Author Identifier

Ashan Weerakkody: http://orcid.org/0000-0002-2949-3385

Date of Award

2025

Document Type

Thesis

Publisher

Edith Cowan University

Degree Name

Doctor of Philosophy

School

School of Medical and Health Sciences

First Supervisor

Barbara Singer

Second Supervisor

Erin Godecke

Abstract

Background

Modified constraint-induced movement therapy (mCIMT) improves upper limb (UL) function after stroke, but its routine delivery in rehabilitation settings remains limited.

Aims

The objectives were to determine the feasibility, acceptability, and sustainability of implementing mCIMT within an early-supported discharge (ESD) rehabilitation service, using existing resources and staffing.

Aims were to:

  • Develop and deliver a multi-modal behaviour change intervention to clinicians to increase mCIMT delivery.
  • Explore the acceptability of mCIMT among stroke survivors, carers, therapists, and allied health managers.
  • Identify program adaptations to better suit stakeholder needs.
  • Evaluate the process of implementing mCIMT in the ESD service.

Methods

This thesis comprised four main sections:

  1. A clinician behaviour change intervention was developed over five stages using informal discussions and an online survey (N = 35). Barriers and enablers were mapped to the Theoretical Domains Framework (TDF), and behaviour change techniques were guided by the Behaviour Change Wheel.
  2. Semi-structured interviews with stroke survivors and carers (N = 25) and focus groups with therapists and managers (N = 24) were conducted. Reflexive thematic analysis was followed by mapping data to the Capability, Opportunity, Motivation- Behaviour model (for interview data), and the TDF (for focus group data).
  3. Retrospective file audits were conducted over two six-month periods. The first audit (N = 237) assessed the feasibility of mCIMT in the ESD service, while the second audit (N = 303) evaluated program adaptations and sustained mCIMT delivery. Data included patient demographics, mCIMT eligibility, and whether mCIMT was offered and received.
  4. The RE-AIM QuEST framework evaluated the process of implementing mCIMT, informed by quantitative and qualitative data from all aspects of this study.

Results

  1. Determinants influencing implementation operated across the TDF domains of knowledge, skills, environmental context and resources, and social influences. The behaviour change intervention consisted of education, training, environmental restructuring, and modelling.
  2. Stroke survivors and carers found mCIMT offered considerable benefits compared to other UL therapies. Multi-faceted education strategies could increase their preparedness and engagement in mCIMT programs. Clinicians and managers found mCIMT was acceptable in the ESD service and felt a responsibility to provide it. Key adaptations for sustained delivery included ongoing training, resource adaptation, and enhancing patient and carer engagement. 3. In the first audit, 82 stroke survivors were eligible, of whom 17% were offered and 11% received mCIMT. In the second audit, 86 stroke survivors were eligible, 34% were offered and 26% received mCIMT. These results were presented in Adoption (audit 1) and Maintenance (audit 2) sections of the process evaluation.
  3. Reach: 31% of all stroke survivors, including 80% of those assessed as having UL impairment, were eligible for mCIMT. Implementation: Changes to the program included ongoing/booster training, resource adaptation, and formalising mCIMT into learning objectives.

Conclusion

This study demonstrated that the co-designed implementation of mCIMT within an ESD rehabilitation service was feasible and acceptable among all stakeholders using existing resources and staffing. However, barriers to sustained service delivery persist, requiring continuous engagement to ensure mCIMT becomes standard care for eligible stroke survivors.

DOI

10.25958/6sb8-k359

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