survey focus group & questionnaire...

Survey–focus group & questionnaire Report

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Development of innovative Training contents

based on the applicability of Virtual Reality in the field of

Stroke Rehabilitation

Project information:

Contract Number 2017-1-PL01-KA202-038370

Title of Contract Development of innovative Training contents based on the applicability of Virtual Reality in the field of Stroke Rehabilitation

Acronym Brain4Train

Report information:

Report Title: Survey Report

Deliverable number ID.1.2

Delivery date: March 2018

Dissemination Level: Public Confidential

Prepared by:

Partner Name Date

IBV

SUT

FPM

Cristina Herrera

Joanna Bartnicka

Esteban E. Pavan

March 2018

This project has been funded with support from the European Commission. This publication reflects the

views only of the author, and the Commission cannot be held responsible for any use which may be

made of the information contained therein.

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Contents

1. INTRODUCTION 3

2. MATERIAL AND METHODS 3

3. RESULTS 5

3.1 QUALITATIVE RESULTS 5

3.1.1 CURRENT KNOWLEDGE, BACKGROUND AND TRAINING COURSES RECEIVED (IF ANY) APPLIED

TO THE NEW TECHNOLOGIES IN THE DIAGNOSIS AND TREATMENT OF STROKE PATHOLOGIES 6

3.1.2 KNOWLEDGE AREAS REQUIRED FOR THE APPLICATION OF NEW TECHNOLOGIES IN THE

DIAGNOSIS AND TREATMENT OF STROKE 9

3.1.3 PREFERENCES REGARDING TRAINING 12

3.2 QUANTITATIVE RESULTS 13

3.2.1 SAMPLE 13

3.2.2 EXPERIENCE IN STROKE ACCIDENT TREATMENT 16

3.2.3 STROKE TREATMENT RECOGNITION 18

3.2.4 STROKE SELF-REHABILITATION KNOWLEDGE 21

3.2.5 COURSE FEATURES 32

3.2.6 TRAINING EXPERIENCE 34

3.2.7 TRAINING NEEDS 37

4 CONCLUSIONS 41

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1. Introduction

This report is performed under the frame of the European project BRAIN4TRAIN.

BRAIN4TRAIN arises to generate a learning offer addressed to healthcare

professionals involved in the use of new technologies for the assessment and the

treatment of neurological diseases, especially stroke or cerebrovascular accident

(CVA) in Europe, to complement the learning outcomes of current formal high

educational programmes with a training in new technologies for assessment and

treatment of post-stroke patients. The objectives of this activity are the extraction,

gathering, specification and analysis of the training preferences of target users, the

health professionals directly involved in neurological rehabilitation in Europe. User-

centred methodologies were used in this task to assure representativeness of the

whole collective of final users, prioritize their preferences and provide a new course

with a high innovation component. The main objective of this study is to establish the

standards and requirements for the curriculum, in order to suit the specific needs of

stroke rehabilitation professionals at EU level.

The specific objectives of the project are:

To define the formative needs in matter of the target groups across Europe,

conducting an analysis of needs/demands.

To adapt and transfer the knowledge generated in previous projects.

To generate courses adapted to the training needs of the professional agents

involved in this discipline.

2. Material and Methods

The methodological process followed in this phase has consisted of two stages, each

performed to gather qualitative and quantitative data, as indicated in the Figure 1.

Figure 1. Phases in the methodological process

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Qualitative research/methodology is one of the research methods used primarily in the

social sciences, based on theoretical principles such as phenomenology,

hermeneutics, social interaction, characterized by using data collection methods that

are not quantitative, in order to explore the social relations and describe reality as

experienced by individuals. Qualitative research requires a deep understanding of

human behaviour and the reasons that govern it.

Unlike quantitative research, qualitative research intends to explain the reasons for the

different elements of such behaviour. In other words, it investigates why and how they

make a decision, whereas the quantitative research aims to answer questions such as

what, where, when and how much/many.

As a qualitative method the Focus Group panels was chosen. Focus Group is a

strategy that is becoming increasingly important in social research. Surge individual

subjectivity to confront the group, and you want to contact different perspectives,

experiences, views, etc. This traditional way of conducting the focus group is a carefully

planned discussion designed to obtain information on a particular topic, in a

permissive, non-directive way.

The focus group is a group conversation with a purpose, and consists of a relatively

small group of people, from four to eight, guided by an expert moderator, in a relaxed

and comfortable environment for the participants, in order to know what they think, how

they feel or what they know about the topic of study.

The people who composed the group were selected by a criterion of homogeneity

related to the topic of study, namely the physicians specialized in Physical and

Rehabilitation Medicine and other professionals involved in post-stroke treatment.

In research conducted with qualitative methodology, the discussion group is

particularly appropriate when the study objective is to describe the perceptions of

people about a situation, a program, an event, or, in this case, a rehabilitation approach

based on the use of innovative technologies.

The main objective was to obtain comprehensive information on the needs, interests

and concerns of a particular group of health professionals involved in rehabilitation.

The focus group has been set as an equal dialogue between several persons

belonging to the rehabilitators group and another person, who was part of the research

team, through the dialogue, had de mission of building a collective interpretation of the

subject matter under investigation.

For the set-up of the discussion group, firstly the skills and knowledge of the group are

evidenced. Then, from the dialogue that is established in the group itself, the

interpretations and conclusions are drawn from a second, coordinated discussion.

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3. Results

3.1 Qualitative results

Three focus group sessions were designed in order to gather information about the

different rehabilitation aspects in three countries:

1. In Spain;

2. In Poland,

3. In Italy.

The health professionals who participated in the focus groups, as well as their

specialization and affiliation, are described in Table 1.

