To describe the barriers to implementation of evidence-based recommendations (EBRs) for stroke rehabilitation experienced by nurses, occupational therapists, physical therapists, physicians and hospital managers.
The Stroke Canada Optimization of Rehabilitation by Evidence project developed EBRs for arm and leg rehabilitation after stroke. Five Canadian stroke inpatient rehabilitation centers participated in a pilot implementation study. At each site, a clinician was identified as the "local facilitator" to promote the 6-month implementation. A research coordinator observed the process. Focus groups done at completion were analyzed thematically for barriers by two raters.
A total of 79 rehabilitation professionals (23 occupational therapists, 17 physical therapists, 23 nurses and 16 directors/managers) participated in 21 focus groups of three to six participants each. The most commonly noted barrier to implementation was lack of time followed by staffing issues, training/education, therapy selection and prioritization, equipment availability and team functioning/communication. There was variation in perceptions of barriers across stakeholders. Nurses noted more training and staffing issues and managers perceived fewer barriers than frontline clinicians.
Rehabilitation guideline developers should prioritize evidence for implementation and employ user-friendly language. Guideline implementation strategies must be extremely time efficient. Organizational approaches may be required to overcome the barriers. [Box: see text].
Exercise not only benefits physical and cardiovascular function in older adults with multiple chronic conditions but may also improve cognitive function. Peak HR, a physiological indicator for maximal effort, is the most common and practical means of establishing and monitoring exercise intensity. In particular, in the absence of graded maximal exercise test (GXT) results, age-predicted maximal HR values are typically used. Using individuals with stroke as a model for examining older adults with coexisting cardiovascular and neuromotor conditions, the purpose of this article was to examine the determinants associated with achieving age-predicted maximal HR on a GXT, with respect to neurological, cognitive, and lower limb function.
Forty-seven participants with stroke (age, 67 ± 7 yr; 4 ± 3 yr poststroke (mean ± SD)) performed GXT. The peak values for gas exchange, HR, and RPE were noted. Logistic regression analysis was performed to examine determinants (neurological impairment, leg motor impairment, Montreal Cognitive Assessment score, and walking ability) associated with the ability to achieve age-predicted maximal HR on the GXT.
V?O2peak was 16.5 ± 6 mL·kg·min. Fourteen (30%) participants achieved =100% of age-predicted maximal HR. Logistic regression modeling revealed that the ability to achieve this threshold was associated with less leg motor impairment (P = 0.02; odds ratio, 2.3) and higher cognitive scores (P = 0.048; odds ratio, 1.3).
These results suggest that noncardiopulmonary factors such as leg motor impairment and cognitive function are important contributors to achieving maximal effort during exercise tests. This study has important implications for poststroke exercise prescription, whereby training intensities that are based on peak HR from GXT may be underestimated among individuals with cognitive and physical impairments.
Participation in daily physical activity (PA) post-stroke has not previously been investigated as a possible explanatory variable of health-related quality of life (HRQL). The aims were 1) to determine the contribution of daily PA to the HRQL of individuals with chronic stroke and 2) to assess the relationship between the functional ability of these individuals to the amount of daily PA.
The amount of daily PA of forty adults with chronic stroke (mean age 66.5 +/- 9.6 years) was monitored using two measures. Accelerometers (Actical) were worn on the hip for three consecutive days in conjunction with a self-report questionnaire [the PA Scale for Individuals with Physical Disabilities (PASIPD)]. The daily physical activity was measured as the mean total accelerometer activity counts/day and the PASIPD scores as the metabolic equivalent (MET) hr/day. HRQL was assessed by the Physical and Mental composite scores of the Medical Outcomes Study Short-Form 36 (SF-36) in addition to the functional ability of the participants. Correlation and regression analyses were performed.
After controlling for the severity of the motor impairment, the amount of daily PA, as assessed by the PASIPD and accelerometers, was found to independently contribute to 10-12% of the variance of the Physical Composite Score of the SF-36. No significant relationship was found between PA and the Mental Composite Score of the SF-36.The functional ability of the participants was found to be correlated to the amount of daily PA (r = 0.33 - 0.67, p
Consistently low rates of physical activity are reported for older adults, and there is even lower participation if a chronic disease is present.
To explore the predictors of physical capacity and participation in older community-dwelling individuals living with multiple chronic diseases.
This was a descriptive cross-sectional investigation of physical capacity (physiological potential) and physical activity participation (recorded engagement in physical activity). Multiple regression and odds ratios were used to investigate determinants of physical capacity (6-min walk test) and physical activity participation (Physical Activity Scale for Individuals with Physical Disabilities Questionnaire; pedometer steps per day).
Two hundred community-dwelling ambulatory participants living with two or more chronic diseases were assessed. Sixty-five percent (65%) were women, and the mean age was 74 +/- 6 yr (range 65-90 yr). Mobility (timed up and go) was a consistent determinant across all three primary outcomes. For the 6-min walk test, determinants included mobility, BMI, grip strength, number of medications, leg strength, balance, and Chronic Disease Management Self-Efficacy Scale (r2 = 0.58; P = 0.000). The determinants for the self-reported participation measure (Physical Activity Scale for Individuals with Physical Disabilities Questionnaire) was mobility (r2 = 0.04; P = 0.007). For the mean daily pedometer steps, the determinants included mobility, body mass index (BMI), age, and Chronic Disease Management Self-Efficacy Scale (r2 = 0.27; P = 0.000). There were higher risks for inactivity associated with impairments compared with the presence of a chronic disease. In addition, more than a third of participants had sufficient physical capacity but did not meet minimal recommendations of physical activity.
