A descriptive analysis of physical therapy group intervention in five midwestern inpatient rehabilitation facilities

Gelsomino, Kristi L

ABSTRACT. Throughout the nation, the rapidly changing health care system has led to the use of more cost-effective and time-efficient means of intervention in rehabilitation. Group therapy has been utilized as a solution to these challenges. The purpose of this study was to describe the characteristics, utilization, frequency, and implementation of therapeutic groups in five midwestern inpatient rehabilitation facilities. Staff and group participants were observed within these facilities in order to describe each facilities 'group intervention. Clinic visitations were arranged, and data were collected by means of a data collection tool, researcher observations, and staff interviews. Information was gleaned regarding number of patients seen per day; predominance of group therapy versus individual therapy, number and types of groups offered, number of patients per group, number of offerings per week, length of group sessions, staff involvement, billing issues, and subjective reactions from group leaders and patients. Responses given during data collection were used to describe characteristics, utilization, frequency, and implementation of groups. All facilities were treating more than 60 patients per day. All facilities were using a combination of individual therapy and group therapy The number of groups per facility varied from 2 to 9. The most commonly offered groups included: spinal cord injury, mat, upper ex

tremity, stroke, gait/ambulation, and wheelchair. The number of patients per group varied from 3 to 12. Group treatments were conducted 1 to 6 times per week. Group meeting times varied from 30 to 120 minutes. Group leaders were either physical therapists or physical therapist assistants in all facilities. Facilities 'group charges ranged from 33% to 100% of their individual treatment charges. Group leaders described group physical therapy as a good adjunct to individual therapy. Many of the participants appeared to enjoy the groups and were motivated by each other Group intervention is a viable option to the demands placed on therapists with shortened length of stays and decreased reimbursement.

INTRODUCTION

Throughout the nation, the rapidly changing health care system has led to the use of more cost-effective means of intervention for patients undergoing rehabilitation. Health care costs have increased five times the general inflation rate.1 Current trends in health care have allowed less time for patients to be seen in rehabilitation.2 Organizing therapeutic groups has been beneficial to the health care system by decreasing the cost and time spent for rehabilitation.3-6 According to Gauthier and colleagues, "The group approach is ... very cost-effective, only one or two therapists are needed for 8-10 patients for a period of 20 hours.."4(P363> The placement of patients into groups for therapy not only has been proposed to increase the speed of recovery7,8 but also has been shown to decrease costs of physical therapytreatments.1,3,6

PHYSICAL THERAPY LITERATURE

In the physical therapy literature, a lack of referred publications exists regarding therapeutic group intervention; however, several published abstracts address the use of physical therapy groups in the outpatient setting.9-15 More relevant to this research are those containing information on inpatient groups that describe dividing group treatment classes into the type of activity the group performs. For example, transfer and ambulation groups,16 bronchopulmonary fitness groups,17 balance groups,18 functional exercise,19 and interdisciplinary community reentry groups20 have been proposed.

The New American Webster Handy College Dictionary defines a group as "a number of persons or things gathered or classified together, usually because of likeness or common purpose."21(p242> Duncombe and Howe define a group as "an aggregate of people who share a common purpose which can be attained only by group members interacting and working together."3(p202) In relation to these definitions, inpatient and outpatient groups are generally categorized according to patient diagnosis or group activity.

In 1987, Nishimoto and Schunk6 presented a case in which physical therapy treatment groups were initiated due to an inadequate number of therapists to handle the large number of patient referrals. All patients were initially evaluated with individual functional goals established. The patient's functional status primarily determined appropriateness for group therapy versus individual therapy, although diagnosis was also a consideration. The group treatments focused on exercises followed by functional activities in follow-theleader, buddy system, or circuit training formats. Treatment outcomes for patients in these groups included increased socialization, camaraderie, attention span, memory skills, and progress toward individual goals.

Szekely and colleagues7 provided comprehensive group therapy to patients with Parkinson disease and their families. Seven volunteers participated in a 13-week course of 2-hour sessions, with the first hour consisting of exercises for flexibility, walking, and marching. Families were included in this session, and cassettes and exercise logs were given to each patient to reinforce exercising at home. In the second hour, family members met in a group with a nurse coordinator and a nurse psychologist and discussed home and family issues. Meanwhile, patients met with the physical therapist, a nurse coordinator, and a nurse psychologist for further discussion, support, and education. Improvements in objective gait measures and reports of psychological gains were noted.

Kurasik8 studied 15 patients with cerebrovascular accidents, of which 10 patients were treated with group therapy and 5 patients were treated individually for rehabilitation. All patients receive therapy two times each day for 5 days. At the end of 2 weeks, the group therapy patients showed greater gains in function and mental attitude compared with the individually treated patients.