Table 1. Professionals involved in the qualitative phase

IBV (Spain)

Alex Cortes: rehabilitator. Hospital Arnau de Villalonga (Valencia)

Victoria Iñigo: rehabilitator. Hospital General (Valencia)

Lola moreno: rehabilitator. Hospital Clínico (Valencia)

Geno Sanchez: rehabilitator. Hospital Arnau de Villalonga (Valencia)

Ara bermejo. rehabilitator. Neurologist and rehabilitator. Hospital Universitario

La Fe Hospital (Valencia)

SUT (Poland)

Dariusz Mosler: Physiotherapist. Jan Długosz University in Częstochowa,

Faculty of Pedagogy, Institute of Physical Education, Tourism and

Physiotherapy (Częstochowa)

Iga Garbowska: rehabilitator. St. Barbara Provincial Specialist Hospital No. 5

in Sosnowiec; The Jerzy Kukuczka Academy of Physical Education in

Katowice (Sosnowiec, Katowice)

Monika Dyba: rehabilitator. St. Barbara Provincial Specialist Hospital No. 5 in

Sosnowiec; The Jerzy Kukuczka Academy of Physical Education in Katowice

(Sosnowiec, Katowice)

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Agnieszka Małecka: rehabilitator. The Jerzy Kukuczka Academy of Physical

Education in Katowice (Katowice)

Artur Serwatka: rehabilitator. St. Barbara Provincial Specialist Hospital No. 5 in

Sosnowiec; (Sosnowiec)

FPM (Italy)

PRM-Doctor, Director of a Complex Structure of Physical Rehabilitative

Medicine, Bologna

PRM-Doctor, Department of Rehabilitation and responsible of Gait Analysis

Laboratory, Milan

PRM-Doctor and University Teacher, Director of the Department of Physical

Rehabilitative Medicine, Modena

PRM-Doctor and University Teacher, Director of the Physiotherapy Service,

Milan

PRM-Doctor, Responsible of the Rehabilitation department, Pavia

Physiotherapist, Reponsible of Research in rehabilitation, Milan

Physiotherapist, Responsibe for the Physical Rehabilitation service and Gait

Analysis Laboratory, Rimini

The Italian experts expressed their impartial opinion in a disinterested way, without involving their institutions, for this reason they preferred their names to remain blind in order to avoid possible issues or any conflict of interests with the system developers

3.1.1 Current knowledge, background and training courses received (if any) applied to

the new technologies in the diagnosis and treatment of stroke pathologies

One of the main findings of this work was that, in general, the current knowledge about

to the new technologies applied in the assessment and treatment of stroke pathologies

is very low. This can be explained by considering the factors affecting the medical

systems of many countries.

In public hospitals, where the resources to afford the costs of the new technologies are

very limited, the devices for the assessment and treatment of stroke pathologies are

consequently very scarce too. Nevertheless, in private hospitals that have more

resources, innovative technology devices may be more common.

There are however some exceptions. In Spain, the public hospital Dr.Moliner is a

reference stroke rehabilitation Unit in Comunitat Valencia. In this hospital, there are

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some cognitive therapy programs. They use a Wii and Neuronap programme for

patients treatment.

According to the professionals participating in the focus group, another factor affecting

the knowledge and use of new devices is the age, and they consider that young people

have more experience in the use of new technologies. This is also evinced from the

difference in the skills in the use of new technologies between older professionals and

young professionals.

But the main problem affecting the current training level of young specialists is that,

although most of them want to learn about new technologies, the public administration

have not resources for this purpose.

The treatment of Neurological diseases, especially CVA requires more training and a

more multidisciplinary interaction among different professionals than many other

pathologies. Such as, in many public General hospital, they are working in the creation

of CVA Units with the following professionals: Physical and Rehabilitation Medicine

physicians, physiotherapist, occupational therapist, speech therapist, and

neuropsychologist. These Stroke Units are becoming more common in many countries,

also in public hospitals like already happens in Italy.

In general all experts agreed that, in general, no courses are provided for learning

about the new technologies, neither for the diagnosis nor for the treatment of post-

stroke survivors. On the contrary, there are many courses about classic therapies but

these courses are not useful for learning the principles of new technology-based

rehabilitation approaches.

Many courses offered currently their materials there are out of phase. For example, in

the rehabilitation paramedicine course, there aren’t updated contents and the material

about new technologies is very basic and with bibliographic references very older.

In Poland, this aspect of implementing new solutions in rehabilitation is similar.

Particularly there is a very low level of knowledge in the use of biomechanical and

virtual reality technologies. Trainings on these subjects are organized basically by

companies that sell rehabilitation devices or computer programs for rehabilitation. The

purpose of such trainings is to, possibly, increase the sales of their products, but not

increasing the awareness of physiotherapists on multimedia tools for rehabilitation

(including those using at home by patients).

Experts from the Polish focus group, which have participated in trainings conducted by

sales representatives, confirmed that they did not possess a good knowledge, nor any

experience in the treatment of patients with central nervous system damages requiring

special care and different rehabilitation tools than other groups of patients.

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Most of the physiotherapists or PRM-doctors in Poland have no knowledge about the

use of new technologies for the treatment of neurological patients. Often, this group of

patients is offered a treatment inadequate to their real therapeutic needs.

Regarding the differences between public and private health providers in Italy, the

situation is similar to other countries. Among the experts, three of the physiatrists had

no technological facilities in the rehabilitation hospitals where they work, mainly

because of money shortage, although they are interested in using new technologies.

