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Abstract
Objectives To gain a consensus among therapists for reasons why a person who had a stroke may not receive the Royal College of Physicians’ recommended minimum of 45 min of daily therapy.
Design Three-round remote e-Delphi study.
Setting National study, based in the UK.
Participants Occupational therapists and physiotherapists with experience of delivering therapy after stroke and awareness of the 45 min guideline.
Results Forty-five therapists consented to participate in the study. Thirty-five (78%) completed round one, 29 of 35 (83%) completed round 2 and 26 of 29 (90%) completed round three. A consensus (75%) was reached for 32 statements. Reasons why a person may not receive 45 min were related to the suitability of the guideline for the individual (based on factors like therapy tolerance or medical status) or the capability of the service to provide the intervention. In addition to the statements for which there was a consensus, 32 concepts did not reach a consensus. Specifically, there was a lack of consensus concerning the suitability of the guideline for people receiving Early Supported Discharge (ESD) services and a lack of agreement about whether people who need more than 45 min of therapy actually receive it.
Conclusion Some people do not receive 45 min of therapy as they are considered unsuitable for it and some do not receive it due to services’ inability to provide it. It is unclear which reasons for guideline non-achievement are most common. Future research should focus on why the guideline is not achieved in ESD, and why people who require more than 45 min may not receive it. This could contribute to practical guidance for therapists to optimise therapy delivery for people after stroke.
- Stroke
- Physical Therapy Modalities
- REHABILITATION MEDICINE
Data availability statement
No data are available. Raw data from this study (in the form of completed Delphi questionnaires) are not available, as we do not have consent from participants to share these. However, the Delphi statement analysis, participant information sheet and other information pertaining to this research are available at: https://eprints.soton.ac.uk/468842/ (please note, this is under embargo, until this paper is published).
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
We recruited occupational therapists and physiotherapists from specialist interest groups to examine a consensus among therapists for the reasons why a person who had a stroke may not receive the Royal College of Physicians’ recommended minimum of 45 min of daily therapy within the UK.
Three rounds of a Delphi study were undertaken, between October 2019 and May 2020.
Recruitment for the second and third Delphi rounds was below target recruitment.
Due to the nature of the method, reasons for a lack of consensus presented have not been confirmed by participants.
Introduction
Following a stroke, people participate in occupational therapy and physiotherapy as part of inpatient1 and Early Supported Discharge (ESD) services.2 These therapies are reported to be appropriate for 80% and 85% (respectively) of people as part of inpatient stroke unit care3 and aim to support recovery from stroke. The Royal College of Physicians (RCP) provides guidelines for the management of stroke care in England, Wales and Northern Ireland. This includes a specific recommendation regarding the amount of rehabilitation to be delivered:
People with stroke should accumulate at least 45 minutes of each appropriate therapy every day, at a frequency that enables them to meet their rehabilitation goals, and for as long as they are willing and capable of participating and showing measurable benefit from treatment4 (p.25).
According to the Sentinel Stroke National Audit Program (SSNAP), therapy should be goal directed and can be provided to either an individual or a group. It includes home visits (where the person is present) and training of people who had a stroke and their carers. It does not include non-person contact activities, such as documentation and case reviews. Details regarding the audit of this guideline, including what constitutes therapy, are published in the SSNAP core dataset help notes.5
The recommendation for a minimum of 45 min of daily therapy is based on the consensus of the RCP guideline working party, influenced by systematic review evidence that more therapy leads to better outcomes in the first 6 months after stroke.6–9 However, this may be a simplification of the effect of time spent in therapy after stroke.10
The SSNAP reports that, from April 2021 to March 2022, 32% of people considered appropriate for physiotherapy and 34% for occupational therapy received this guideline amount,11 based on delivery of therapy 5 days a week. It is unclear why not all people considered appropriate achieve this amount of rehabilitation.
