Managing Mobility After Stroke: Education Of Physiotherapists, Physiotherapy Students And Patients

197 Pages·2015·8.85 MB·English

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MANAGING MOBILITY AFTER STROKE: EDUCATION OF
PHYSIOTHERAPISTS, PHYSIOTHERAPY STUDENTS AND PATIENTS

Elisabeth Preston, MHlthSc (USyd)

Thesis presented for the degree of

Doctor of Philosophy

Faculty of Health Sciences

The University of Sydney

2015
This is to certify that the thesis entitled “Managing mobility after stroke:
Education of physiotherapists, physiotherapy students and patients” submitted
by Elisabeth Preston in fulfilment of the requirements for the degree of Doctor of
Philosophy is in a form ready for examination.

Signed

Date 3rd June 2015

Dr Louise Ada
School of Physiotherapy,
Faculty of Health Sciences,
The University of Sydney.

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TABLE OF CONTENTS

PAGE

LIST OF FIGURES .................................................................................................... iv

LIST OF TABLES ....................................................................................................... v

ABSTRACT ................................................................................................................ vi

STATEMENT OF AUTHORSHIP .......................................................................... viii

PUBLICATIONS AND PRESENTATIONS ............................................................. ix

ACKNOWLEDGMENTS .......................................................................................... xi

CHAPTER 1: INTRODUCTION ......................................................................... 1

Rationale of the project ........................................................ 2

Increasing knowledge for clinicians about
prognosis of walking after stroke ....................................... 6

Increasing skill of physiotherapy students in
training walking after stroke .............................................. 12

Increasing physical activity in people after stroke ............. 19

Outline of the thesis ........................................................... 32

CHAPTER 2: STUDY 1: PROBABILITY OF NON-AMBULATORY
PATIENTS AFTER STROKE REGAINING
INDEPENDENT WALKING ..................................................... 34

Introduction ........................................................................ 35

Method ............................................................................... 36

Results ................................................................................ 40

Discussion .......................................................................... 51

CHAPTER 3: STUDY 2: PHYSIOTHERAPY ESKILLS TRAINING
ONLINE ...................................................................................... 58

Introduction ........................................................................ 59

Method ............................................................................... 62

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Results ................................................................................ 65

Discussion .......................................................................... 69

CHAPTER 4: STUDY 3: PROMOTING PHYSICAL ACTIVITY
AFTER STROKE VIA SELF-MANAGEMENT: A
FEASIBILITY STUDY .............................................................. 73

Introduction ........................................................................ 74

Method ............................................................................... 77

Results ................................................................................ 81

Discussion .......................................................................... 89

CHAPTER 5: DISCUSSION ............................................................................. 95

Summary of findings .......................................................... 96

Comparison with recent literature ...................................... 98

Implications for future research ....................................... 103

Implications for clinical practice ..................................... 107

Limitations of the studies ................................................ 109

Conclusion ....................................................................... 110

REFERENCES ......................................................................................................... 112

APPENDIX A ETHICAL CONSIDERATIONS .............................................. 127

APPENDIX B MEASUREMENT .................................................................... 145

APPENDIX C EXPERIMENTAL PROCEDURES ......................................... 157

APPENDIX D INDIVIDUAL PARTICIPANT DATA STUDY 2 AND
STUDY 3 .................................................................................. 165

APPENDIX E STATISTICS ............................................................................ 178

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LIST OF FIGURES
Figure 1.1 Information-motivation-behavioural skills model ......................... 24

Figure 1.2 Theory of planned behaviour ......................................................... 25

Figure 2.1 Inclusion criteria ............................................................................ 37

Figure 2.2 Flow of studies through the review ............................................... 41

Figure 2.3 Probability (95% CI) of patients after stroke who are
initially non-ambulatory regaining independent walking at
3 months when managed in a rehabilitation unit by
pooling data from 9 studies (n=1373) ............................................ 48

Figure 2.4 Probability (95% CI) of patients after stroke who are
initially non-ambulatory regaining independent walking at
6 months when managed in a rehabilitation unit by
pooling data from 3 studies (n=444) .............................................. 48

Figure 2.5 Probability (95% CI) of patients after stroke who are
initially non-ambulatory regaining independent walking at
3 months when managed in an acute unit by pooling data
from 5 studies (n=634) ................................................................... 50

Figure 2.6 Probability (95% CI) of patients after stroke who are
initially non-ambulatory regaining independent walking at
6 months when managed in a rehabilitation unit by
pooling data from 2 studies (n=405) .............................................. 50

Figure 2.7 The probability of patients after stroke who are initially
non-ambulatory regaining independent walking and
managed in a rehabilitation unit and an acute unit ........................ 52

Figure 3.1 The Physiotherapy eSkills Training Online menu page
where students can select the specific practical skill. .................... 60