In effect, they do recognize the potential of virtual reality and robotics in rehabilitation,

after having exchanged experiences with colleagues who use them. Occasionally, they

have attended some panel session or some lecture during the congress of medical

societies and other conferences. Instead, some physiatrists from private healthcare

providers, are currently using this technology for rehabilitation purposes, either in their

department as well as in the frame of a home-based tele-rehabilitation service.

Moreover, for research purposes, they have made some controlled studies and the two

senior physiotherapists (jointly with medical doctors) were also involved in research

projects about this topic, and already have a good practical knowledge of the available

systems and gathered a good expertise about the use of such systems for neurological

rehabilitation. Regarding the training level of Italian physiatrists in the use of new

technologies for the assessment and treatment of stroke survivors, there was the same

prevalent opinion like other European countries: in general, training about new

technologies in rehabilitation seems inexistent or very poor, just limited to participation

to seminars and product demonstration from companies. Few medical doctors,

because they were personally interested in these applications, found their own

educational way through international literature and direct experience in their

rehabilitation department, where VR and robotics are already available. Some medical

doctors participate to European projects oriented towards new technologies in

rehabilitation, like tele-rehabilitation, where technological devices are already adopted.

About the knowledge of physiatrist on these topics and whether it is appropriate and

sufficient, there was a general consensus that the own skills appropriateness directly

depends on the experience personally gained in the field by the rehabilitator itself; the

best way to learn is by experience. In effect, those physiatrists and physiotherapists

that are interested in these technologies, and have had the possibility of using them,

have achieved a considerable level of expertise and were able to define the objectives

of the application consistently with the characteristics of the devices. Moreover, thanks

to their know-how, they were able to use these tools by taking into account potentials

and limitations of each system. Instead, those professionals, who have not such a

direct experience, believe that they should have more knowledge than they actually

have, and that, regarding the use of the technology applied to rehabilitation, the basic

education currently provided by the core curriculum of the Medical studies is

insufficient to cover this rapidly evolving field.

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There were recognized Strengths and Weaknesses regarding supporting rehabilitation

of post-stroke patients.

Strengths: The availability of Biofeedback devices, that take into account the needs of

neurological patients, increases with each passing year. In Poland, the purchase of

such devices is largely reimbursed by the Ministry of Health. The National Health Fund

places facilities equipped with the above-mentioned rehabilitation equipment at a

higher ranking level, which creates them higher possibility to receive or increase the

financial support. Physiotherapists in Poland learn, with great commitment in the field,

about the neurophysiological methods, such as Bobath, PNF, Vojta - and they have an

increasing awareness of the sophisticated needs of patients after stroke and are able

to verify the usability of multimedia devices available from Polish suppliers.

Weaknesses: It is recognized that there is a very limited access to international sources

of information in the field of using new technologies and methods in neurological

rehabilitation. We can observe an information chaos concerning the use of new

technologies in rehabilitation. There are no medical authorities who deal with this

subject in a transparent way. In some countries, information on biomechanical

methods is provided by unreliable sources. The high price and the high degree of

complexity of medical devices make it impossible to be bought by an average Pole.

Patients cannot afford to buy these home appliances, they are also unable to hire them.

Apart from the Spanish and Polish focus groups, a group of Italian experts, most of

them directly involved in the rehabilitation of post-stroke patients, was also recruited to

better know the situation in Italy, a country with a long tradition in clinical biomechanics

assessment. Seven healthcare professionals expressed their opinions and gave some

suggestions about the different aspects concerning a professional training on the use

of new tools, based on biomechanics and virtual reality, for improving the rehabilitation

pathway of these patients. The group was composed of five medical doctors,

physiatrists (Physical and Rehabilitation Medicine Physician), and two senior

physiotherapists that have a strong experience in the use of such technology in the

field of neurological rehabilitation.

3.1.2 Knowledge areas required for the application of new technologies in the diagnosis

and treatment of stroke

The training content should include knowledge on technologies that take into account

the multidimensionality of stimulation, meeting all the needs of patients with deficits

and neurological syndromes (multidimensional rehabilitation, including treatment of

motor, cognitive and motivational functions, aimed at balancing the emotions of the

patient.).

Summarizing, the course characteristics was defined and presented in the Table 2.

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Table 2. The suggested main knowledge areas of the course

Regarding the training topics that might be most interesting for a rehabilitator, an

important topic, which experts feel worth deepening, regards the definition of the

indication and application of rehabilitation-related tools, as to answer important

questions: what patient’s conditions are consistent with the principles of a specific

application? In which phase of the recovery path should it be used? What objectives

can be reasonably pursued? How the technological application must be included as a

part of a more traditional procedure?

Reflecting the general principles of Evidence Based Medicine, the experts consider

that it is very important to provide examples of successful applications of these

technologies, possibly including documented conditions of the patients before and after

the treatment. They also believe that a detailed description of the methods and

protocols to be adopted will be also very useful.

Based on focus group experts’ opinion, the desirable training content was formulated

taking into account two areas:

1. Technology useful for assessment and treatment (Table 3).

2. Specific topics and level of interests (Table 4).

Table 3. Technology useful for assessment and treatment

Ideal course approach:

• functional evaluation • deficit detection • degree disability treatment design

Topics and characteristics regarding technologies useful for

assessment and treatment

Therapy and scientific evidences about new technologies use and

how to have better results.

Instruments and tools to detect deficits that the patient may have.

