Introduction
An Outdoor Mobility Rehabilitation Training Manual was produced for therapists to provide a guide on an outdoor mobility intervention to be offered to stroke patients. As this was a large multicentre trial, this manual served as an important guide to ensure that therapists followed a similar treatment programme across sites. The intervention outlined in the manual was based on knowledge gained during an earlier single-centre study. In this study the intervention was found to have made a massive difference to people’s lives by helping them out of the house more often. The manual is split into different sections and each section is summarised below.
Background
Background information on the prevalence of stroke, and the effect of strokes upon the lives of people with stroke, is provided in this section. Research data are provided to support the figures presented. The section moves on to provide the rationale behind providing an outdoor mobility training intervention for people with stroke. Research is cited to support the need for such an intervention study.
It is outlined in this section that the multicentre trial, to which the manual relates, follows on from a single-centre study that found clear benefits with the intervention. However, the generalisability of this study was limited as the intervention was delivered by a single therapist, in one city, and there was no health-economic evaluation. It is argued that a multicentre trial is now needed to determine whether the intervention is effective and cost-effective before it can be recommended for wider adoption across the NHS.
Models and approaches to rehabilitation
In everyday practice, therapists use a combination of physical and psychological models and approaches when devising treatment programmes for stroke patients. These models and approaches provide a theoretical base for the intervention. Therapists will often use a combination of models and approaches when deciding on a treatment programme. Although there have been papers published describing the models there is very little research to evaluate or compare the models. There is no strong evidence to suggest that one model or approach is superior to another. The manual therefore lists and describes models and approaches that therapists may choose to use in their treatment sessions. These may be used together with the practice of outdoor mobility activities. The models described include the Compensatory or Functional model, the Model of Human Occupation, the Cognitive Frame of Reference, and the Adaptive Skill model. The neurodevelopmental approach is also described, along with the main techniques used by therapists, including the Bobath, Rood, Conductive Education, Proprioceptive Neuromuscular Facilitation and Sensory Integration techniques. It is stressed in the manual that this is not a comprehensive list and other models and approaches can be adopted.
Benefits and barriers to going outside
This section looks at why people wish to get out of their home and the barriers preventing this. It includes two checklists. The first checklist provides a list of possible destinations. This serves as an aid to prompt patients to identify outings of personal interest to them. The second checklist provides a list of possible factors that may hinder trips out of the home for the patient. These issues can then be discussed and addressed by the therapist and patient.
Assessing for limitations
This section provides a screening form to be completed with the patient to help the therapist and patient to plan the outdoor intervention. The form includes 11 screening questions on transport options and outdoor mobility. The form is completed during the treatment planning stage of the intervention. The form can also be used at intervals during therapy if progress seems slow.
Building a useful address and information resource
This section provides a template for the therapist/other team members/patient to insert useful contact details of local transport and community services. Examples include the Blue Badge Scheme for car parking, Dial-a-Ride, voluntary car schemes, Shopmobility and the local Disability Living Centre contact numbers.
Goal planning and activity analysis
The importance of goal setting is emphasised in this section. Several activities are broken down into smaller more detailed goals as examples of possible outdoor goals that could be completed with patients. The activities include walking outside, driving a car, using the bus and train, using Dial-a-Ride, the voluntary driver scheme and electric pavement scooters.
Pre-outing checklist
In this section a checklist is provided to help the therapist and patient to identify any potential risks, hazards or challenges that might arise during community outings. This checklist is completed prior to the first outing. It ensures that factors are considered which will help to make the trip both safe and more successful. The checklist includes mobility, upper limb function, cognitive and perceptual function, vision and continence. Each area is broken down into skills and abilities that need consideration.
It is recommended in the manual that the therapist observes performance around the home before venturing outside.
Protocol for the first outing
This section prompts the therapist to assess and plan ahead for all contingencies prior to the first outing. Examples of early outings recommended in the manual are walking to the garden gate, walking to the street corner, walking to the closest bus stop or a walk around the block. A checklist is provided of considerations and contingencies for this first outing, along with consideration of activities that can be practised first in the home environment.
Protocol for outdoor walking
In the single-site outdoor mobility study, walking outdoors was found to be an important goal for patients. Of the 78 main goals recorded, 22% focused on walking outdoors. In the protocol it is recommended that this activity starts with simple and small goals, such as walking to the garden gate, and progresses once skills are consolidated to encompass more demanding situations. The protocol stipulates setting practice targets between sessions aimed at increasing confidence and fitness, and includes activities such as daily trips to the street corner with a family member.
The protocol for walking is broken down into three levels. The first level incorporates walking over a short distance in a quiet environment, requiring minimal attention and physical demands. The second level progresses to incorporate more moderate demands involving road crossings, kerbs and gradients. The final level requires multitasking activities, such as carrying a bag, handling money while standing, and walking in a busy location.
Protocol for using the bus
In the single-site outdoor mobility study, catching the bus was the second most popular goal. Of the 78 main goals recorded, 17% focused on taking a bus. It is recognised in this protocol that not all therapists themselves may be familiar with using public transport. To this end guidance is provided on the steps and skills to consider for this activity, including recognising and hailing the correct bus, managing money and ticketing, boarding and disembarking the bus, and recognising the correct destination.
Once again the protocol is broken down into three levels. The first level involves home practice of reading timetables, handling money, and preparing contingency plans. The second level moves on to supervised outings. Maximum prompting and close supervision is provided at this level. The final level progresses to just standby or distant supervision.