Other research has considered factors that influence delivery of the 45-minute guideline using mixed-methods case studies,12 ethnography13 14 and secondary analysis of SSNAP data.15 Collectively, these studies found that availability of resources (in terms of therapists’ time) and clinical presentation of people who had a stroke influence therapy provision.12–15 In previous work, we have undertaken therapist focus groups, which provide additional insights into why people might not receive the recommended minimum amount of therapy from the perspective of those delivering intervention.16 This study found that reasons for non-delivery of the guideline related to either (a) suitability of the guideline for the person who had a stroke or (b) ability to deliver the guideline. It concluded that therapists decide who should receive therapy and how much they should receive, in the context of resource availability and therapist’s judgement of the person’s need and the benefit they will likely experience.
In the UK, therapists are autonomous professionals, who use assessment and observation to decide who will receive therapy after stroke, and the amount they will receive.12 14 Despite therapist views related to delivery of the 45-minute guideline being sought,12 13 16 to our knowledge, no study has aimed to gain a consensus from therapists on reasons why the 45-minute guideline is not always achieved, nor considered delivery of the 45-minute guideline beyond the inpatient setting. Consensus methods are used to gain agreement in areas, such as this, where there is limited research evidence.17 18 We considered that a consensus method could be used to investigate which of the potential reasons for non-delivery of the 45-minute guideline were agreed by the majority of therapists. Additionally, the 45-minute guideline was determined via expert consensus, so a consensus method to determine why the guideline is not always achieved was considered an interesting parallel.
This study aims to gain a consensus from occupational therapists and physiotherapists regarding the reasons why some people who had a stroke do not receive the recommended minimum of 45 min of therapy, 5 days a week, and the factors that influence therapy provision, in inpatient and community settings.
Methodology
Study design
A Delphi methodology was used to gain a consensus among therapists for reasons why a person who had a stroke might not receive the recommended minimum of 45 min of therapy. Delphi statements were developed using our focus group data16 and relevant research literature.12–14 19–24 Code-level focus group data were compared with and contrasted with the identified influences on therapy delivery from the relevant research data. The research team used this information, in addition to clinical experience, to formulate 51 statements for the initial Delphi questionnaire (see online supplemental table 1). A physiotherapist, who met the selection criteria below, piloted the questionnaire to test acceptability and ensure there were no ambiguities. Statements were revised accordingly. For each Delphi statement, participants rated their agreement using a 6-point Likert scale. Responses ranged from strongly disagree to strongly agree. Statements that were experience dependent also included the option ‘unable to answer based on my experience’. For all statements, participants had the opportunity to comment and, in round one, to suggest further criteria for consideration. The questionnaire was administered electronically.
Supplemental material
Prior to data collection, consensus was defined as 75% agreement. There is no universally recognised definition of consensus for a Delphi study,25 26 but values of around 70% are common,26 and the agreement of three out of four clinicians was considered a reasonable consensus.
Recruitment
Based on Delphi method literature, target recruitment was 30–50 participants,17 27 who met the following criteria:
Occupational therapist or physiotherapist.
Experience in delivering therapy after stroke (in inpatient, ESD or community).
Aware of the 45-minute guideline.
Participants were recruited by email, sent via specialist interest groups (Royal College of Occupational Therapists-Specialist Section for Neurological Practice and Association of Chartered Physiotherapists in Neurology), with the request that group members forward the invitation to anyone else who may be interested in participating. Those who met the criteria (self-reported) and provided consent for the Delphi process at recruitment were included in the study. Nominal demographic data were collected to characterise the study sample.
Data collection
Data were collected electronically, using the University of Southampton iSurvey software (www.isurvey.soton.ac.uk). After providing written informed consent, participants were given a link to the first Delphi questionnaire. Each Delphi questionnaire presented a series of statements, with which participants were asked to rate their level of agreement, using Likert scales. Those who had not responded were prompted via email, in line with ethical approval. After each round, statements that achieved a consensus were removed and those which did not achieve a consensus were revised and included in the next Delphi round. This process continued, until further consensus was considered unachievable. Only participants who had completed the previous round were eligible to participate in the next round.