Very important the cognitive part, resources for treating such kind of

deficits

Upper limbs function

Lower limbs

Balance and locomotion recovery

Instrumentals functions

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Table 4. Specific topics and level of interests

Topics Level of interest

General aspects of stroke

accidents (classifications,

symptoms, causes, clinical

consequences)

Training based only on the motor sensory

system does not interest them. Higher

function training should be included (eg,

apraxias)

Concepts in stroke recovery:

motor rehabilitation;

cognitive rehabilitation

Interesting and important. Know how to

detect it

Stroke self-rehabilitation:

concepts, methods, cases

Interesting and important. It could

incorporate telecare, mobile applications.

Introduction to Virtual

Reality. Basic concepts,

tools, software

Interesting and important.

Virtual Reality in medicine

and stroke rehabilitation – a

review


Scientific evidence of conventional

rehabilitation versus virtual Reality

Virtual Reality tool for stroke

rehabilitation – concept,

assumptions and

implementation


Relations between Virtual

Reality and Biomechanics


Physiopathology, neuroanatomical correlates and functional. The

professionals apply the technique but they do not know the real base.

It is important to know and understand the technique, how it works,

what neural networks they use.

Basic knowledge about how the devices work.

Clear indications of how effective therapy is and when it is necessary

to stop the treatment

Currently, rehabilitators use valuation scales, which are basic tools,

but do no offer information enough

Objectives instruments help to assess patients and complement the

scales

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Practical training simulation

of using Virtual Reality and

Biomechanics tools in certain

cases of stroke patients


Attention to families and

family care

Interesting and important. The rehabilitators

do not pay enough attention to the relatives.

Family members give you clues to the

patient's deficiencies.

Scales Scales that should be used for the

evaluation. Unification of scales. Which are

the most appropriate? Few scales and short.

Scientific evidence

Correlation between the clinical scales and

the results of the treatments.

Introduction General review of the current cutting-edge

technologies

3.1.3 Preferences regarding training

Table 5 presents the experts preferences about the technical features of the training.

Table 5. Technical features of training

Topic/Questions Description

Length of the courses 50-100 hours

Suitable timetable October-May

Type of

complementary/supplementary

documentation (apart from the

contents)

Audio-visual materials, photos, platform for

the international exchange of experiences

in the field of neurological rehabilitation,

samples of pilot programs; case studies

Most adequate method to evaluate

the accomplishment of the course

Test assessment

Case analysis

Should training be theoretical or

practical?

80% theory 20% practice

Who should organize and give the

training?

The organizer should be an institution with

experience in conducting e-learning

courses, and leading specialists in the field

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of neurological rehabilitation with many

years of experience in conducting therapy

in patients after stroke. The specialists

conducting the training must be selected

from an international team, because in

certain country there could be little

knowledge in the practical use of these

methods.

Particularly these specialists should be

experienced professionals in the following

fields: biomechanics, rehabilitation

professionals and virtual reality

Which qualifications should be

provided and who should give it? An international group of specialists,

including experts from various disciplines:

neurologists (with clinical experience),

research professionals (experienced in

clinical research), physiotherapists,

neurologopedists, psychologists and

psychotherapists, dieticians, ergotherapists

and occupational therapists.

How much should the course

cost? Who should pay for it?

Fully funded course should be provided by

public Institutions. In Valencian Community,

the most adequate institution is Escuela

Valenciana de Estudios Superiores. (EVES).

Basically, such specialist training should be

financed from external sources, such as EU

funding, the Ministry of Health or the budget

Universities.

3.2 Quantitative results

The following section shows the results concerning the quantitative phase of the

analysis, namely the survey performed to gather information about training needs

assessment and the preferences of the different rehabilitation professionals, by means

of a questionnaire diffused in all European countries.

3.2.1 Sample

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A total of 227 responses were gathered from 34 different countries, mainly located in Europe.

Nationality

In the Figure 2, the distribution of respondents by country is presented, where there was at least two respondents.

Figure 2. The distribution of respondents by country

81 respondents (36%) of the sample were from Poland, followed by Italy, 35 respondents (15%), Spain, 21 respondents (9%) and Portugal 15 respondents (7%). The rest of the countries was represented by less than 10 people. The total data regarding respondents in presented in Table 6. Table 6. Sample for countries

Algeria 0.88% 2

Australia 0.44% 1

Bélgica 1.76% 4

Bosnia y Herzegovina 1.32% 3

Brasil 0.88% 2

Croacia 0.44% 1

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Egipto 0.44% 1

Finlandia 0.44% 1

Francia 3.08% 7

Grecia 3.52% 8

Honduras 0.44% 1

Islandia 0.88% 2

Irán (República Islámica de) 0.88% 2

Irak 0.44% 1

Irlanda 0.44% 1

Israel 0.44% 1

Italia 15.42% 35

Letonia 0.44% 1

Lituania 0.88% 2

Montenegro 0.44% 1

Países Bajos 1.32% 3

Polonia 35.68% 81

Portugal 6.61% 15

Qatar 0.00% 0

República de Corea 0.44% 1

Rumania 1.32% 3

Federación de Rusia 0.44% 1

Serbia 0.44% 1

Eslovenia 0.88% 2

España 9.25% 21

Suecia 0.88% 2

Suiza 0.88% 2

Antigua República Yugoslava de Macedonia 0.88% 2

Turquía 3.96% 9

Ucrania 0.44% 1

Reino Unido de Gran Bretaña e Irlanda del Norte 0.88% 2

Gender

The vast majority of the respondents were women: 59% of the professionals, all involved in post-stroke rehabilitation (see Figure 3).