Figure 3.2 The webpage for an individual practical skill from The
Physiotherapy eSkills Training Online resource,
highlighting the demonstration video, and including menu
buttons for the Aim and Rationale, Equipment, Key
Points, Common Errors, Progression and Variety, and a
Downloadable PDF. ....................................................................... 60

Figure 3.3 Design and flow of participants through the trial .......................... 66

Figure 4.1 Flow of participants through the trial ............................................ 82

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LIST OF TABLES

Table 1.1 Summary of prognostic studies of non-ambulatory stroke
survivors on walking outcomes ....................................................... 7

Table 1.2 Summary of prognostic studies of ambulatory and non-
ambulatory stroke survivors on walking outcomes ......................... 9

Table 1.3 Definitions of 26 behaviour change techniques and
illustrative theoretical frameworks ................................................ 27

Table 2.1 Quality of included studies ............................................................ 42

Table 2.2 Summary of included studies ......................................................... 43

Table 2.3 Summary of excluded studies ........................................................ 45

Table 3.1 Characteristics of participants ........................................................ 67

Table 3.2 Mean (SD) of practical examination marks for each group
and difference (95% CI) between groups ...................................... 68

Table 4.1 Characteristics of participants ........................................................ 83

Table 4.2 Feasibility and adverse events ....................................................... 84

Table 4.3 Participants’ perception, mean (SD) .............................................. 85

Table 4.4 Number and % of participants completing 30 min/day of
moderate activity for each group, and mean (95% CI) risk
difference ....................................................................................... 87

Table 4.5 Mean (SD) outcome for each group, mean (SD) within-
group difference and mean (95% CI) between-group
difference ....................................................................................... 88

Table 5.1 Summary of studies which examine predictive factors for
outcome after stroke .................................................................... 104

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ABSTRACT

Stroke is a major cause of disability worldwide. Poor mobility, specifically the
inability to walk and low levels of physical activity, as a result of stroke, leads to
decreased participation in the community, reduced quality of life and increased risk
of recurrent stroke. The aim of this thesis, therefore, was to enhance mobility
outcomes after stroke by facilitating education of physiotherapists, physiotherapy
students and stroke survivors. Specifically, this thesis aimed to increase knowledge
of physiotherapists about walking outcome after stroke; increase physiotherapy
student skills in training walking after stroke; and finally increase physical activity in
stroke survivors via self-management.

Study 1 was a systematic review and meta-analysis of studies which examined the
likelihood of regaining independent walking in stroke survivors who were initially
non-ambulant. It determined the likelihood of non-ambulatory stroke survivors
regaining independent walking at 3-months, 6-months and 12-months, in both acute
and rehabilitation units. This study found that 60% of initially non-ambulatory
stroke survivors managed in a rehabilitation unit regained independent walking at 3
months and this increased to 65% by 6 months after stroke. In an acute unit only
39% of initially non-ambulatory stroke survivors regained independent walking at 3-
months. This increased to 69% at 6 months after stroke.

Study 2 was a controlled study examining the effectiveness of e-learning in teaching
physiotherapy students the practical skills related to training walking after stroke. It
compared e-learning as an adjunct to usual teaching, with usual teaching alone. The
results indicated that e-learning improved physiotherapy students’ ability to
implement practical skills effectively, as well as their ability to provide a rationale
for the practical skill. Students also perceived the e-learning resource to be very
useful for learning the practical skills related to rehabilitation of walking after stroke.

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Study 3 was a single-group Phase I feasibility study. It investigated whether a 3-
month, home-based, self-management program was feasible and potentially effective
for increasing physical activity after mild stroke. Self-management was found to be
a feasible strategy for increasing physical activity. The results also suggested that
self-management can increase the proportion of participants who complete 30
min/day of moderate activity, as well as the average amount of time spent in
moderate physical activity/day. Self-management can also improve self-efficacy for
exercise, walking ability, participation and quality of life, but cardiovascular risks
were unchanged.

A majority of people regain the ability to walk after stroke, but there is still scope to
improve this outcome by implementing effective walking interventions, and to
further enhance mobility by increasing the amount of physical activity completed by
stroke survivors. Physiotherapists should utilise the increased knowledge regarding
prognosis of walking after stroke to provide early and accurate education and goal
setting for patients, and to more effectively allocate resources during stroke
rehabilitation. Physiotherapists working in higher education should consider the use
of e-learning as an adjunct to usual teaching, to enhance learning of the practical
skills related to training walking after stroke in physiotherapy students. Finally,
educating and empowering stroke survivors themselves, via self-management, may
be a promising strategy for increasing physical activity, and optimising mobility after
stroke, therefore should be further investigated.
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I, ELISABETH PRESTON, hereby declare that the work contained within this
thesis is my own and has not been submitted to any other university or institution as
a part or a whole requirement for any higher degree.

In addition, ethical approval from the University of Sydney Human Ethics
Committee was granted for the second and third studies presented in this thesis.
Participants were required to read a participant information document and informed
consent was gained prior to data collection.

Name Elisabeth Preston

Signed

Date 3rd June 2015

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