This study suggests that it is easier to predict an individual's physical capacity than their actual physical participation.
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Many older adults rely on a manual wheelchair for mobility but typically receive little, if any, training on how to use their wheelchair effectively and independently. Standardized skill training is an effective intervention, but limited access to clinician trainers is a substantive barrier. Enhancing Participation in the Community by Improving Wheelchair Skills (EPIC Wheels) is a 1-month monitored home training program for improving mobility skills in older novice manual wheelchair users, integrating principles from andragogy and social cognitive theory. The purpose of this study is to determine whether feasibility indicators and primary clinical outcome measures of the EPIC Wheels program are sufficiently robust to justify conducting a subsequent multi-site randomized controlled trial.
A 2 × 2 factorial randomized controlled trial at two sites will compare improvement in wheelchair mobility skills between an EPIC Wheels treatment group and a computer-game control group, with additional wheelchair use introduced as a second factor. A total of 40 community-dwelling manual wheelchair users at least 55 years old and living in two Canadian metropolitan cities (n = 20 × 2) will be recruited. Feasibility indicators related to study process, resources, management, and treatment issues will be collected during data collection and at the end of the study period, and evaluated against proposed criteria. Clinical outcome measures will be collected at baseline (pre-randomization) and post-intervention. The primary clinical outcome measure is wheelchair skill capacity, as determined by the Wheelchair Skills Test, version 4.1. Secondary clinical outcome measures include wheelchair skill safety, satisfaction with performance, wheelchair confidence, life-space mobility, divided-attention, and health-related quality of life.
The EPIC Wheels training program offers several innovative features. The convenient, portable, economical, and adaptable tablet-based, home program model for wheelchair skills training has great potential for clinical uptake and opportunity for future enhancements. Theory-driven design can foster learning and adherence for older adults. Establishing the feasibility of the study protocol and estimating effect size for the primary clinical outcome measure will be used to develop a multi-site randomized controlled trial to test the guiding hypotheses.
Participating in regular physical activity is an important part of healthy aging. There is an increased risk for inactivity associated with aging and the risk becomes greater for adults who have a chronic disease. However, there is limited information on current physical activity levels for older adults and even less for those with chronic diseases.
Our primary objective was to determine the proportion of older adults who achieved a recommended amount of weekly physical activity (>or=1,000 kcal/week). The secondary objectives were to identify variables associated with meeting guideline leisure-time physical activity (LTPA), and to describe the type of physical activities that respondents reported across different chronic diseases.
In this study we used the Canadian Community Health Survey Cycle 1.1 (2000/2001) to report LTPA for adults aged 65 years and older. This was a population-based self-report telephone survey. We used univariate logistic regression to provide odds ratios to determine differences in activity and the likelihood of meeting guideline recommendations.
For adults over 65 years of age with no chronic diseases, 30% reported meeting guideline LTPA, while only 23% met the recommendations if they had one or more chronic diseases. Factors associated with achieving the guideline amount of physical activity included a higher level of education, higher income and moderate alcohol consumption. Likelihood for not achieving the recommended level of LTPA included low BMI, pain and the presence of mobility and dexterity problems. Walking, gardening and home exercises were the three most frequent types of reported physical activities.
This study provides the most recent evidence to suggest that older Canadians are not active enough and this is accentuated if a chronic disease is present. It is important to develop community-based programs to facilitate LTPA, in particular for older people with a chronic disease.
Physical inactivity contributes to atherosclerotic processes, which manifest as increased arterial stiffness. Arterial stiffness is associated with myocardial demand and coronary perfusion and is a risk factor for stroke and other adverse cardiac outcomes. Poststroke mobility limitations often lead to physical inactivity and sedentary behaviors. This exploratory study aimed to identify functional correlates, reflective of daily physical activity levels, with arterial stiffness in community-dwelling individuals >1 year poststroke.
Carotid-femoral pulse wave velocity (cfPWV) was measured in 35 participants (65% men; mean ± SD age 66.9 ± 6.9 years; median time poststroke 3.7 years). Multivariable regression analyses examined the relationships between cfPWV and factors associated with daily physical activity: aerobic capacity (VO2 peak), gait speed, and balance ability (Berg Balance Scale). Age and the use of antihypertensive medications, known to be associated with pulse wave velocity, were also included in the model.
Mean cfPWV was 11.2 ± 2.4 m/s. VO2 peak and age were correlated with cfPWV (r = -0.45 [P = .006] and r = 0.46 [P = .004], respectively). In the multivariable regression analyses, age and the use of antihypertensive medication accounted for 20.4% of the variance of cfPWV, and the addition of VO2 peak explained an additional 4.5% of the variance (R2 = 0.249).
We found that arterial stiffness is elevated in community-dwelling, ambulatory individuals with stroke relative to healthy people. Multivariable regression analysis suggests that aerobic capacity (VO2 peak) may contribute to the variance of cfPWV after accounting for the effects of age and medication use. Whether intense risk modification and augmented physical activity will improve arterial stiffness in this population remains to be determined.
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