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Figure 3. Gender

Age

Regarding the age of survey participants, see Figure 4, most of the respondents were aged between 25 and 45 years (55% of the sample), but there was also a high percentage of aged, expert professionals.

Figure 4. Age

3.2.2 Experience in stroke accident treatment

Medical specialization

The survey outcomes reflect the multidisciplinary aspect of stroke survivors’ rehabilitation.

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Figure 5. Medical specialization

Most of the sample belongs to the profile rehabilitator (65%).

Number of years of experience in stroke patients

The reliability of the survey outcomes and, consequently, the identification of training needs that would be necessary to improve post-stroke rehabilitation, strongly depends on the respondents’ expertise in this field. In the Figure 6, it is presented the distribution of respondents according to their professional experience in rehabilitating stroke patients. The most experienced group of respondents, i.e. from 16 to more than 20 years of practice, was represented by 32% of the professionals, and 20% of them have treated more than 500 post-stroke patients per year (see Figure 7). These numbers give greater validity to the sample.

Figure 6. Years of experience in stroke patients

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Number of stroke patients

Figure 7. Number of stroke patients

3.2.3 Stroke treatment recognition

67% of the sample claims that patients should be rehabilitated in specialized

healthcare institution and at home (Figure 8).

For 12% of the respondents, mainly rehabilitators and physiotherapists, it is essential

that rehabilitation is also performed at home, in addition to the ambulatory

rehabilitation. This outcome confirmed the importance of providing self-rehabilitation

guidelines, e.g. those based on online training, to support, from one side, the medical

staff and, from the other side, the patients and their family.

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Figure 8. Patient should be rehabilitated

In the Table 7 there are presented comments for particular answers regarding the place

where rehabilitation should be performed.

Table 7. Sample comments regarding the place where rehabilitation should be performed

WHY? SAMPLE COMMENTS

Only in specialized

healthcare institution

Due to the need of a multidisciplinary team.

It has been shown that rehabilitation at home is not

effective as family/care givers that do not have the

required knowledge to do that are performing it.

Hospital based rehabilitation must be done by

rehabilitation specialists (M.Ds). Planes organized and

prescribed by the rehabilitation doctors mostly efficient

and reliable. For the patient safety and worldwide

scientific rules the benefits depends on the discipline

that sees the patient in a wide perspective.

High commitment in the initial post stroke period.

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It is essential to

rehabilitate at home

apart from

institutional

rehabilitation

The goals achieved during rehabilitation must be

integrated into the daily life.

Rehabilitation must be task oriented and must

objectively demonstrate that activities of daily life

became easier

Rehabilitation must include both the hospital

rehabilitation path and, if necessary, the treatment at

home or outpatient

It is necessary for long-term management ("chronic

stroke").

Rehabilitation is a complex, continuous process and

should influence all areas and all aspects of life.

the rehabilitation program have to be comprehensive,

implemented by the multiprofessional team and

continued at home

It is easier, less expensive, can be more efficient and

duration can be longer...

Forma the state it is cheaper. Forma the patient more

familiar and comfortable

To prolong the time of proper interaction and minimize

the effects of the wrong one.

Active behavior is context dependent.

It is essential to rehabilitate at home apart from

institutional rehabilitation

Continuity of care

To success it is necessary a real implication of the

patient and his family in his natural environment

It is necessary for the disabled patient to be reintegrated

into their environment as soon as possible

The goals achieved during rehabilitation must be

integrated into the daily life

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3.2.4 Stroke self-rehabilitation knowledge

Almost one third of respondents (26%) do not know any kind of instruction

guidelines for self-rehabilitation of post-stroke patients (Figure 9) and do not know

where or how they could obtain the available guidelines.

Figure 9. Knowledge of guides for rehabilitation after stroke

In the Table 8 there are presented comments about possible information sources of self-rehabilitation for patients after stroke. Table 8. Sample comments regarding possible information sources about self-rehabilitation

Sample comments

Medical studies

paper brochures+internet resources+workshop+lectures

consensus conferences and congress results

We performed clinical trial on this topic. We read several scientific papers.

We prepare android app to do rehab by self

NeuroRehab project Madeira

Education and family support

Based on the neuroplasticity principles. Neuromuscular facilitation

techniques used to induce motor control or to decrease spasticity based on

neurologic patterns - like Bobath, Kabath, Root techniques.

Virtual reality

i.gsc

Prescription of doctors of home programs and some tecnology like SWORD

Health or virtual reality games

Neurorehabilitation books and articles

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25% of the sample don’t know where could possess this type of guide for self-

rehabilitation for patients (Figure 10).

Figure 10. Guides for self-rehabilitation

The 14% of the respondents receive regularly guides for self-rehabilitation. They

specified what kind (Table 9):

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Table 9. Sample comments of respondents regarding guides for self-rehabilitation

Please specify what kind:

Newest medical guidelines

Brochures

Internet information

Self-Rehabilitation book for hemiplegic patients- Bonnyaud C et al. Italian

edition by SIRN

I have the opportunity to buy a book, but I don't care

Educational material provided by companies specialized in the field of

rehabilitation material

Software for patients' self-rehabilitation

Neurorehabilitation in virtual reality at home

Paper instructions+internet adress

Articles published in indexed journals, international and national conferences

JM Graciès Autoreeducation guidée

Peer to peer support

Leaflet written by rehab team, sometimes with the help of Drug Company.

Modular exercise program for stroke pts. Also in app available

I always give specific exact instructions for home

exercise/activities/positioning, since patients will not improve if they just

perform conventional exercises

Rehabilitation program developed by a physiatrist (PMR) in a university

hospital (Henri Mondor France)

As feedback combined with other methods

Rehabilitation Projects from MITI

Exercises education

Spasticity rehab

Instruction booklet for hand rehabilitation after stroke

Folders and instructions to the app

Paper brochures offered by botulin toxin labs.