Data analysis
Based on the recommendation of Black,17 the 6-point Likert scales were divided into thirds, to indicate agreement (responses of strongly agree or agree), disagreement (responses of strongly disagree or disagree) or an ambiguous outcome (responses of slightly agree or slightly disagree). In addition to this descriptive analysis, median of scores and IQR are presented, to demonstrate the distribution of opinion. Median and IQR were generated by giving each Likert scale response a numerical score, from 1 (strongly disagree) to 6 (strongly agree) and calculated using Microsoft Excel. Analysis of the Delphi statements adhered to the following iterative process for each of the three rounds:
Step one: statements that achieved a consensus (75% or more respondent agreement in either agreement, disagreement or an ambiguous outcome) were removed from the Delphi questionnaire.
Step two: statements for which a consensus was not achieved were reviewed by three authors (BAC, JT and JB) and either reworded for inclusion in the following round or excluded if participants’ responses suggested that a consensus was unlikely. These decisions were made in the context of the spread of responses and content analysis of participants’ comments. A table was developed to manage the statement review process (table 1 gives examples of statements reviewed). Full analysis of all the Delphi statements can be found in online supplemental table 2.
Supplemental material
Example of table used to review Delphi statements
Following completion of round one, additional topics for consideration identified by participants were reviewed and statements added to round two. In rounds two and three, any statement that was reworded from the previous round included a link to the results of the previous statement, so participants could consider their response in relation to the group response in the previous round.
Three rounds were undertaken, between October 2019 and May 2020. A fourth round was considered, but not executed, as the number of respondents had dropped and there was potential for increased pressure on participants, due to the COVID-19 pandemic.
Patient and public involvement
This study is part of a wider programme of work, within which the opinions of people who had a stroke on the 45-minute guideline have been sought. However, as this study is specifically about therapists’ implementation of the guideline, the opinions of people who had a stroke did not directly influence this study.
Results
Forty-five participants consented to study participation and 35 (78%) completed round one. Of the 35 who completed round one, 29 (83%) completed round two and 26 (90%) completed round three. Please see table 2 for participant details.
Participant information
Across the three Delphi rounds, a total of 121 statements were presented to participants. Of these, 32 statements reached a consensus (see tables 3 and 4). These tables give the round of the Delphi in which the statement gained a consensus, the statement, the number of participants who contributed to the consensus, the results of the consensus (percentage and median (IQR)) and whether the statement relates to a reason for guideline non-achievement or a factor that influences therapy delivery. A further 37 statements were removed from the process (see table 2, online supplemental table 2). Online supplemental table 2presents the concept addressed in various statements, the Delphi round in which the statement was presented, the statement, the result (percentage agreement, disagreement or an ambiguous outcome), the reason the statement was removed from the Delphi study and whether the statement relates to a reason for guideline non-achievement or a factor that influences therapy delivery. Please see figure 1 for a flow chart of the movement of statements through the Delphi rounds.
Flow chart of the movement of statements through the Delphi rounds. In each round, statements that achieved consensus were removed and added to table 3 or table 4, statements that were unsuitable to remain in the study were removed and added to the online supplemental table 2, the remaining statements were reworded and included in the next round of the Delphi and new statements were added to the next round of the Delphi as identified. *One statement inadvertently missed from round 2 and added to round 3.
Statements for which there was consensus agreement
Statements for which there was consensus disagreement
Of the 32 statements which reached a consensus, 25 statements were agreed (see table 3) and 7 were disagreed (see table 4). There were no statements with an ambiguous outcome (ie, slightly agree/slightly disagree). Of the statements that were agreed, 10 related to the suitability of the person for the guideline, 11 related to the ability of the organisation to provide the guideline and 4 were contextual factors that influence therapy delivery. Of the statements that were disagreed, five related to the suitability of the person for the guideline and two were contextual factors (ie, there was a consensus that these were NOT reasons/factors why someone would be considered inappropriate for the guideline).
Of the 37 statements removed, 32 were removed as a consensus was considered unachievable and the remaining statements were removed as they were contained in other statements. Some of the 37 statements removed had been reworded from previous Delphi rounds (see online supplemental table 2).
