The organization of rehabilitation interventions differs within and between European countries [
Health care in both Denmark, which has 5.7 million inhabitants, and Norway with 5.2 million comprises two complementary public sectors: the regional specialised hospital services and the primary health care system, each with separate obligations and regulated by distinctive laws and regulations. In Denmark, areas of responsibility and division of labour between regions and councils were reorganised following municipal reform in 2007 and changes in the health legislation in 2006 [
Once a patient is discharged from hospital, the responsibility for rehabilitation falls to the municipality. The two countries’ respective primary sectors consist of 98 Danish and 428 Norwegian municipalities. Each of these provides primary health care, long-term care services, home-based care, and social care provision, accommodated to the needs of citizens and within the bounds of available economic and professional resources. The legal basis for stroke rehabilitation is regulated by a range of laws. Patients’ needs generally require the participation of professionals across several fields, such as health, social care, education, and employment. Furthermore, collaboration and preclarification of the patients’ rights are defined by general rules. Thus, the legal framework and sectoral legislation reflect the complexity and diversity of stroke rehabilitation [
Denmark provides centralized neurorehabilitation with a large patient volume to achieve specialization. The Danish Health Authority provides general guidelines for the organization and provision of services included in rehabilitation programs following a stroke. The Health Technology Assessment (MTV) report [
The Norwegian Health Authority provides national guidelines regarding treatment and rehabilitation following a stroke [
The level of access to a contiguous coordinated intervention conducted by a specialized interdisciplinary team that works in collaboration with patients and relatives can have a major influence on rehabilitation outcome [
The aim is to describe the citizens’ rehabilitation needs present at discharge after stroke and how professionals in the municipalities experience these are met, focusing on regaining a meaningful everyday life. The study is a substudy of a multicenter study “The NORDA-study”, which describes and compares stroke pathways in Norway and Denmark.
Qualitative content analysis was suitable to explore and describe the multifaceted phenomena of ongoing relational rehabilitation practices [
Patients: Eleven individuals, aged 25-65 and suffering from a confirmed diagnosis of stroke with moderate disability, were followed from the time of discharge from hospital until about one year after onset. The inclusion criteria were that they had lived an active, independent life before the injury and that they were discharged to their own home in one of two Danish municipalities. In Norway, we included patients consecutively, comprising their home municipalities, five in all. Professionals included were members of the municipal health services who were involved in service provision to any of the included patients. Exclusion criteria were cognitive and communication changes that made it impossible to share the patients’ experiences.
Focused field studies of each informant were used to examine interactions between patients and professionals in the municipal health services. This included conversations with professionals about their reflections, with patients about personal aims regarding and experiences of the rehabilitation process [
Ongoing rehabilitation practice from the rehabilitation professionals’ perspective was explored by semi-structured focus group interviews, which allowed for exchange and the elaboration of experiences and ideas among colleagues [
The study was carried out according to the ethical guidelines for nursing research in the Nordic countries [
Denmark: The two Danish municipalities have 61,000 and 48,000 citizens, respectively. In each municipality, following a stroke, all citizens younger than 65 are offered rehabilitation at a health centre. The rehabilitation is organised across employment, social and health administrations as well as professional organisations in an interdisciplinary “Brainteam” affiliated to the health centre.
Norway: Patients were included from five different municipalities. Of these, four have fewer than 10,000 and the remaining municipality has 72,000 citizens. In one of the municipalities, the rehabilitation professionals involved were team organized. In the remaining municipalities, professionals worked separately as privately-practising or/and on individual locations.
See Table
Included cases.