Short patient information leaflets, short information booklets for

carers/relatives

43% of the sample give a guide for self-rehabilitation your patient in front to 25%

that they don’t (Figure 11).

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Figure 11. Guides for self-rehabilitation to patient

The respondents provided comments regarding type of instructions for patients (Table

10). Table 10. Sample comments regarding possible information sources about self-rehabilitation

Type of instruction guidelines for patients

Verbal instructions; brochures

Home exercises

Indications regarding techniques to prevent secondary complications from

non-use, indications for locomotor activity, indications for the use of the upper

limb in ADL.

Suggestions about performing common gestures to transform everyday

activities into rehabilitation exercises

It must be done according the individual rehabilitation planning

Dedicated protocols with specific exercises and training for patients and

caregivers

Biofeedback

I think self-rehabilitation is very important, I provide personalized indications

for behaviour / exercise on the basis of patient observation during

hospitalization (they are NOT really guidelines)

SPREAD

Guideline ISO-SPREAD 2016

Protocols deduced from scientific literature on this topic

We have training courses for patients and their families and each patient gets

own instruction from doctor and physiotherapist

Written instructions or recorded movie on smartphone of ADL activities and

postural alignment

Repeat daily what they have learned during neurorehabilitation

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Balance, stretching, voluntary movement ,Occupational Therapy

Self-exercise, activities of daily living etc.

Simple paper instructions+web adresses

Instruction for mobilization and re-education in ambulation

Self-management education

Paper and internet

Self-rehab lower or/and upper limbs

Instructions on improvement of motor functions, speech, memory etc

Cognitive training, motor training

Exercise brochures, virtual plataforms, interactive games

How to sit to standing fropm chair, proper feeding techniques, etc

Specific exercises; specific training techniques; tips for ADL's

I always give specific exact instructions for home

exercise/activities/positioning, since patients will not improve if they just

perform conventional exercises

We are involved in the program developed by our colleague an we are

instructing patients at the end of rehabilitation period (usual in hospital in

France at subacute phase)

We prepared many video clips for any kind of problems related to stroke

Hospital’s own guidelines means handbook of home programs

Manage training for performing independent executive function for ADL and

cognition deficits

They must continue the medical exercises that they have learned in the

hospital from working daily with a stroke kinetotherapist. Then I say to them

to try to do all the usual ADLs with the hemiplegic hand (a part of the

constrained therapy theory) and I teach them how to prevent possible future

complications (irreducible vicious positions, ankilosis, contractures-

retractures of muscles or tendons) and how to try to exercise the gait to be as

physiologically as possible regarding their deficit.

Rehabilitation program sheets

Differentiate self-training programs for spasticity

Exercise guidelines

Depends on the problems

lifestyle, diet, kinetotherapy

folders , verbal instructions and the smartphone app

Stretching and active movements after botulin toxin injection.

I work med pain rehab

Some instructions for a specific problem

Mostly oral and/or short patient information leaflet

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25% of the sample not give guide for patient. The comments to this kind of answers

are provided in Table 11.

Table 11. Sample comments regarding not giving guide for patients

Why don't you give a guide for self-rehabilitation to your patient?

I do not have access or I do not know any

Because I am already retired.

I do not look after patients brain stroke

Actually, I have no contact with patients after brain stroke

I'm not directly involved in rehabilitation

I give some suggestions or exercises, but not guidelines

I personalize advice on what to do at home without referring to a specific

guideline

I'm not interested in self rehabilitation as it is currently proposed

Other colleagues provide written indications for treatment

I treat patient with severe stroke

Because we treat patients during the first phase; then patients move to day

hospital for continuing the rehabilitation

I do not have any material in this regard, but it would be useful. I certainly

suggest informal indications and I am available for my patients for any doubt

and/or clarification.

I believe that at early stage multidisciplinary approach is essential. After

discharge patient should follow instructions tailored to his incapacity.

No time to explain, lack of any guides

Not seeing stroke patients regularly

Because the patient don't need, they prefer to have and not to do

Because it’s difficult use by patient him self

To be done, ... loss of time

I don't have easy access to it and many patients don't have the capacity to

follow them

They are inpatient. For the outpatients, i don t have any document on it.

Lack of adherence

I believe the pt is fundamental

There is no process for this in my establishment

I tell the patients some verbal instructions but not in an organized guide or

form

Usually, they are sent for outpatient treatment or transferred to a different

institution

Other comments that are included into questionnaires regarding guide or instructions

to patient are presented in Table 12.

27




Table 12. Additional comments regarding guides for patients

Other , specify:

In the phase of social reintegration, possible autonomy recovery,

depending on residual deficits

Information during rehabilitation visit in medical center

I do not provide specific guidelines but only suggestions for maintaining the

obtained outcomes

Patient tailored retraining

Oral information and instruction

I give instructions for certain procedures I want them to follow until next

visit

The patient is taught self-rehabilitation before leaving the ward

I explain the directives of the guidance to the patient and his entourage

At the end of the home treatment

I explain a number of self exercises and some modifications that can be

done

Guide is given by therapists

I explain specific exercises to patient and family

I will guide a patient for self-rehabilitation only if a trained therapist was not

available to supervise or for a specific problem e.g. stretching exercises

post botulinum toxin

According to survey only 18% of practitioners know some virtual reality (VR) tools

in rehabilitation and use them in practice. 26% of the sample know some VR tools

for stroke rehabilitation, but do not use in practice. All answers in this regard are

presented in Figure 12.

