Abstract
According to estimates by the World Bank and the World Health Organization appro- ximately one billion people (about 15% of the population) live with some form of disability, with the highest incidences seen in developing countries. In Europe, by the end of 2020, it is estimated that people with disabilities will represent up to one-fifth of the population.
Stroke (CVA), as a subset of acquired brain injury (ABI), is refer- red to as a silent epidemic. It is, therefore, clear that caring for people after a CVA is one of the key issues for many health professions.
The abovementioned estimates, and in conjunction with the current situation in the Czech Republic concerning the implementation of a coordinated rehabilitation program using a interdisciplinary team approach (in particular the absence of suitable legislation), led to the submission of a unique project funded by the University of South Bohemia in České Budějovice called "Coordinated rehabilitation in patients with brain injuries" (project number GAJU 138/2016/S, solution time: 2016-2018). The aim of the research project was to map (using a qualitative research strategy) and partially measure (using quantitative methods and techniques) the outcomes of coordinated rehabilitation of ABI clients in their home environments - and at the same time using social work, physiotherapy, occupational therapy, medicine, speech therapy, and psychotherapy to improve quality of life (QoL) and help clients start to regain their independence (despite the limitations caused by the disease).
The formulation of the objectives included the use of mixed research strategies. The qualitative part took place in the client's home environment and focused on providing a thorough description of the social and health issues faced by clients after a stroke.
Data collection took the form of structured interviews and observations of the home environment (e.g., assessment of the home to determine what modifications were needed to make it wheelchair accessible). Standardized functional tests such as the Functional Independence Measure (FIM), the WHO Disability Assessment Schedule 2.0, as well as additional questionnaires specific for physiotherapists and social workers were used in the evaluation process.
The results were statistically processed in Microsoft Excel 2010. Interview records were processed using the ATLAS.ti program.
Basic descriptor statistics were used to evaluate the project's quantitative results. To meet the research goals of the project, two target groups were assessed (1) clients after a stroke together with their family members (total number of clients = 21), and (2) social workers directly responsible for providing social services (all organizations in České Budějovice that provide services to clients after an CVA were approached (a total of 20 were approached, and 12 agreed to be interviewed)).
At first glance, this might seem to be an insignificant group, but it is important to note that since each client received roughly 56 visits (44 visits for physiotherapists, 6 visits for occupational therapists, and 6 visits for the social worker) the amount of data collected was significant. Clients were monitored for 9 months after discharge from the hospital and received on average 2,201 hours of direct care during the project (about 2 hours per visit to clients and their families).
The role of social work in a coordinated rehabilitation system: One of the essential tasks of social work, which distinguishes it from the other profe- ssions involved in the interdisciplinary team working with clients that have movement problems, is the so-called biopsychosocial assessment, which is part of a multisyste- mic approach to practice. Unfortunately, there is no legislative pathway in the Czech Republic (i.e., the draft law was not adopted) for coordinated rehabilitation, and "coordination - as an activity" is not covered by health insurance companies or even within the social services system.
Despite the desperate need for inter-professional team care, coordinated rehabilitation in community care does not exist. As such, clients were dependent on the uncoordinated services they received through referrals from various professionals.
When caring for clients after an ABI, it has been shown that support from all com- ponents of a coordinated rehabilitation program is very important. The case manager for the interdisciplinary team plays a key role; they advocate in the interest of the client and their family as well as serving as the coordinator for the interdisciplinary team.
The coordinator established clear rules for cooperation within the team, especially with regard to information sharing among team members. They also coordinate team meetings and determine which experts should participate in the client's rehabilitation.
Concise legislation regarding coordinated rehabilitation could significantly reduce confusion over the competences of individual team members. Physiotherapy as part of a interdisciplinary team: One of the goals of the project was to create an interprofessional cooperation system in the rehabilitation community, led by experts in the fields of physiotherapy, occupational therapy, and social work, to help facilitate coordinated interdisciplinary rehabilitation.
The task of physiotherapists was to set up a rehabilitation program for clients after an ABI to address all existing neurological disorders associated with the condition, e.g., sensory disorders, impaired cognitive function, weakness and/paralysis (central paresis), impaired speech, reading and writing, and balance and coordination problems. During the physical therapy sessions, regular assessments are made using standardized tests.
Results from the longitudinal follow-up of 17 clients following a CVA show an improvement in postural and motor functions as well as improved self-sufficiency and quality of life; these outcomes clearly demonstrate the benefits of a three-month in-home coordinated rehabilitation program. Fifteen of 17 clients had improved scores on the Timed Up and Go (TUG) standardized walking test and the Berg Balance Scale (BBS) balance assessment.
Fifteen of 17 clients showed improvement after a three-month physiotherapy intervention, and none of the clients experienced a deterioration in the endpoints. Based on Four Step Square Test (FSST) measurements, after a three-month physiotherapeutic intervention, 13 of the 17 clients had improved, and none of the clients had deteriorated.
Key elements of the project were: (1) increased motivation associated with the in-home setting, (2) family involvement in the rehab program, (3) the very close co- operation between the physical therapist and occupational therapist. The role of occupational therapy in a coordinated rehabilitation program: The main objective of occupational therapy is to establish the best quality of life, and maximum possible self-sufficiency and independence for each client relative to their particular type of disability (physical, psychological, mental, sensory, or social) and age.
For occupational therapy to be appropriately adapted to the individual needs of a person with a disability, a careful and complete assessment of self-sufficiency is important. Interactions people-activity-environment is the central triad of ergonomic therapy, with increased activity and a return to employment being not only goals but also a means of therapy.
Social work within a coordinated rehabilitation system : for clients after acquired brain injury (especially strokes) with special attention directed toward intervention in terms of social work, physiotherapy, occupational therapy, and other selected professionsThe ergotherapeutic goal of the research was to determine which therapeutic strategies provided the greatest benefit for people after an ABI and, on the basis of real-world experiences with clients, to create a methodology that would promote deinstitutionali- zation and facilitate the best quality of life for people with acquired brain injury, with an emphasis on interprofessional cooperation and coordinated rehabilitation. In view of the above, the main research problem, from an ergotherapeutic point of view, was what were the best methods to facilitate the client's self-sufficiency upon return from the hospital to the home environment.
Simply describing various tools or gadgets that can be used after an ABI in the home environment is not enough. This simplistic approach is detrimental to patients with ABIs because it does not prioritize a barrier-free home environment; thus, it fails to promote the maximum possible self-sufficiency, and in some cases, may prevent the timely return of clients back to their home environment.
This publication is certainly important from a scientific and practical standpoint; however, it is also important because it addresses a critical human need within our society, which, thanks to the work of the project's team members, is now being con- fronted. In essence, it was an experiment whose results proved extremely effective for ABI clients and their families (and especially those in the role of informal caregivers).
All those involved in the implementation of the project effectively showed that coor- dinated rehabilitation, especially cooperation with a comprehensive interdisciplinary team designed to address the specific needs of clients, should be routinely available and an integral part of the health and social services provided in the Czech Republic.