Pt | Sex | Age | Pre injury vocation | Dwelling | Days at | Citizes in municipality | Functional impairment at discharge from hospital (described by professionals in epicrisis, interdisciplinary status or rehabilitation plan) |
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1/DK | Fe | <60 | pension | cohabiting | 3 | 61.000 | Sensomotor right-sided impact: Muscle strength and muscle tone slightly reduced, slightly reduced balance control. Leg lagging behind and impaired arm swing. Cognitively: Reduced executive and memory function. Fatique. Linguistic: Clearness in speech, but easy difficulty in steering the tongue. |
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2/DK | Ma | ≤65 | flexijob | cohabiting | 57 | 61.000 | Sensormotor: No functional changes. Cognitively: Reduced concentration and attention, especially persistent attention, reduced memory and cognitive language difficulties. Distinct executive difficulties with impaired idea generation, reduced work memory, lack of overview and problem solving ability. Reduced recognition and insight into own situation. |
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3/DK | Ma | <50 | Full time | cohabiting | 51 | 61.000 | Sensomotor right sited impact: Slightly reduced strength. Reduced fitness and endurance. |
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4/DK | Fe | <40 | Full time | cohabiting and children | 91 | 48.000 | Sensomotor left sited impact: Increased tone, reduced strength as well as light changes in fine motor function in shoulder, arm and hand, increased tone in cheek and tongue. Reduced endurance. Cognitively: Difficulties in divided attention challenging to rest and maintain activity. Slightly reduced memory function and easy dysarty. Fatigue. |
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5/DK | Fe | <55 | Part time at night | cohabiting | 2 | 48.000 | Sensomotor right sited impact: Heaviness of extremities, sensory disturbances around the mouth. Able to walk independently, but she fells a bit insecurity. Some fatigue. |
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6/DK | Ma | <55 | unemployed | cohabiting | 37 | 48.000 | Sensomotor left sited impact: Slight reduced control and reduced strength of the hand and leg. Left foot lags behind Balance problems, especially in the case of change of direction. |
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7/N | Ma | <50 | Full time | cohabiting with sister and his son | 28 | 4.800 | Sensomotor right sited impact: Paralytic arm. Non-functional activation of arm and hand, but can easily activate both flexors and extensors in arm as well as supination and pronation. Incipient hand grip and dorsal reflection by hand. Reduced strength 3-4 / 5 in leg but walks without support indoors. Slight facial paresis. Cognitive: No disturbances. |
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8/N | Ma | ≤65 | Partial pension | Single | 37 | 72.000 | Sensomotor right sited impact: Reduced strength in the leg, but is able to walk with support, Reduced strength and fine motor movement in hand and fingers but has an important support function. Dysarthria. No cognitive disturbances |
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9/N | Fe | <50 | pension | single | 57 | 9.500 | Sensomotor: Slightly tense right arm. Going independently indoor and with surveillance also outdoor. Dizziness, double vision. Cognitive: Reduced memory. Slight word finding difficulty, not fluent speech. Easily distracted by noise, other people and mess, but manage to move on in activity. Easily tired and need small breaks |
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10/N | Ma | <45 | Full time | Cohabiting and children | 56 | 3.500 | Sensomotor right sited impact: Reduced stability in hip, knee, reduced quadriceps activation. Reduced strength and stability in shoulder and elbow. Walks short distances in-door. Reduced fine motor precision in hand. |
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11/N | Ma | <60 | Partial pension | Cohabiting and child | 29 | 5.500 | Sensomotor left sited impact: Reduced sensitivity in hand/arm. Reduced attention to and stability in shoulder. Unimpressive walk without fall risk |
Seamless cross-sectoral rehabilitation services are hallmarks, in both Denmark and Norway. Following discharge from hospital, the municipal health services are required to facilitate coordination between different services. However, we found wide variation. In Denmark, there was a lack of continuity from discharge to municipal rehabilitation in cases 1, 3, 5, and 6. Similar discontinuity was identified in the Norwegian cases 8, 10, and 11 (Figure
Duration of different professional rehabilitation services.
According to national recommendations in both countries, professionals in a multidisciplinary neurorehabilitation team are required to have specialist expertise in neurorehabilitation. Team members include physicians, nurses, physiotherapists (PT), occupational therapists (OT), social workers, psychologists, speech therapists, social workers, job consultants, and course coordinators. We found a wide variation in the composition of rehabilitation teams (Figure
Figure
Sensorimotor changes in the hand and or arm were described in all cases, except for case 2 (Table
To group and abstract the various aspects of the patient’s life the professionals described to address during the rehabilitation process, the conceptual framework of the ICF was used to outline rehabilitation work related to body function, activities, and participation as well as environmental and personal factors.
Physiotherapy was conducted as individual self-training and as group exercises for patients with similar challenges, and the PTs and OTs emphasized the importance of time for the social aspect to facilitate recognition and participation (Table
Physiotherapeutic contributions in the eleven cases during rehabilitation.
Case | Individual 1:1 start number per week | Self training in centre primary focus on strength, condition with PT instruction number per week | Group exercise in centre with selected peers instructed by OT/PT | Public fitness centre without instruction |
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1/DK | 2 | 1 | 1 | |
2/DK | 3 | 1 | ||
3/DK | 1 | 1 | ||
4/DK | 1 | 1-2 | ||
5/DK | 1 | 1 | 1 | 1 |
6/DK | 3 | 2 | 2 | |
7/N | 3 | |||
8/N | 5 | |||
9/N | 2 | |||
10/N | 3-2 | |||
11/N | 2 | 5 |
A physical focus appears in both countries, despite the prevalence of severe cognitive disturbances. Physiotherapy was offered as first-line rehabilitation, and it was also the most enduring service.