Figure 12. Knowledge about virtual reality tools

28




Professionals, who heard on VR tools indicated different information sources (Table

13).

Table 13. Information sources about VR tools

Information sources about VR tools

Internet

Interactive video games

Conference, congresses

ESPRM

Hospital Virgen del Rocio (Sevilla, España)

Information in mailbox and medical journal

PMR congress SOFMER

Scientific newsletter, News articles

Some reunions

Papers (PubMed), books

During the XX ESPRM congress

During exhibitions in Congresses (3) (rewire)

Courses (Neuroathome)

Neuroforma

Kynovea, but we don't have it at our institution

At work

In ergotherapy treatment

At the rehabilitation facility i trained

Our PTs use specific software program

In our lab, in a research context

Online info and symposia

University / rehab center (Rehacom & VR4neuropain)

Workshops (wii)

During PhD study in New Zealand (Computer base functional training for

weak hand)

2016 AHA stroke guidelines

I collaborate in a European project (rewire)

PRM facility

Instituto de Biomecánica de Valencia (evalanz)

Respondents indicated certain products or software the know or use (Table 14).

29




Table 14. Products or software regarding VR tools

The names of products or software

Hocoma locomat, armeo power

PROMOTER

Riablo, interaction with software through Leap Motion and Kinect

Tools such as Wii, rather than Kinect, but also software that allowed the

patient to perform exercises with the support of a computer, through virtual

reality but I do not remember the name.

Polemus, experimental software

Walker View Tecnobody

VRRS Khymeia, Nirvana BTS

Helmet HMD, kinect, robot manipulandum

Handtutor, armeo, Kinect

Neuroforma

Wii games

Nintendo

IVI-HMUS

Rheoambulator

xBox, virutalrehab

Riablo

Our software prepared in Persian languages

Rewire

Algomir, IVS3

ReJoyce, Arm Assist

NeuroRehabLab, NeuroRehabNet, Virtual City

Leap motion, oculus and kinect

KineLabs

Neuro at Home

21% of the sample only heard about biomechanical tools for stroke rehabilitation

and 18% know some but do not use in practice (Figure 13).

30




Figure 13. Knowledge about biomechanical tools

Professionals, who heard on biomechanical tools indicated different information

sources (Table 15).

Table 15. Information sources about biomechanical tools

Information sources about VR tools

Rehabilitation congress

Internet

Symposium

Literature and discussion with colleagues

PubMed publications

Presentation in Rehab week in London

Hospital Virgen del Rocio (Sevilla, España)

Journals

Uptodate, medline

In the online course biomechanics for rehabilitation

Hospital Arnau Valencia

Motion Analysis course in UK

Hospital Virgen del Rocío

Hospital Fundación Jiménez Díaz

Conducting a large trial in France

Working in neuromuscular research center

Motion analysis

Internship in Switzerland

Working with exoskeletons

In my hospital and with partnerships with universities

Respondents indicated certain products or software the know or use (Table 16).

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Table 16. Products or software regarding biomechanical tools

The names of products or software

GLOREHA

GEO-System, NESS

Lokomat, supported treadmill

Armeo

Walking & Balance training

Armin etc

Nintendo

Gait analisis

NedDiscapacidad/IBV

NedSVA

Qualisys, Rsscan, Tekscan

NedSVE, Neurocom, BTS

ERIGO-LOKOMAT

Gait analysis, kinematics and EMG of limbs

Robot rehabilitation Luna EMG

Armeo spring, gloreha

Different robotic devices

In Motion2, Amedeo, Geo System, Ekso Bionics, Khymeia, Nirvana

Robot manipolandum

Gloreha

Exoskeleton, mainly oriented on gait

Reo go

Armeo spring

Persian language software

Float (assisted free gravity walking)

Walk around tredmill

Armeo Spring upper extremity and locamot gör Lower extremity

Ekso-Indego

Biodex balance system

32




3.2.5 Course features

According to respondents’ opinion, online courses seem to be the appropriate learning

form in this sense. The more that it is increasingly popular in the healthcare field [10].

This opinion corresponds with respondents’ expectation: the vast majority of them

(55%) claimed that an e-learning course could be suitable or very suitable for

professional training. Only 14% of them have opposite opinions (Figure 14).

.

Figure 14. Opinion about appropriateness of online training

At the same time, the international group of respondents agreed that an on-line training

course should last between 20 and 50 hours (30%, see Figure 15), or less than 20

hours (23%), though 10% of respondents said that more than 50 hours would be more

appropriate.

Figure 15. The preferred duration of e-learning course according to respondents’ opinion

33




The main motivations for the course are (from most to least important) – Figure 16:

Increase my general knowledge about stroke self-rehabilitation (40%)

Retrain professionally through new techniques (36%)

Better serve my clients / patients (35%)

Know how to select the most appropriate tools in self-rehabilitation (32%)

Figure 16. The motivation to take a training course

The main requirements for the course are (from most to least important) – Figure 17:

Contents focused on practice (40%)

Application to clinical practice (36%)

Useful content for the job (31%)

Usability and ease of access to online course (42%)

34




Figure 17. Requirements for the course

3.2.6 Training experience

Regarding respondents’ instruction and, in particular, any training previously done

about the use of Virtual Reality tools and biomechanical technologies in self-

rehabilitation process, the major part of the respondents have not taken part in any

training in the last two years or never (Figure 18).

