Every person is an individual: physical therapist clinical reasoning used in inpatient rehabilitation for walking assistive device prescription in patients with stroke and brain injury

Abstract

Purpose

A complete description of the process of physical therapy clinical reasoning for walking assistive devices in patients with stroke and brain injury has never been undertaken. Describing the clinical reasoning process used in post-acute inpatient rehabilitation is important to shed light on the clinical activities and factors used in practice, prevent device abandonment, and, inform entry-level clinical training. The two purposes were first, to describe the clinical reasoning process used during inpatient rehabilitation for walking assistive devices in patients with stroke and brain injury, and second, to determine whether clinical reasoning differed by two facility types and by diagnosis.

Methods

A mixed methods study of 67 participants in either an online survey or focus groups.

Results

A consistent and comprehensive method to determine the need and justification for a walking assistive device regardless of diagnosis or facility type was found. The clinical reasoning process included five primary factors, considered throughout the rehabilitation stay (safety, balance, cognition, strength, and function). The three therapist-related factors (experience/preference, training parameters, and use of objective tools), and seven patient-related factors (experience/preference, fluctuations, fear, age, diagnosis/comorbidities, discharge environment, and payer) individualized care. Definitions of the five primary factors were derived from participants’ responses.

Conclusions

Results from this study revealed complexity in the clinical reasoning process used in physical therapy practice to determine the best walking assistive device for patients with stroke and brain injury during inpatient rehabilitation. Information from this study can inform post-acute physical therapy practice and education, and may reduce device abandonment.

Implications for rehabilitation

• Clinical reasoning (CR) is a complex process in which a clinician must consider multiple factors, which requires non-linear and iterative thinking, and involves many people, making it shared among the patient, caregivers, and the healthcare team.

• Describing the actual CR process used by physiotherapists when prescribing a walking assistive device (WAD) will identify the factors considered, thus more accurately explain the process of care.

• Such a description could lead to better justification of rehabilitation for patients with stroke and brain injury, and furthermore, determine whether treatments are rendered consistently and when, if ever, divergent approaches occur.

• Better understanding of the CR process of WAD prescription may also reduce the possibility of device abandonment.

Keywords:

• Clinical reasoning
• walking assistive device
• physical therapy
• stroke
• brain injury

Disclosure statement

The authors report no conflicts of interest.