ADVANTAGES OF GROUP TREATMENT

The patient benefits of therapeutic group intervention include functional improvements, greater psychological and social awareness, and educational opportunities. According to Gauthier and colleagues, "It is important to keep in mind that interventions addressing motor and functional problems should be coupled with interventions aimed at improving socialization, motivation, interpersonal and family relationships, self esteem, and knowledge of the disease."4(p364)

The literature indicates that group therapy facilitates improvements in physical components of patient function and conditioning. In one study, patients with Parkinson disease exhibited improvements in gait measures such as standing, walking, and transfers when participating in physical therapy groups.7 Another study showed that patients participating in groups advanced to walkers and crutches, whereas patients receiving individual therapy remained in the parallel bars. Overall, patients in these groups achieved their goals an average of 8 days faster than the individually treated patients.8 Another study showed that group participants met goals approximately 1 week earlier than the individually treated patients.1

Group therapy can integrate psychological and social aspects of human nature that contribute to the common well being of the patients involved. Patients in groups interact with others facing similar situations and actively assist each other in enduring and coping with these problems.22,23 According to Ellmo, "The group provides a motivating and nonthreatening environment in which members can develop group interaction, cognitive, physical, emotional, communicative and other skills."24(p6) Many psychosocial factors can positively influence patients during group interaction such as encouragement,25 motivation,25 fear,25 feelings of isolation,26 hope,27 self-esteem,28 comfort,25 control,28 shared experiences,7,8 group cohesion,25,27,29 support system,7,25 trust,29 and anxiety.30 Interacting with other patients may provide an opportunity for increased understanding. In a group therapy setting, the rehabilitation is being guided by a therapist, but in many cases is also directed by the interaction among the group members.

An integral factor of group dynamics involves interaction among its members. Contributing to the socialization of the individual are outside social associations such as family, peer groups, religious affiliations, and organizations. Social qualities that develop within a therapeutic group consist of interactions among group members who engage in different roles. According to Payne, "Group learning for clients with chronic illnesses facilitates emotional adjustment, resocialization, and redefinition of the self and of one's role."31(p269> Dynamic group situations allow for patients to share and solve problems occurring with their conditions.32 When the group members share similar experiences with the discharged patients,33 the members become hopeful that they might also be able to integrate themselves back into society.5,8,29 By socializing within the group, patients tend to develop camaraderie by sharing their different experiences from real-life situations.6,28,29 The group approach has led to behavioral and attitudinal changes34,35 while diverting the patients' attention away from their pain13 and toward their relationships within the group.5

Group treatments also provide an opportunity for patient education. Education classes are often utilized in facilities to help defray medical care costs. Education within groups is provided not only by instructors but also by personal experiences shared by its group members. Patient contributions in a group setting lead to increased awareness for the entire group, whereas one-on-one therapy can only cover a small selection of topics. Education is most beneficial to members if the people belonging to the group have similar needs or medical conditions.5,8,31

DISADVANTAGES OF GROUP TREATMENT

Many positive elements of group therapy have been discussed; however, a few negative elements of group therapy include: (1) comparison of progress,28 (2) lack of adequate individual attention,28 (3) staff and patient resistance to group therapy sessions,5,33 (4) inconsistent attendance and participation, and (5) negative attitudes and atmospheres.28 Patients may tend to compare their own progress with the advancement of other group members. If other group members are progressing at a faster rate, some patients may feel incompetent within the program and may require more individual treatment. Moreover, hospital staff, such as physicians, nurses, and transporters, may not cooperate in getting patients to their group sessions on time.34 Overall, a negative attitude and atmosphere can also create detrimental effects on the group,28 including decreases in attendance and patient involvement.

PURPOSE

Hospital stays are getting shorter, and the population is living longer, thus requiring more medical care to be administered2,25; therefore, group educational and therapeutic programs will be essential to rehabilitation in the future. Much of the literature available on group intervention entails psychological and social aspects of patients involved in psychotherapy and occupational therapy. There is a paucity of published data directly related to physical therapy groups, making research in this area extremely important and timely. Because groups are becoming a common means of physical therapy intervention, data need to be collected and published to qualify the utilization and implementation of current physical therapy groups to better patient care. The purpose of this study was to describe characteristics, utilization, frequency, and implementation of physical therapy group intervention in five midwestern inpatient rehabilitation facilities. Data on group implementation, group assignment, patient transportation, patient performance, patient incentives, patient complications, billing, and group leader opinions were collected and compared with the literature.

