Title: Why do stroke patients not receive the recommended amount of therapy?
Funder: Department of Health (England)

Abstract: Stroke is the commonest cause of disability in England with more than 110,000 people having a new stroke each year12. Stroke can result in impairments affecting upper and lower limb function, cognition, vision, swallowing and speech and language. Assessment and treatment by multidisciplinary teams in stroke units improves patient outcomes1. A fundamental element of stroke unit care is assessment and patient specific therapy provided by physiotherapists (PTs), occupational therapists (OTs) and speech and language therapists (SALTs), with increasing evidence demonstrating the effectiveness of a range of interventions and that increased intensity is better5-7. Research in the United States, United Kingdom (UK) and Europe has consistently identified that stroke patients can spend long periods of time inactive and that time in receipt of therapy is often low2-4,8-10. Research in four European stroke units demonstrated that patients spent more than 72% of their time in non-therapeutic activity. UK patients spent less time in therapy (1 hour per day) when compared to patients in Germany and Belgium (~2 hours) and Switzerland (~3 hours); this despite available therapist time being higher in the UK4,9-10. This evidence contributed to the UK quality standard and National Clinical Guideline recommendations that forty-five minutes of each active therapy be provided on at least five days a week to patients if the therapy is appropriate and the patient can tolerate it11.. National Sentinel Stroke Audit data identified that this standard was not achieved for most patients13-14. Between a third (for physiotherapy) and two thirds of patients (for speech and language therapy) were not considered appropriate for this amount of therapy in the first twenty days post-stroke; these findings raised serious questions about why the standard was not being met. Existing research on patient and therapy activity in stroke units has relied almost exclusively on behavioural mapping techniques (recording actions at timed intervals)3-4,9-10. This has contributed to our understanding of therapy content and activity, but has not explored how therapists understand and manage their practice, or explained factors influencing therapists' decision making regarding therapy provision. Whether the current standard is appropriate for stroke patients with differing levels of impairment is unknown. Patients’ views on the therapy they received have also received little attention15. Our research will take an ethnographic approach to enable us to gain greater understanding and insights into therapy provision, how stroke unit staff interpret the forty-five minute standard and their clinical decision making about therapy provision. A multi-site case study design16 will be used in six stroke units, which the national audit indicates provide a divergent range of compliance with the forty-five minute standard. Modified process mapping17 will be used to establish a framework of patients’ therapy experiences. A process mapping meeting will identify what stroke unit teams consider occurs to all patients post-stroke, this will be followed by retrospective case notes review to compare the recorded therapy journey for five patients with mild, moderate and severe post-stroke impairment. Observations of practice for up to twelve weeks will follow in each unit, and documentary analysis will add context, depth and detail to process mapping data. Interviews with those involved in managing, providing, supporting and receiving therapy will provide for exploration of observed practice, clinical decision making and identify barriers and facilitators to therapy provision. We anticipate interviewing fifteen members of staff and 10 patients and carers (jointly) in each unit. Findings will be summarised and following three iterative expert seminars, recommendations will be made to inform development of implementation strategies to optimise therapy provision for in-patients after stroke.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: STROKE