Discussion
This Delphi study gained a consensus between therapists on 32 statements related to the 45-minute guideline, but was unable to gain a consensus on a further 32 statements. As therapists’ decision-making determines therapy delivery, therapists’ views on this topic are important. The three main findings identified by this study are discussed: (1) reasons why a person might not receive the guideline amount of therapy (the person’s suitability vs the organisation’s ability), (2) challenges regarding the guideline in ESD and (3) statements on which a consensus could not be achieved.
Reasons why a person might not receive the recommended 45 min
The 21 agreed reasons why a person may not receive the guideline amount of therapy fall almost equally into one of two categories. Ten of the reasons are relative to a person’s therapy tolerance, medical status or progress with therapy, which impacts their suitability for the guideline. The remaining 11 statements relate to the organisation’s ability to provide the guideline, for reasons such as size of therapists’ caseload and other priorities competing with rehabilitation delivery.
Support for the guideline suitability/organisation’s ability is found in a study by Gittins et al,15 who applied multilevel mixed-effects regression models to SSNAP data to investigate factors associated with amount of therapy delivered. They found that patient-related characteristics, such as pre-morbid disability and stroke severity, had the strongest influence on therapy delivery, but that there were organisational factors, such as day and time of admission and type of stroke team, that were also influential. Clarke et al12 also found that there were issues with an organisation’s ability to deliver the 45-minute guideline in terms of resource usage and availability.
The guideline acknowledges that not all people are suitable for 45 min of therapy, 5 days per week, stating those ‘willing and capable of participating and showing measurable benefit from treatment’4 (p.25) should receive it. SSNAP accounts for this in the calculation of guideline achievement, by excluding any people who had a stroke who were not appropriate for therapy at any point during their admission. However, 6 of the 10 consensus reasons related to suitability indicate that some people who are suitable for therapy may not be suitable for the full 45 min or may be able to engage with therapy some days, but not others. For example:
A therapy session may end if the stroke survivor is not able to maintain attention to the therapy input, despite strategies to increase and/or motivate attention. (Delphi statement that achieved consensus in round three, 80.8% agreement).
This suggests that some people who are suitable for therapy are not suitable for 45 min of therapy every day.
It is unclear if the issues of a person’s suitability and the organisations’ ability are mutually exclusive or if they are ends of a spectrum along which therapists make decisions about those most suitable for the 45-minute guideline in the context of resource availability. The latter possibility is supported by a consensus on contextual factors, which therapists agree influence the delivery of the guideline (such as the therapists’ knowledge and experience) and the finding from other research that therapists allow their knowledge of resource availability to influence their judgement of who is suitable for therapy.13
It is notable that none of the reasons why a person might not receive the 45-minute guideline reached a 100% consensus. While differences between individuals can be expected, there were some statements where this was particularly surprising. For example, the statement: ‘A stroke survivor may not receive the recommended amount of therapy if they do not consent to therapy’ achieved an 85% consensus in round one; one participant disagreed with this statement, one slightly disagreed and three only slightly agreed. This is unexpected, as consent for therapy is usually considered important. Comments suggest that those participants who did not agree/strongly agree were considering issues around mental capacity to consent. Potentially, if the statement had been reworded, it would have achieved a greater degree of consensus. Medical reasons and tolerance of therapy were other areas that, although they reached the predetermined level of consensus in round one, reached a lower degree of consensus than anticipated. Analysis of participants’ comments related to these statements provides some explanation for the lower-than-anticipated levels of consensus.
