Upper Limb Rehabilitation following Brain Injury: Complex, Multifaceted and Challenging

Abstract

Neurological upper limb rehabilitation is influenced by a diverse range of factors within the practice environment. Clinical reasoning is the means by which occupational therapists make sense of such factors in order to make decisions that promote individual occupational goals. However, changes in neurological knowledge, the limited availability of research evidence and the need to maintain a focus on client-centred practice in rehabilitation settings are factors that contribute to clinical reasoning uncertainty. A protocol that aims to structure clinical decision making in the light of such diversity has been developed to guide upper limb rehabilitation after brain injury. As part of a larger study designed to determine the conceptual usefulness of the protocol, 11 expert occupational therapists were asked to describe the challenges that they faced in their practice. Four themes emerged from the focus group data, described in terms of (a) the complexity of domain-specific knowledge and the paucity of evidence for practice; (b) the diversity of upper limb presentation; (c) the need to balance client-centred practice and professional duty of care; and (d) uncertainty regarding clinical decision making. Although the data supported the participants' expertise, they nevertheless articulated a need for guidance in structuring the clinical reasoning and decision making underlying neurological upper limb rehabilitation. Various strategies are described that can be used to guide clinical reasoning, including research evidence, the differentiation of situations requiring the application of artistic or scientific knowledge, reflective and reflexive practice, and the application of system aids such as decision-making protocols.

Occupational therapists’ perceptions of requirements for competent upper limb hypertonicity practice

“…Therapists need to know when to apply the interventions, when not to apply them and how to change interventions when they need changing, all of which require ongoing clinical reasoning skills. Due to the variability between and within each client, clinical reasoning is intrinsic to hypertonicity practice [15]. The importance of individualising interventions has recently been highlighted in other areas of neurological practice such as spinal cord injury medicine [33].…”

“…Second, personal characteristics such as age, cognition, previous experiences with interventions, caregiver support and goals for intervention differ among clients [12,15,16,19,20]. In addition, brain injury often has life-long effects, and changes in upper limb presentation and life circumstances over time mean that variations within each client are likely.…”

“…In an evaluation of this protocol, novice therapists' clinical reasoning skills were enhanced and the protocol guided clinicians to make more consistent intervention decisions [12,16]. Even expert therapists found use of the protocol's guidance helpful in making clinical decisions [15].…”

“…Previous literature has investigated development of expertise in hypertonicity practice [14][15][16]27,28]. When expert therapists were compared to beginners, expert therapists were found to prescribe more invasive interventions, be more consistent with their intervention choices, have a holistic understanding of the client and empower the client to make decisions through a collaborative relationship [13,15,16,28]. In another area of rehabilitation (lumbar syndromes), empowering the client, client-centred care and collaborative reasoning were found to be elements of expert practice [29].…”

Sensory impairment after stroke: Exploring therapists’ clinical decision making

“…Developing and testing this approach is likely to be of benefit across all fields of occupational therapy. Kuipers and McKenna (2009), in a qualitative study of 11 expert occupational therapists, noted that occupational therapy neurological practice is characterized by uncertainty and lack of confidence, and even expert therapists sought guidance and structure for their CDM. They recommended using evidence-based decision aids and training therapists in CDM skills.…”