| Author: | Wong, Ngai Kiu |
| Title: | The impact of an international classification of functioning, disability and health (ICF)-based post-stroke rehabilitation program in promoting patients’ community reintegration |
| Advisors: | Chan, Chetwyn (RS) |
| Degree: | Ph.D. |
| Year: | 2023 |
| Subject: | Cerebrovascular disease -- Patients -- Rehabilitation Cerebrovascular disease -- Patients -- Care Hong Kong Polytechnic University -- Dissertations |
| Department: | Department of Rehabilitation Sciences |
| Pages: | xv, 134 pages : color illustrations |
| Language: | English |
| Abstract: | This thesis investigates the application of the International Classification of Functioning, Disability and Health (ICF) model in the design of a new post-stroke rehabilitation program (i.e., the ICF-PSRP) to promote community reintegration of post-stroke patients. The first part of the thesis presents a narrative review that examined the extent to which the ICF model has been applied in post-stroke patient assessments and rehabilitation interventions. The second part reports a qualitative study that explored how use of the ICF model influenced the rehabilitation processes, program delivery and outcomes of the ICF-PSRP. The third part presents an outcome study that examined the effectiveness of the ICF-PSRP in enhancing outcomes in a group of post-stroke patients. In the narrative review, the design and delivery of rehabilitation for post-stroke patients in the ICF model was explored as stipulated in the UK Stroke Guideline (hereinafter “the Guideline”). In the 36 ICF studies related to post-stroke rehabilitation, 151 clinical assessments were identified and these addressed more than two thirds of the topics covered by the Guideline. However, only four ICF-related clinical assessments had exact content matches to the Guideline’s cognition, mobility (i.e., weakness and ataxia) and sensation topics. More than two thirds of the ICF-related assessments were categorized into either the Activity domain alone or the Activity and Participation (ICF-A&P) domains with no clear distinction. Environmental factors (EF) were also not emphasized in the ICF-related assessments. The Participation domain and EF comprise the core content required to promote independent living and community integration after stroke, so emphasis should be placed on these domains. Furthermore, 14 ICF-related post-stroke interventions were found in 25 studies, addressing only approximately one third of the intervention topics covered by the Guideline. Nine of these 14 ICF-related interventions showed exact content matches to those in the Guideline, such as arm function, communication (i.e., aphasia and activities of daily living), extended activities of daily living and mobility (i.e., balance). This narrow scope highlights the need for researchers to explore, design and test novel post-stroke interventions. In addition, these interventions did not comply with the ICF-based neurorehabilitation process, as they did not incorporate goal-setting for intervention personalization. It is recommended that future studies of ICF-based interventions incorporate the Participation domain and EF by incorporating goal-setting into interventions. In the qualitative study, feedback from patients and other stakeholders was collected on the extent to which the use of the ICF model influenced the rehabilitation processes, program delivery and outcomes of the ICF-PSRP. Thirty-three patients participated in intake and pre-discharge semi-structured interviews. Three case therapists and five clinical experts conducted a one-time semi-structured interview. The goals set by the patients and their caregivers showed a broadening of treatment concerns from intake to pre-discharge interviews. Their concerns focused on stroke problems related to the Body Function (ICF-BF) and Activity domains and on problems related to the Participation domain and EF. Patient–therapist interactions increased from intake to pre-discharge during the goal-setting and evaluation processes. The participants reflected on the importance of goal-setting, particularly when these goals guided the design and delivery of treatment content. The therapists and experts interviewed emphasized the importance of promoting the ICF concepts to patients, beginning with the goal-setting process. Tailoring treatment content to these goals further enhanced the patients’ exposure to their living environments and thus helped to prepare them for reintegration into the community. Future studies should therefore further explore how patient–therapist interactions, exposure to EF and personalized interventions maximize the benefits of applying the ICF model to the community reintegration of post-stroke patients. The quantitative study tested the impact of the ICF-PSRP in enhancing community reintegration of post-stroke patients. Fifty-two post-stroke patients who joined the ICF-PSRP were recruited. The ICF-PSRP uses a multidisciplinary approach of physiotherapy, occupational therapy and speech therapy to improve patient performance in the ICF-A&P domains. A quasi-experimental within-subjects design was used to assess the patients’ primary outcomes in the ICF-BF domain (e.g., cognition and muscle strength) and in the ICF-A&P domains (e.g., mobility and instrumental activities of daily living) and secondary outcomes based on their perceived improvements in ability (e.g., quality of life). Comparisons of primary outcomes at intake with those at pre-discharge showed significant improvements in areas under the ICF-BF and ICF-A&P domains, with the exception of cognitive function under the ICF-BF domain. Path analyses were conducted to test the relationships between improvements in the ICF-BF and ICF-A&P domains to enable the prediction of secondary outcomes. One important finding was that the ICP-BF domain (i.e., improvements in expressive and receptive functions) was mediated by the ICF-A&P domains (i.e., improvements in everyday language) and predicted the secondary outcome of satisfaction with quality of life related to language. Another important finding was that the ICF-BF domain (i.e., improvements in upper extremity function) was mediated by the ICF-A&P domains (i.e., improvements in lower extremity mobility) and predicted the secondary outcome of satisfaction with quality of life related to work and productivity. Other less important findings were that the ICF-BF domain was mediated by some ICF-A&P domains and that that there were some reciprocal relationships, i.e., some ICF-A&P domains were mediated by the ICF-BF domain. Content analyses helped explain the relationships between the ICF-BF and ICF-A&P domains, showing that most treatment program content combined both types of intervention modules. The combined or integrated approach involved patients engaged in both types of training either within or across treatment sessions. These integrated arrangements are common in lower extremity training and language-related training. Moreover, these arrangements reflected that the content of the treatment was largely personalized with respect to the patients’ goals set at the start of the program. However, the results of upper extremity training showed that the integrated approach tended to shift to the ICF-BF domain in the latter part of the program. This may be because the recovery period required for the upper extremities is quite long, whereas the duration of the ICF-PSRP was limited to 8–12 weeks. Future studies should use a randomized controlled trial design to explore the efficacy of the ICF-PSRP for post-stroke patients. In summary, the ICF-PSRP is effective in promoting the functional recovery of post-stroke patients to enable their life role resumption and community reintegration. The findings of this thesis reveal several features and advantages unique to the design of rehabilitation programs based on the ICF model, namely goal-setting conducted by patients and case therapists, personalized treatment content, interventions based on the ICF-BF or ICF-A&P domains and integration of ICF-BF and ICF-A&P intervention modules. The main limitations of this study include its having been single-group design and not a randomized controlled trial, not having covered all ICF components and not having explored the relationship between all ICF domains in post-stroke rehabilitation. |
| Rights: | All rights reserved |
| Access: | open access |
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