Challenges regarding delivering the guideline in ESD
This study identified specific challenges regarding delivery of the guideline in ESD services. Twelve of 14 therapists with experience in ESD responded strongly agree/agree when asked if returning to someone more than once per day is difficult (which is required if they are unable to tolerate 45 min of therapy in one session). This study also found that some people who would benefit from ongoing therapy do not receive it, due to ESD services being time-limited (eg, 6 weeks maximum input). The guideline states that people should continue to receive 45 min if they are showing measurable benefit4; therefore, time-limited ESD services may interfere with achievement of this. However, therapists in ESD services may teach people to manage their own rehabilitation and, therefore, ongoing daily therapy input may not be appropriate. This possibility may explain the lack of consensus on the appropriateness of the guideline in ESD services. Despite 13 of 18 therapists agreeing that ‘the guideline for 45 min of therapy is appropriate for most stroke survivors receiving ESD’, there were therapists who disagreed with this statement commenting that it was dependent on the person’s goals and that ESD needs to be less prescriptive and adapt to the needs of the individual. Additionally, there was a lack of consensus on whether people receiving ESD had more than one session per day (in total, not per-discipline involved). Some participants commented that interprofessional working is key and some people do not want more than one visit per day, as they find it intrusive. These issues may contribute to the reduced amount of therapy delivered in ESD compared with inpatient care.28 Taken together, these findings suggest that the 45-minute guideline may not be suitable for people receiving ESD input and, potentially, a different recommendation should be provided for ESD.
Statements on which consensus could not be achieved
Reasons for lack of agreement were based on a qualitative analysis of participants’ comments. Lack of consensus appears to be due to either (a) structural and/or institutional differences between services or (b) differences between therapists’ approach to a given situation. An example of differences between services was the lack of consensus regarding the effect of therapy space and/or equipment. Such resources may vary between services, rendering this a consideration for some sites, but not for others. An example of differences between therapists’ approach was the lack of consensus on the effect of a person’s cognitive impairment on guideline delivery. Content analysis of the related comments suggests that some therapists would use strategies, some felt they would be unable to undertake their planned session and some felt it would depend on the impact of the cognitive impairment. These differing views reflect the similar lack of agreement regarding the impact of cognitive impairment on rehabilitation participation found in literature.29 30 A consensus was also not reached on statements that explored the impact of goals on guideline delivery. Goals are considered to be a key component of stroke rehabilitation31; however, a consensus was not reached for the effect that the absence of meaningful, achievable goals has on delivery of the guideline. This suggests inconsistency among therapists regarding the role of goals in therapy.
Another concept which did not reach a consensus was that people who require more than 45 min of therapy per day are able to receive it. Only 7 of 26 participants agreed that this happened, with staffing levels heavily cited as the reason. Statements related to this concept were only included in rounds one and three of the Delphi study (see study limitations below). The guideline states that 45 min is the minimum requirement and is the standard audited via SSNAP. Guideline achievement contributes to an overall ‘SSNAP level’ for an organisation, rated from A to E, with A being the most desirable score.32 For physiotherapy and occupational therapy, an ‘A’ rating is achieved if 45 min is delivered to a predetermined percentage of people. The ability to achieve the top rating by only providing the minimum recommended may not incentivise organisations to provide beyond the minimum. This means some people are not receiving the therapy that would allow them the greatest chance of recovery.
Some of the statements which did not achieve a consensus are reported in other studies as reasons why someone might not receive therapy. For example, Taylor et al21 report that lack of social support may affect rehabilitation input. However, in our study, therapists did not reach a consensus regarding the effect that lack of social support had on achievement of the 45-minute guideline in the community. Similarly, Skidmore et al23 report that depressive symptoms affect participation in rehabilitation, yet in our study, a consensus was not reached for the effect of low mood on therapy input, despite being included in all three rounds.
Overall, the lack of consensus among therapists suggests that there are differences between services and between individual therapists regarding therapy delivery. Therefore, a person’s experience of stroke care will be dependent on the service they access and potentially, their therapist too. Variation in therapy delivery is identified in other literature.13 21 28 Potentially, variation could be reduced by providing therapists with summarised, evidence-based information regarding how to optimise therapy delivery and by developing national stroke therapist competencies.