35




Figure 18. Training experience regarding Virtual Reality and Biomechanics technologies in

stroke-rehabilitation

12 respondents related that trainings on virtual reality in stroke rehabilitation, they

took part in two last year, were suitable (Figure 19).

Figure 19. Training assessment regarding Virtual Reality technologies in stroke-rehabilitation

(training available in maximum last two years)

37% of the sample never taken part in such training. However the majority who

took part two or more years ago found these training suitable (Figure 20).

36





(training available two or more years ago)

24 respondents related that trainings on biomechanical systems in stroke

rehabilitation, they took part in two last year, were suitable (Figure 21).

Figure 21. Training assessment regarding biomechanical systems in stroke-rehabilitation

(training available in maximum last two years)

34% of the sample never taken part in such training. However the majority who

took part two or more years ago found these training suitable (Figure 22).

37





(training available two or more years ago)

In the Table 17 there are provided reasons why trainings were unsuitable.

Table 17. Reasons of unsuitability of trainings

Reasons of unsuitability

Useful only at the medical centre

To old stylish, no new interventions

Short time

It was suitable to some extent

Unstructured

Focus of biomechanics mostly on orthopaedic conditions and

biomechanical theory rather than neurological rehabilitation

3.2.7 Training needs

Figures 23 and 24 show the level of importance for professionals’ work in the proposed training fields and if would take this training.

38




Figure 23. Importance of training fields

The most important contents are (from most to least important):

Concepts in stroke recovery: motor rehabilitation; cognitive rehabilitation

Stroke self-rehabilitation: concepts, methods, cases

Practical training: simulation of using Virtual Reality and Biomechanics tools in certain cases of stroke patients

General aspects of stroke accidents (classifications, symptoms, causes, clinical consequences)

39




Figure 24. Declaration of training participation

The most interesting contents are (from most to least interest):

Practical training: simulation of using Virtual Reality and Biomechanics tools in certain cases of stroke patients

Virtual Reality in medicine and stroke rehabilitation – a review

Introduction to Virtual Reality. Basic concepts, tools, software

In addition there was analysed preferences of rehabilitators group only because of their direct contact with post-stroke patient and involvement in rehabilitation process.

Figures 25 and 26 presents importance of training needs and declaration of training participation regarding rehabilitators only.

40




Figure 25. Importance of training fields (rehabilitators only)

41




Figure 26. Declaration of training participation (rehabilitators only)

It should be highlighted that a part of survey participators did not complete all fields in questionnaire that may reduce the percentage of people interested in training, which, as showed from the focus study, is a necessary and key element in improving the rehabilitation process of people after stroke.

4 Conclusions

PROFILE SAMPLE

36% of the sample is from Poland, followed by Italy 15% and Spain 9%.

59% of the sample was a female, aged 25-35 years (28%) and 36-45 years

(27%)

Most of the sample belongs to the profile rehabilitator (65%)

42




EXPERIENCE IN THIS FIELD AND STROKE TREATMENT RECOGNITION

26% of participants have less than 5 years of experience with stroke patients.

Another interesting fact is that 17% of the participants have more than 20 years

of experience with this type of patients, giving greater validity to the sample.

And 21% have treated less than 50 stroke patients, very interesting the 20%

have treated more than 500 stroke patients.

67% of the sample claims that patients should be rehabilitated in specialized

healthcare institution and at home.

STROKE SELF-REHABILITATION KNOWLEDGE

26% of the sample not know any kind of instruction guidelines for self-

rehabilitation for patients after stroke.

25% of the sample don’t know where could possess this type of guide for self-

rehabilitation for patients.

43% of the sample give a guide for self-rehabilitation your patient in front to 25%

that don’t

26% of the sample know some about virtual reality tools for stroke rehabilitation,

but do not use in practice

21% of the sample only heard about biomechanical tools for stroke rehabilitation

and 18% know some but do not use in practice.

COURSE FEATURES

55% of the sample believes that the course should be suitable or very suitable

is online mode for training related to Virtual Reality in the field of stroke

rehabilitation.

30% of the sample believes that the course should be suitable should last

between 20 and 49 hours (similar to conducting training courses)

The main motivations for the course are (from most to least important):

o Increase my general knowledge about stroke self-rehabilitation (40%)

o Better serve my clients / patients (35%)

o Know how to select the most appropriate tools in self-rehabilitation (32%)

The main requirements for the course are (from most to least important):

o Application to clinical practice or useful content for the jo (67%)

o Contents focused on practice (40%)

o Usability and ease of access to online course (27%)

36% of the sample not received any training related to virtual reality in stroke

rehabilitation in the last two years.

37% of the sample never taken part in such training

43




52% of the sample not received any training related to biomechanical systems

in stroke rehabilitation in the last two years.

34% of the sample never taken part in such training

TRAINING NEEDS

The most important contents are (from most to least important):

o Concepts in stroke recovery: motor rehabilitation; cognitive rehabilitation

o Stroke self-rehabilitation: concepts, methods, cases

o Practical training: simulation of using Virtual Reality and Biomechanics

tools in certain cases of stroke patients

o General aspects of stroke accidents (classifications, symptoms, causes,

clinical consequences)

The most interesting contents in training are (from most to least interest):

o Introduction to Virtual Reality. Basic concepts, tools, software

o Practical training: simulation of using Virtual Reality and Biomechanics

tools in certain cases of stroke patients

o Virtual Reality in medicine and stroke rehabilitation – a review

44




This project has been funded with support from the European Commission. This publication reflects the views only of the author, and the Commission

cannot be held responsible for any use which may be made of the information contained therein

survey focus group & questionnaire...

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