#PEDroTacklesBarriers to evidence-based physiotherapy: Success stories. Part 1 – individual-clinician perspective

The #PEDroTacklesBarriers to evidence-based physiotherapy campaign shared tips on tackling the four biggest barriers to evidence-based physiotherapy – lack of time, language, lack of access, and lack of statistical skills. The final two months of the campaign will showcase success stories of how physiotherapists have overcome different barriers to ensure patients receive evidence-based care.

This month we cover success stories from an individual clinician-perspective in the fields of stroke rehabilitation and oncology.

Kate Scrivener (consultant physiotherapist Sydney, Australia) presents how implementing guidelines on stroke rehabilitation helped her patient (Sharon) gain significant function after a stroke.

The context: Sharon was a stroke survivor in her 40s who was initially very disabled and discharged to an aged care facility. Fortunately, the facility had a rehabilitation centre on site.

The evidence: Evidence-based clinical practice guidelines on stroke rehabilitation recommend high-intensity, intensive and task specific practice.

The barriers to implementation: Sharon had several impairments, including motor planning issues and severe spasticity, which made implementing guideline recommendations very challenging. As a result, she initially needed two people to stand and couldn’t walk.

The solution: With a lot of problem solving and trial and error, Kate and her team found a way to ensure Sharon performed intensive, task specific practice. Key strategies included using whole (vs. part) task practice linked to meaningful daily activities to overcome the motor planning issue and using a zimmer split to ensure her knee stayed extended during standing and walking practice.

The outcomes: Between 6 and 12 months after her stroke, Sharon transitioned from walking with an aid, to without, and then to walking outside the facility. She eventually left the aged-care facility and now lives on her own in supported accommodation.

Rohit Raykar (first year graduate physiotherapy, Sydney Australia) presents how evidence increased a cancer survivor’s motivation to exercise.

The context: Rohit was a student on placement and treating a woman in her 60s who had ovarian cancer. Due to her chemotherapy, she was suffering from severe fatigue.

The barriers to implementation: The patient had a hysterectomy to remove the ovaries affected by cancer and Rohit was seeing her to encourage her to exercise post-operatively. The patient was very reluctant to engage in an exercise program due to the fatigue and past negative experiences of exercising when fatigued.

The evidence: Rohit had been told exercise was beneficial for people with cancer but wanted to see the evidence for himself. Using his searching and appraisal skills, he found a high-quality systematic review on the effects of exercise for people with cancer. The review showed that exercise has numerous benefits including reducing weight gain, cognitive dysfunction, lymphedema, and the risk of cancer relapse and secondary cancers just to name a few.

The solution: Rohit communicated this evidence to his patient at the next session and she was astounded by the benefits. Rohit reassured her that any amount of exercise was a good starting point and that she could gradually increase this over time.

The outcomes: Rohit referred the patient to an outpatient exercise physiologist where she was able to gradually increase her activity levels over time.

Ashleigh (private practice physiotherapist in Toowoomba, Australia) presents how using guideline recommendations on stroke rehabilitation to modify her exercise program helped her patient (Wendy) improve her walking after a stroke. Wendy also shared her perspective on the changes to the exercise program and her improvement.

The context: Wendy is in her 60s and had a stroke 5 years ago. She was walking 1km per day after a few years of rehabilitation but wanted to get back to 5km like before the stroke.

The problem: Ashleigh noticed Wendy had plateaued with her improvements after a few years of rehabilitation. Wendy was mostly doing hydrotherapy and doing only 1-3 sets of exercises that were not task specific (e.g. leg extensions, sit to stand). Ashleigh decided to look for evidence to see if there’s anything she could do differently.

The evidence: The most recent evidence-based clinical practice guideline on stroke rehabilitation recommends high-intensity, intensive and task specific practice. Ashleigh found the guideline easy to use to help adapt Wendy’s program to have more task-specific exercises relevant to her goals.

The barriers to implementation: Ashleigh suggested Wendy needed to do more land-based training instead of hydrotherapy. However, Wendy enjoyed hydrotherapy and had made a lot of new friends there. There was a need to find a balance between what Wendy wanted to do, and what she needed to do to reach her goals.

The solution: Wendy was allowed to continue hydrotherapy but also had to perform high-repetition practice of land-based exercises which were more specific to her goals of walking more (e.g. 400-600 repetitions of moving the leg faster during the swing phase of gait).

The outcomes: Walking speed improved from 0.8m/s to 1.3m/s over the course of a few months and walking distance improved from 1km to 2km per day.

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