Weerakkody Ashan, Godecke Erin, Singer Barby
Rehabilitation in the Home, South Metropolitan Health Service, Department of Health, Fremantle, WA, Australia.
School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia.
BMC Health Serv Res. 2025 Aug 15;25(1):1086. doi: 10.1186/s12913-025-13273-9.
Modified constraint-induced movement therapy (mCIMT) improves upper limb (UL) function after stroke. Despite extensive evidence supporting its efficacy and multiple clinical practice guidelines recommending its provision, very few eligible stroke survivors receive mCIMT internationally. A multi-modal behaviour change intervention, guided by the Theoretical Domains Framework (TDF) and Behaviour Change Wheel, was implemented across a large early-supported discharge (ESD) rehabilitation service in Perth, Australia, to increase delivery of mCIMT within existing resources. As part of this iterative implementation process, qualitative data from stroke survivors, carers, clinicians and managers informed program adaptations to support sustained mCIMT delivery. This study aimed to evaluate the process of implementing mCIMT across the seven sites of this ESD service.
This mixed methods process evaluation was guided by the RE-AIM QuEST framework. Data collection included patient file audits (conducted twice over six-month periods) (N = 540), clinician training attendance records, interviews with stroke survivors and carers (N = 25), and focus groups with clinicians and managers (N = 24). Quantitative data were analysed descriptively. Qualitative data were analysed using reflexive thematic analysis and mapped to the Capability, Opportunity, Motivation- Behaviour model for interviews and TDF for focus groups.
Reach: 31% of all stroke survivors admitted to the ESD service, including 80% of those with an UL impairment, were eligible for mCIMT. Twenty-eight facilitated workshops were conducted across all sites (four per site).
Clinicians reported that the behaviour change intervention improved their knowledge, skills and confidence to identify suitable stroke survivors and deliver mCIMT programs. Adoption: 17% of eligible stroke survivors were offered mCIMT and 11% received it (Audit 1).
7/9 programs were delivered with protocol fidelity. Adaptations included ongoing/booster training sessions and resource refinement. Maintenance: 34% of eligible stroke survivors were offered mCIMT, with 26% receiving it, and all programs adhered to the protocol (Audit 2).
mCIMT was feasibly and acceptably integrated into the ESD service, demonstrating that complex interventions can be implemented within existing resources. However, concerns persist regarding sustained delivery. Future research should investigate long-term sustainability and target policy-level change to ensure stroke survivors consistently receive evidence-based interventions.
改良的强制性使用运动疗法（mCIMT）可改善中风后的上肢（UL）功能。尽管有大量证据支持其疗效，且多项临床实践指南推荐采用该疗法，但在国际上，很少有符合条件的中风幸存者接受mCIMT治疗。在澳大利亚珀斯的一项大型早期支持出院（ESD）康复服务中，实施了一种以理论领域框架（TDF）和行为改变轮为指导的多模式行为改变干预措施，以在现有资源范围内增加mCIMT的提供。作为这一迭代实施过程的一部分，来自中风幸存者、护理人员、临床医生和管理人员的定性数据为项目调整提供了依据，以支持mCIMT的持续实施。本研究旨在评估在该ESD服务的七个地点实施mCIMT的过程。
本混合方法过程评估以RE-AIM QuEST框架为指导。数据收集包括患者档案审核（在六个月内进行两次）（N = 540）、临床医生培训出勤记录、对中风幸存者和护理人员的访谈（N = 25）以及与临床医生和管理人员的焦点小组讨论（N = 24）。定量数据进行描述性分析。定性数据采用反思性主题分析进行分析，并根据访谈的能力、机会、动机-行为模型和焦点小组的TDF进行映射。
覆盖范围：所有入住ESD服务的中风幸存者中，31%符合mCIMT治疗条件，其中80%上肢有损伤。在所有地点共举办了28场促进性研讨会（每个地点4场）。
临床医生报告称，行为改变干预提高了他们识别合适的中风幸存者并实施mCIMT项目的知识、技能和信心。采用情况：17%符合条件的中风幸存者被提供了mCIMT，11%接受了该治疗（审核1）。
9个项目中有7个按照方案保真度实施。调整措施包括持续/强化培训课程和资源优化。维持情况：34%符合条件的中风幸存者被提供了mCIMT，26%接受了该治疗，所有项目均遵守方案（审核2）。
mCIMT已切实可行且可接受地融入了ESD服务，表明复杂干预措施可在现有资源范围内实施。然而，但在持续实施方面仍存在担忧。未来的研究应调查长期可持续性，并针对政策层面的变革，以确保中风幸存者始终能接受基于证据的干预措施。
