On aspects of context in rehabilitation after stroke : views of patients and therapeutists

Sammanfattning: Contextual factors have lately come more into focus contributing to the individual's health condition. Previous research indicates that contextual factors are poorly accounted for in stroke rehabilitation and that the patient's participation in planning and decision making in the rehabilitation process is very limited. Professionals working with stroke rehabilitation need to develop an understanding of the contextual aspects and incorporate them in their rehabilitation strategies. The overall aim of this thesis was to explore and describe rehabilitation after stroke in different contexts. Data for Study I were collected from participant observation of therapy sessions in hospital and at home and from semi-structured interviews and documents. Three patients and two therapists participated. In Study II, data were collected by participant observations in hospital and semi-structured interviews with nine patients and ten physiotherapists. A descriptive, comparative approach for data analysis was applied in Studies I and II. In Study III data were collected from therapeutic stories told by 13 therapists working in the patient's home. The transcribed data were analysed with a phenomenological approach. The present thesis describes differences in rehabilitation after stroke in the hospital and in the home. It has put words on tacit knowledge of the meaning of working with rehabilitation after stroke in the patient's home. The findings in Study I indicate clear differences between a rehabilitation session in the patient's home versus one in the hospital. Both the therapists and the patients assumed different roles in the different contexts and at home the patient took initiative and expressed his goals, which was not the case for the patients in the hospital. In Study II differences between the patients' and the therapists' descriptions of what characterises a physiotherapy session in the hospital was revealed. In the theme Facilitating active patient involvement the physiotherapists reported an interest for taking the patients personal experiences into account. This was not recognised by the patients. One of them explicitly expressed how the personal interest was not included in the rehabilitation process. In Study III one of the characteristics was Supporting continuity, where the patient as an individual with his/her life-story was in focus. The findings in the three studies support and confirm each other by giving descriptions on aspects of context involving both environmental and personal factors. In addition, the findings describe contextual aspects in relation to experiences of the body after stroke. Contextual factors were considered of great importance for the rehabilitation after stroke by both the therapists and the patients, but only in rehabilitation at borne they were clearly included in the therapy sessions or the rehabilitation process. Ways to include contextual factors in the rehabilitation in hospital needs to be developed e.g. to encourage the patients' participation in the rehabilitation process. Contextual factors in the hospital in general were not regarded as conducive to activities neither by the patients nor the therapists. Hence, this is an area open for improvements.