An Exploration of the Influences on Clinical Decisions made by Chartered Physiotherapists in Relation to the Hemiplegic Upper Limb Following Stroke

Bamborough, Gill (2015) An Exploration of the Influences on Clinical Decisions made by Chartered Physiotherapists in Relation to the Hemiplegic Upper Limb Following Stroke. Doctoral thesis, Northumbria University.

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Abstract

Introduction
This study explored the clinical reasoning and influences on decisions of physiotherapists’ identification and treatment of upper limb movement difficulty following stroke.

Methods
This was a pragmatic, practice based, mixed methods approach, undertaken in three sequential phases. Physiotherapists practicing in neurological rehabilitation (n=143) responded to a survey to identify broad areas of influence on examination and treatment of stroke. Semi-structured telephone interviews were conducted with a sub-group of respondents (n=10) in order to further explore influences on the content and structure of examination and selection of interventions for the upper limb.

A separate group of neuro-physiotherapists (n=5) and service users (n=5) was recruited from the stroke service of an NHS Foundation Trust Hospital. A single physiotherapy treatment session was recorded and a semi-structured interview conducted with each participant whilst viewing the tape of the session in which they had been involved. Physiotherapists were asked to describe their reasoning during delivery of the intervention; service users to describe their experience of the treatment.

Data analysis
Phase 1 data were analysed using SPSS® version 21 (Chicago, Illinois). Thematic analysis was conducted from interviews in phases 2 and 3 with regard to examination, planning and delivery of a physiotherapy treatment session.

Findings
Survey results found that clinical decisions were primarily influenced by clinical experience and theoretical knowledge. Other influences were time after stroke, structural features of the service including skill mix and working with other health care professionals.

Thematic data analysis of telephone interviews supported influence of clinical experience, theoretical knowledge and service structure. A structured but flexible approach was discussed in relation to examination and interpretation of findings. Wider holistic influences included the sensory and emotional aspect of stroke and therapists’ perspective of their role and professional responsibilities.

Interviews conducted when viewing the recorded treatment session indicated agreed perception of treatment as a physiotherapist led but interactive process. Collaboration and service user’s contribution to decision making varied and confidence in their contribution was influenced by sensory awareness. Therapist’s decisions regarding session structure and content were influenced by theoretical knowledge, experience and technical skill.

Service users described personal objectives tempered by uncertainty regarding what therapy should comprise and achieve. Sensory aspects of movement were valued regardless of direct translation into function and desire reported for more discussion to support both functional gain and independent exploration of movement.

Conclusion
Although findings are limited by the small number of participants this study generates insight into influences on decisions made during the selection and delivery of physiotherapy post-stroke. Findings identify features contributing to a flexible examination structure which accommodates differing client presentation, the collaborative nature of examination and treatment and the value accorded by service users to sensory aspects of movement.

Suggestions
Further research into physiotherapy treatment decisions about aspects of movement change after stroke, within different time frames, stroke services and geographical areas is required. Service user perspective should be explored in greater depth and detail.

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