Protocol for using the train
As with the bus protocol it is recognised in this section that not all therapists will be familiar with using trains. Equally people with stroke may not be familiar with this mode of transport, particularly if they drove before their stroke. To this end guidance is provided on the steps and skills to consider for this activity, including reading the indicator board, purchasing a ticket, accessing the platform, identifying the correct train, negotiating crowds, and boarding and leaving the train.
Similar to the bus protocol the train protocol is broken down into three levels. The first level involves home practice of reading timetables, managing money and preparing contingency plans. The second level progresses to supervised outings with close supervision and maximum prompting. The final level involves just standby or distant supervision.
Protocol for using outdoor pavement scooters
In the single-site outdoor mobility study, being able to use a (personally owned) motorised scooter was a primary goal for six people with stroke, although using a scooter on a temporary loan for shopping around town (part of the Shopmobility service in England) was a primary goal for another six people with stroke.
The protocol for using an outdoor pavement scooter is broken down in the manual into two levels. The first level involves a trial off road. This enables practice operating the scooter controls and familiarisation with charging the scooter battery. The second level progresses to a trial on the road. Practice progresses from quiet to busy roads, crossing at traffic lights, negotiating kerbs, slopes, gradients, obstacles and pedestrians, and parking the scooter outside shops and home beside the battery-charging location.
Once again, the protocol includes a checklist of the skills and competencies needed to safely drive an outdoor pavement scooter.
Each level of the protocol for outdoor walking, using the bus, using the train and using outdoor pavement scooters is clearly stipulated so that therapists across sites follow similar treatment programmes for each activity. Family members are encouraged to assist in the practice of skills and, importantly, the protocols advocate the setting of practice targets between sessions to assist in the consolidation of skills.
Intervention record form
This section provides the therapist intervention paperwork for the study, which includes:
A form requiring the therapist to break down the components of each intervention into minutes. The therapist records the time spent on mobility task training, other rehabilitation training, adaptive equipment, referral to other agencies, information provision, confidence and motivation, and goal-setting activities.
A form to record the patient’s goals and their relevant medical history.
A form to record the running records of each session completed.
Case vignette of treatment plans
A case vignette taken from rehabilitation notes is provided as a guide for therapists in this section when planning treatment sessions. This vignette outlines a clinical history of a person with stroke. Information is provided on their ability and skills around personal and domestic activities of daily living, their transfer ability and their level of mobility. The vignette incorporates their social situation and outlines their local environment, including access to their home property. The vignette moves on to focus on the person’s experience of using different modes of transport, and then highlights the goals set with this person. This is followed by a detailed breakdown of the six treatment sessions completed.
Confidence and motivation
As self-confidence to complete a task and the motivation to persevere are such important aspects of the outdoor mobility intervention, this section of the manual is dedicated to explaining the significance of these two attributes.
Self-confidence in relation to the study is about having the confidence to complete outdoor mobility. This not only relates to confidence in self, but also to having confidence and trust in others, such as the therapist. This is particularly important when therapists are encouraging people with stroke to try new activities or to push themselves harder.
Motivation is the activation or energisation of goal-orientated behaviour. It requires that those enrolled on the study have some desire to undertake outdoor mobility. Individuals need to be able to identify meaningful reasons why they wish to attain goals in order to have the motivation to succeed.
Sample letter for requesting help with purchasing equipment
In this section a sample letter is inserted to provide therapists with guidance when seeking to apply for funding for outdoor mobility equipment for their patients. In the UK, motorised scooters are not generally available via government schemes. Individuals therefore have to purchase their own scooter, and may seek financial assistance from philanthropic agencies, local church groups or service clubs. In these situations therapists may wish to support their applications by writing a letter, as per the sample provided.
References
This section of the training manual provides the full references that have been quoted in the main body of the manual.
PowerPoint slides
The PowerPoint (2007) slides (Microsoft Corporation, Redmond, WA, USA) presented during the therapist training days are provided in this section. The training was provided by Dr Pip Logan, CI; Dr Annie McCluskey, external expert; Professor Marion Walker, Professor of Stroke Rehabilitation; and Dr Matt Leighton, Trial Manager. The training day provided information on the following:
An overview of the multicentre outdoor mobility rehabilitation study.
Roles and responsibilities of those working on the study, and lines of communication and help.
Information on the earlier single-site outdoor mobility study.
The mobility outcome measures being used in the outdoor mobility rehabilitation study.
Timings of baseline visits, intervention visits and follow-up visits.
The outdoor mobility rehabilitation study documentation.
Goal setting.
The role of the Stroke Research Network.
The role of the Collaboration in Leadership in Applied Health Research and Care (CLAHRC).
Information on CLAHRC trials being completed.
Information on an Australian study that audited the amount of outdoor mobility training being incorporated into therapy intervention programmes. The barriers behind including outdoor mobility intervention were studied, training on outdoor mobility was provided, and a repeat audit of outdoor mobility intervention was completed.
Published papers
The following published papers are included in the final section of the manual:
Logan PA, Gladman JRF, Radford KA. The use of transport by stroke patients. Br J Occup Ther 2001;64:261–4.
Logan PA, Gladman JRF, Avery A, Walker MF, Dyas J, Groom L. Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke. BMJ 2004;329:1372–5.
Logan PA, Walker MF, Gladman JRF. Description of an occupational therapy intervention aimed at improving outdoor mobility. Br J Occup Ther 2006;69:1, 2–6.