Strengths and limitations of the study
To our knowledge, this study is the first to examine consensus among therapists for the reasons why a person may not receive the 45-minute guideline after stroke, adding to the currently small evidence base for its implementation. Not only was the Delphi method a novel approach, but also appropriate for answering the research question, due to the limited evidence currently available.18 Therapists’ opinions regarding why someone may not receive the guideline are relevant considering the role that their decision-making plays in therapy delivery, in the UK. Arguably, therapists may wish to represent themselves when providing rationale for this decision-making. A Delphi study was chosen to specifically consider which reasons for guideline non-achievement were consistent among therapists, although it is interesting to also consider the findings which did not achieve a consensus.
Findings of this study must be considered in light of its limitations. A criticism of the Delphi technique is that results only represent simplified concepts.33 In the context of this study, we cannot consider that the reasons that reached a consensus are the only reasons why a person might not receive the recommended minimum amount of therapy. The many concepts where a consensus could not be achieved also represent reasons why some people might not receive the guideline. Based on content analysis of the comments in the Delphi rounds, reasons for the lack of consensus have been presented. However, due to the nature of the method, those reasons have not been confirmed by participants, nor did all participants provide comments. The diversity of participants may have influenced the lack of consensus. Greater levels of consensus may have been gained from a more homogeneous group, focusing on a single aspect of the stroke pathway (eg, acute inpatient or ESD).
Another limitation is that the second and third rounds of the Delphi were completed by fewer than the lower target of 30 participants, potentially resulting in findings that are not generalisable to a wider therapist population. This may be particularly the case for statements which were experience dependent. A consensus on one such statement is attributed to the responses of only 14 participants. It is possible that some of the statements that did not achieve a consensus would have done so with a larger sample. On the other hand, those who did participate were predominantly very experienced stroke therapists. Based on those who participated in round one, therapists had a median 9 years’ experience in stroke and were a median band 7. The views of less experienced therapists (who may form a large proportion of the therapy workforce) are not well represented and may be different to therapists with more experience. Finally, unfortunately, one statement reworded from round one was inadvertently missed from round two of the Delphi. It was included in round three, to mitigate, but means this statement only had the opportunity to be reviewed twice in the Delphi study, and it did not reach a consensus. Based on the comments made by participants, study authors did not feel this statement would reach a consensus with a third Delphi round.
Unanswered questions and implications for future research, guidelines and clinical practice
This study adds to the emerging evidence for the implementation of the 45-minute guideline, but there remain unanswered questions.
Suitability of 45 min of therapy for all people suitable for therapy requires further consideration, as findings of this study suggest that suitability for therapy does not equate to suitability for a minimum of 45 min. A recent Cochrane review found that additional time spent in rehabilitation following stroke had no effect on measures of activities of daily living.10 Potentially, this finding relates to the importance of selecting the right people for intensive rehabilitation.34 35 Therapists would benefit from clear guidance regarding how to make such selections. There is currently some evidence regarding how therapists make these decisions12–14; however, our study and that of Taylor et al13 identify that there are inconsistencies in therapy delivery.
It is not known which consensus reasons are most commonly occurring in clinical practice and if either the suitability of the guideline or the organisations’ ability to deliver the guideline has a greater influence on guideline non-delivery. This could be investigated by undertaking an observational, cross-sectional, prospective survey across England, Wales and Northern Ireland. Additional benefits of undertaking such a study would be validation of the findings of this study and further investigation of potential variations in therapy delivery. This would lead to enhanced understanding of the ongoing suitability for the guideline in clinical practice and the intervention required to increase guideline achievement.
This study has also raised further questions in relation to the 45-minute guideline. There is a question regarding the guideline’s suitability for people receiving ESD and if its unsuitability might help explain the low guideline achievement in this setting. Additionally, further understanding regarding delivery of the therapy beyond the minimum recommended 45 min would help to understand if people are receiving the amount of rehabilitation that therapists believe they need, rather than the minimum recommendation.
