Semi-supervised practice in inpatient rehab
Simone Dorsch recently completed a large observational study, which gives some good insights into increasing exercise practice safely and without direct therapist supervision in inpatient rehabilitation gyms.
How much of the day do people in inpatient rehabilitation typically spend doing rehabilitative exercise?
Typically people in rehabilitation spend less than an hour a day exercising. Observational studies show that they spend small amounts of their day in the gym area and even when they are in the gym they are often inactive for more than half of that time.
Why is it so difficult to get these patients to exercise?
Isn’t that precisely what they are admitted to hospital for? Patients are generally not given the opportunity to spend more time exercising. The main reason for this is that most therapy is one-on-one therapy. This limits the time patients can spend exercising as there is often only one or two therapists to around 10 patients on a rehabilitation ward. It is up to therapists to change the way that they work to enable patients to spend more time in the therapy area exercising.
How did you try to tackle this problem?
We tried to enable patients to spend long periods of time in the gym and to exercise when the therapist is not with them (semi-supervised exercise). This means that a therapist generally has several patients in the gym area at the same time rather than one patient at a time. The therapist then spends their time moving between the patients, setting up different semi-supervised exercises and limiting any one-on-one practice to exercises that need to have a therapist present for safety or instructional reasons.
What do you mean when you say ‘semi-supervised exercise’?
We mean exercise that takes place in the gym area—so there is some supervision but the patient is exercising without a therapist directly supervising them. This can include exercising with a family member or friend.
And what did setting up the gym involve?
In order to make semi-supervised practice as safe as possible, the environment needs to be set-up to provide safety. Typically a patient doing semi-supervised exercise would have a plinth behind them, a wall to one side and a height adjustable table on the other side, and a table in front if needed. As well as safety it is important to set-up visual cues in the environment to make the exercises as good as possible, for example, tape on the floor to mark where the patient’s feet should be so they have a narrow base of support while doing balance exercises. It is also important to have systems of counting and recording practice as then patients are more likely to continue to practice without direct supervision.
The gym area needs to be a place where families and friends are welcome and the importance of their involvement is emphasised. Therapists can teach family members how to provide physical assistance and instructional guidance. The involvement of family increases the amount of semi-supervised exercise that takes place and research has shown that family members are less stressed when they are involved in therapy.
Did substantial amounts of semi-supervised exercise happen?
Yes, on average 41 per cent of the exercise being done in the gym was semi-supervised exercise. Over a third of this semi-supervised exercise was being done with the assistance of a family member.
Does your paper give much practical guidance to other physiotherapists who want to set-up their gym to foster semi-supervised practice?
We have included practical advice in box 1 in the article and there are two appendices. Appendix 1 is a diagram of the physical layout of the gym and Appendix 2 contains pictures of patients doing semi- supervised practice that illustrate how the environment has been set-up to provide safety.
Simone Dorsch, APAM, is a lecturer at ACU and a presenter with the StrokeEd collaboration. Her research investigates strategies to increase practice in rehabilitation and the associations between impairments and activity after stroke.
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