of Occupational Therapy, 69, 6901180030. http://dx.doi.org/10.5014/ajot.2015.011965
Juckett, L. A., Wengerd, L. R., Faieta, J., & Griffin, C. E. (2020). Evidence-based practice implementation in stroke rehabilitation: A scoping review of barriers and facilitators. American Journal of Occupational Therapy, 74, 7401205050. https://doi.org/10.5014/ajot.2020.035485