Understanding and supporting occupational therapists clinical decision-making for the management of upper limb post stoke sensory impairment

Background Stroke survivors form the largest client group seen by occupational therapists and a large proportion of these stroke survivors experience upper limb post-stroke sensory impairments (ULPSSI) which impact upper limb function and participation. This thesis addresses the clinical decision-making (CDM) of occupational therapists when managing ULPSSI. No appraised and synthesised summary of the research evidence related to the effectiveness of interventions for ULPSSI is available to support therapists’ CDM. Information on occupational therapists’ practice choices and decisions about managing ULPSSI and the survivors’ perspective on ULPSSI is scant. This information could support occupational therapists CDM when addressing ULPSSI and potentially improve stroke survivors’ outcomes. Thesis Aims This thesis aims to: 1. Synthesise the effectiveness of interventions for ULPSSI; 2. Explore how occupational therapists make and manage decisions regarding ULPSSI management; 3. Describe practice choices occupational therapists commonly make when managing ULPSSI and the sources of information they use to make these decisions; 4. Compare current assessment choices and intervention practices with recommendations from the research evidence and clinical practice guidelines; 5. Describe the stroke survivors’ perspective with regard to ULPSSI; and 6. Design and pilot an evidence-based, theory-driven educational intervention to support occupational therapists’ CDM when addressing ULPSSI. Thesis Methods Five distinct studies addressed the above aims. A Cochrane systematic review evaluated the evidence for the effectiveness of ULPSSI interventions. Twelve occupational therapists participated in a qualitative descriptive study exploring therapists’ practice choices and CDM related to ULPSSI. • Based on the qualitative study, a survey of 187 occupational therapists described therapists’ current practice choices regarding ULPSSI management and factors impacting CDM. A qualitative descriptive study using semi-structured interviews with 15 stroke survivors explored their experience of ULPSSI and the associated rehabilitation encounter. Finally, based on the need for training expressed by the survey participants, a one group pre- and post-test design, feasibility study evaluated the effect of a one day, theory-based educational intervention on 19 occupational therapists’ knowledge, perceived behavioural control, attitudes and intended behaviour regarding ULPSSI management, research utilisation, and shared decision-making. Workshop content incorporated information from the prior research studies forming this thesis. Results A Cochrane systematic review located 13 randomised controlled trials (RCTs) addressing ULPSSI interventions, with benefit shown from individual RCTs evaluating mirror therapy, a graded thermal stimulation, and intermittent pneumatic compression. Other single RCTs reporting statistically significant results for repetitive peripheral magnetic stimulation, early intensive task-orientated training and graded sensory rehabilitation were found but lacked sufficient data to determine effects sizes. Therapists in the qualitative study expressed considerable uncertainty when managing ULPSSI and focused on searching for knowledge especially from peers, reasoning by analogy, and trialling interventions to manage this uncertainty. Therapists described clinical and contextual factors influencing their CDM. The majority of survey respondents reported frequently assessing sensation but failed to use standardised measures. Just over half of the respondents frequently provided ULPSSI interventions, primarily providing non-specific sensory stimulation followed by compensatory strategies differing from those in recent research. Most therapists provided patient/caregiver safety education. Therapists cited lack of knowledge and skills, patients’ short length of stay, and lack of time as barriers to utilising ULPSSI interventions. Most therapists reported not being up-to-date with current research requesting continuing education to support practice. Survey respondents’ lack of awareness of interventions, believing that interventions for motor impairments addressed ULPSSI, and lack of time most commonly led to the decision not to use ULPSSI interventions. Clients’ cognitive status, ULPSSI severity, and time since stroke impacted therapists’ choice between compensatory or remedial approaches. Prior personal experience, trialling interventions, and consulting other therapists most commonly influenced specific intervention choice. Stroke survivors clearly articulated how ULPSSI impacted upper limb functional use. Survivors saw the recovery process extending years beyond current rehabilitation time frames and necessitating considerable work, though many survivors felt they were left on their own to address upper limb impairments. They reported little involvement in decision-making regarding their rehabilitation. A feasibility study of a theory-driven educational intervention demonstrated potential to significantly change therapists knowledge, attitudes and perceived behavioural control, and changes from current behaviour to intended behaviour regarding ULPSSI management, using research, and shared decision-making