The impact of COVID-19 on these findings
Data collection for this study occurred just prior to and during the early stages of the COVID-19 pandemic; there is evidence that the pandemic has affected therapy delivery. Early in the pandemic, there was a reduction in stroke admissions28 and guidance from the RCP was that people should be discharged from hospital as soon as they could safely be cared for at home. This would affect the delivery of inpatient therapy, due to shorter length of stay. Telerehabilitation was encouraged as a means of supporting people’s rehabilitation at home.36 37 Telerehabilitation is the use of information and communication technologies (for example, videoconferencing) to enable communication between a therapist and a person who had a stroke remotely.38 Ford et al37 report that telecommunication can occur synchronously (ie, face-to-face with a therapist in ‘real time’) or asynchronously (ie, using computer-based interventions that remotely monitor and adapt exercises). According to the definition of therapy given by SSNAP,5 therapy delivered via telerehabilitation (either synchronously or asynchronously) could contribute to the 45-minute guideline. The use of telerehabilitation, therefore, would affect the delivery of community-based therapy.
The long-term effects of the pandemic on stroke services are not known, but arguably the use of telerehabilitation in the community will continue, as a way of delivering more therapy where appropriate. There is low-quality evidence that telerehabilitation is as effective as face-to-face therapy in stroke,38 and there is acknowledgement that new models of rehabilitation delivery must be evaluated to ensure outcomes and standards are maintained.37
The findings of this study are likely to remain relevant to inpatient stroke rehabilitation, as there does not appear to have been a significant change to inpatient therapy delivery and, according to SSNAP data, it remains consistently underachieved.39 On the other hand, potentially more rehabilitation is now occurring in the community, particularly if the use of telerehabilitation has been embraced by stroke therapy teams and service users. This may have implications for the findings of this study, related to the success of delivery of rehabilitation in the community.
Conclusion
Confirming the findings of our focus group study,16 the three findings of this study contribute to two conclusions:
First, there are issues concerning the suitability of the guideline; there are some people suitable for therapy who are not suitable for a minimum of 45 min in a day, or may tolerate 45 min of therapy some days, but not others. Additionally, it may not be suitable for some people receiving ESD, as they may believe it stops them ‘getting on with life’. Findings from this study and others16 suggest that therapist decision-making in terms of the 45-minute guideline is complex, which contrasts with the simplicity of the current guideline.
Second, there are issues concerning the delivery of the guideline. Services have limited ability to deliver the guideline, there are inconsistencies between therapists and services in guideline delivery and people who require more than 45 min of therapy do not consistently receive it.
Future research should focus on why the guideline is not achieved in ESD, and why people who require more than 45 min may not receive it. This could contribute to practical guidance for therapists to optimise therapy delivery for people after stroke.
Data availability statement
No data are available. Raw data from this study (in the form of completed Delphi questionnaires) are not available, as we do not have consent from participants to share these. However, the Delphi statement analysis, participant information sheet and other information pertaining to this research are available at: https://eprints.soton.ac.uk/468842/ (please note, this is under embargo, until this paper is published).
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and ethical approval for this study was obtained from the University of Southampton (ERGO II 17994). All participants provided electronic consent for the Delphi process at recruitment.
Acknowledgments
Sincere thanks to the occupational therapists and physiotherapists who participated in this Delphi study. Thanks also go to Sarah Patterson, who supported the development of the Delphi questionnaire, for the first round. This research was undertaken as part of a doctoral research degree, which received financial support from Health Education Wessex, Poole Hospital NHS Foundation Trust and the Elizabeth Casson Trust.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @BethClark_OT
Contributors This study was undertaken as part of the philosophical doctorate undertaken by BC; hence, she initiated and coordinated the research, and is the author responsible for the overall content as the guarantor. The study was undertaken with the support of all authors. BC, JT, JW and JB contributed to the conception and design of this research study, including the design of the Delphi questionnaires. BC, JT and JB undertook the analysis of the Delphi statements and rewording for subsequent rounds. BC, JT, JW, JB, RT and A-MH contributed to the interpretation of results and to the final presentation of this study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests During the undertaking of this work, all authors were employed in academic institutions. Some authors have been involved in other research projects. Some authors have received payment for articles written about related topics (but not this specific topic) and expenses for presenting at conferences. We do not believe there are any competing interests, which have influenced the content of this manuscript.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.