In search of Kipling’s six honest serving men in upper limb rehabilitation: within participant case-crossover experiment nested within a web-based questionnaire

Abstract

Purpose

In search of Kipling’s six honest serving men in upper limb rehabilitation after stroke, we sought to investigate clinicians’ perspective of when and where to begin therapy, how much and what therapy to provide, and who and why (or not) to provide therapy.

Materials & methods: Within-participant case cross-over experiments were nested within an anonymous web-based questionnaire (21 questions, three cases). Graph theory-based voting to produce ranked ordered lists and mixed-effect logistic regression were performed.

Results

In total, 225 Australian stroke clinicians responded: 53% occupational therapists, 61% working in acute/inpatient stroke setting. Most respondents indicated they did not have a protocol/expectation regarding when (62%), how much (84%) or what (60%) therapy to provide in their setting. Respondents ranked 24-h to 7-days post-stroke as the optimal time to commence therapy, and 30- to 60-min per day as the optimal dose to provide. Within-participant experiments demonstrated that greater motor recovery as time progressed increased the odds of offering therapy, while lack of motor recovery, shoulder pain, neurological decline and sole therapist reduced the odds.

Conclusion

We need to develop an evidence base concerning Kipling’s six honest serving men and equip clinicians with clinical decision-making skills aligned with this focus.

IMPLICATIONS FOR REHABILITATION

• Most clinicians did not have access to a protocol / clinical pathway which defines when, how much and what upper limb therapy to provide after stroke, which may be improved by providing individual clinicians with organisational support to make therapy decisions.

• To improve the personalisation of upper limb rehabilitation in clinical practice, we need to understand when and where after stroke to begin therapy, how much and what therapy to provide, as well as who and why (clinical decision-making) to provide therapy.

• Clinicians perceive clinical trials as successful if the therapy can demonstrate recovery that is greater than a minimal clinical important difference (MCID).

Keywords:

• Stroke rehabilitation
• upper extremity
• physiotherapy
• occupational therapy
• early intervention

Ethical approval and consent to participate

Alfred Hospital Ethics Committee Project 409/18.

Acknowledgements

We thank all individuals who participated in our pilot and provided valuable feedback. We express our gratitude to all respondents who generously took the time to participate in this study and people who shared the invitation to participate throughout their professional networks. The Florey Institute of Neuroscience and Mental Health acknowledges the strong support from the Victorian Government and in particular funding from the Operational Infrastructure Support Grant.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Available on reasonable request to KSH or NAL by a qualified researcher.

Additional information

Funding

This work was funded by an Alfred Hospital Small Project Grant awarded to LJ, KSH, NAL, AH, GC. Person-support funding was received by KSH [GNT1088449] and LJ [GNT1114522] from the National Health and Medical Research Council (NHMRC) of Australia; NAL [GNT102055] from the Heart Foundation of Australia.