Possible cognitive changes at admission were described in cases 1, 2, 3, 4, 6, 9, 10, and 11 (Table
Professionals articulated the interaction with equals as a subsidiary goal in group-based training, to facilitate the patient’s cognition and realization their condition. Therefore, both PTs and OTs were present at the training sessions to promote social interaction and to support the patients in cases 2 and 3. An OT explained that “
The rehabilitation services addressing activity were integrated in daily life, work, or leisure activities in the majority of both Danish and Norwegian cases. In both settings, the sensorimotor challenges appeared to be afforded a higher priority than cognitive challenges. Limited coordination between professionals resulted in fragmented and nonevidence-based rehabilitation services. This was due to monodisciplinary interventions and contributions from unsupervised employer and colleagues, which characterised the Norwegian cases. Interdisciplinary team organisation was prevalent in the Danish cases and the individualized interventions related to cognition were mainly compensatory. Group interventions and relations with equals were arranged to improve cognition and realize the changes.
Reintegration into the social network was challenged by uncertainty and stigmatization. This was addressed in case 4, where the pedagogue described the following:
Family integration was present in the Danish cases; the partners were routinely invited to planning and evaluation meetings and some of them also to training sessions. We were unable to identify any similar strategies in the Norwegian cases, but the professionals discussed the possibilities for broader social reintegration with some patients. Group training with peers, exchange of experience groups for patients and relatives, and individual support were described in the Danish settings, in order to facilitate social interaction. This aspect was not described by the Norwegian professionals.
According to the ICF, the personal factors of pre- and poststroke personality consist of an individual’s traits that are essential to the person’s behavior and ability to cope [
Home visits to adapt the environment to the patients’ needs were common in Denmark, but confined to one case in Norway, despite similar challenges in both groups. In all Danish cases and the Norwegian case 8, a PT and an OT visited the patients’ home in order to assess needs and suggested environmental adaptation of furniture, fixtures and fittings as well as the need for aids. The need for assistive aids was also assessed by an OT in Norwegian cases 7, 8, and the 9, but there was no follow-up or involvement of rehabilitation provision. Personal aspects were acknowledged by professionals in both countries, but systematic strategies to identify and improve these were absent.
This qualitative study explores and compares the rehabilitation efforts after stroke in two Danish and five Norwegian municipalities. Homogeneity in the two compared groups is not confirmed as the included participants suffered from a broad variety of changed functions. Both aspects impede the need for great caution in relation to generalize our findings to the entire national populations.
Rehabilitation outcome depends on access to a contiguous, coordinated intervention conducted by a specialized interdisciplinary team that collaborates with patients and relatives [
In the early weeks after a stroke, patients have varied and complex needs which require expertise from different groups of health care professionals. Both Danish municipalities have a coordinator and a specialised brain injury rehabilitation team to address various aspects of functional changes. In Norway, one patient was enrolled in reablement, while the other cases were provided generalist services in stroke rehabilitation. This entails varying competencies and resources, comparable to national findings in 2012 [
National diversity was found in present health profiles, time resources and integration of rehabilitation services in the patients’ everyday lives and home environment. In the Danish municipalities, the integration of rehabilitation provision in valued daily life activities was dominant, while work life movements, counting, and writing in authentic environments were more obvious in the Norwegian cases. A key emphasis on body function appears in the included cases in both settings. This indicates a discrepancy in relation to the ICF which relies on a biopsychosocial (BPS) concept of disease and illness, as formulated by Engel [
In relation to the ICF framework of activity and participation, the patients’ personal experiences and preferences related to their changed life condition should be taken into consideration [
Rehabilitation after stroke basically follows the same guidelines in both settings, but the organization of rehabilitation courses is more team organized in the Danish than in the Norwegian settings. Volume and centralization seem to be pivotal in conducting rehabilitation that addresses the ICF aspects of human life influenced by a stroke. Team organization, multidisciplinarity, and collaboration to assess and target the patients’ needs characterised the rehabilitation services in the two Danish municipalities. Decentralized coordination and monodisciplinary contributions with scarce or unsystematic collaboration were common in the five Norwegian municipalities. Seamless cross-sectoral services are key contributors to holistic rehabilitation. This was challenged in both countries, but most notably in Norway due to unsystematic coordination and waiting lists for privately-practising therapists. The municipal provision emphasized physical functioning in duration and intensity, which might conflict with the patients’ needs, as described at discharge from hospital. Cognitive disturbances and aspects of activity or participation were systematically addressed by the interdisciplinary team in the Danish cases, while practitioners experienced a lack of multidisciplinary collaboration in the Norwegian municipalities, where these disturbances seemed to be scarcely addressed. The patterns of diversity between rehabilitation efforts in Danish and Norwegian municipalities may partly be explained by the variation in population density, geographical extent, available health profiles, time resources, and utilisation of the usual environment.
Greater consideration should be given to the aspects of activity and participation in the context of community settings. This is in order to determine how patients with stroke and those in their closest networks can be supported in becoming less dependent on public services and, as far as possible, able to understand and manage their own everyday lives. This requires an accordance between the ideology of the ICF and clinical rehabilitation practice in the political and the managerial arenas of the health care system.
The empirical data used to support the findings of this study are included within the article.
The authors declare that they have no conflicts of interest.
The authors were jointly responsible for the writing and content of this paper.