METHODS

We completed on-site observations and interviews at five midwestern inpatient rehabilitation settings. One facility from each of five states was chosen based on known utilization of physical therapy groups. The department directors were contacted to arrange a minimum of a one-half day visitation to their facility. We collected information by means of a data collection tool, observation, and feedback from the staff. We developed the data collection tool to clarify how each facility utilized groups, based on information described in the literature as being important aspects of group intervention. Initially, a comprehensive list of issues was compiled that addressed the utilization of groups in physical therapy. These issues were then used to construct a data collection tool to be used at each facility as a guide for researcher observation. Objective questions in the instrument included questions about facility demographics; group dynamics (number of groups, types of groups, size, frequency and length of sessions); staffing for evaluation, treatment, and patient transport; monitoring of patient performance; patient discharge; and billing. Subjective information gathered included goals of group treatments, performance incentives, and complications of group treatments. Finally, a group leader questionnaire was developed to collect opinions on teaching groups, the perception of group dynamics, how staffing shortages are handled, and advantages and disadvantages of group treatments. A copy of the instrument is shown in the Appendix.

Upon our arrival to the facility, the director scheduled time to observe each type of group and to interview the group leaders. Depending on the timing of the groups and the staff's availability, one to three researchers observed each group and were responsible for collecting group leader data. The data collection tool was sent to each facility in advance and was completed by a therapist prior to our arrival. All clinics except one complied with this request. This facility completed the questionnaire while we were on-site. Group leader questions were answered in one of two ways: (1) therapists were interviewed and their answers transcribed by the researchers, or (2) therapists independently answered the questions and returned the sheets directly to the researchers or faxed responses at a later date. This data collection variation was due to the preference and time constraints of the group leaders. Patients were not individually assessed; however, their interactions with other group members and leaders were observed and documented.

Data Analysis

Responses given during data collection were used to describe the characteristics, utilization, frequency, and implementation of groups in the five midwestern inpatient rehabilitation facilities. The data collected from each facility was reduced by listing and tabulating responses to each question. The data were used to compare findings from current literature with clinical observations.

RESULTS

Group Implementation

All facilities had utilized groups in some capacity for many years. More than 60 patients were seen in therapy each day in all facilities. Three of the five clinics had formally documented group protocols for each type of group, which included information on location, length of group session, size, staffing, goals, admission criteria, discharge criteria, and examples of activities to use during sessions. The directors of the other facilities were able to provide this information using the data collection tool, based on their knowledge of these treatments.

All of the clinics had specified goals for each type of group or for group treatments in general. Table 1 shows the frequency the goals were stated across the facilities. Most patients received group treatments as an adjunct to individual therapy in all of the facilities except one, which utilized groups solely on weekends to allow for adequate coverage with available staff. The demographics and staffing of the facilities are shown in Table 2, along with the variety in the number and types of groups used for physical therapy. The frequency each type of group was offered across the facilities is listed in Table 3. The types of groups and the number of patients who participated in each group varied depending on the facility. The range for group size was from 3 to 12, with educational groups being limited primarily by space. The frequency in which groups met ranged from one to six times per week, and the length of group sessions ranged from 30 to 120 minutes. The number of supervising staff members per group ranged from one to four (Table 4). Generally, a physical therapist or physical therapist assistant led the group, developed group activities, and documented in patients' charts. Aides and volunteers were used to help patients who needed extra assistance, to assist with equipment needs, and to prepare and clean group treatment areas. In all facilities, the groups met mostly in a physical therapy gym, while sometimes using classrooms, conference rooms, hallways, or activity rooms for the group session. Assistive devices, free weights, weight machines, resistive bands, therapy balls, and bolsters were types of equipment used during group sessions. The majority of the groups were designed so that patients were completing individual tasks at the same time, especially in mat, strengthening, and slings and springs groups. However, some groups used follow-the-leader formats, circuit training, and obstacle courses, which seemed to increase patient interaction.

Group Assignment

Patients were assigned to groups in various ways. Two of the clinics placed patients into groups by following recommendations from the primary physical therapist assessment of functional level and established goals. One of the clinic's placement of patients into groups was determined by the primary rehabilitation team, which included a physical therapist, an occupational therapist, and a recreational therapist. The primary physical therapist or physician made the group recommendation at another clinic. The fifth clinic placed patients into groups on admission through central scheduling based on the patient's diagnosis.

Patient Transportation

Many individuals assumed responsibility for transporting patients to the group therapy sessions. In one facility, the transporters or volunteers were responsible for seeing that the patients were in the proper place at the assigned time for groups. Because this facility mainly utilized groups on Saturday, the groups met on the unit. In the other rehabilitation facilities, nurses, therapists, or aides from the department in which the patients were last seen transported the patients to the appropriate group.

Patient Performance

All facilities monitored patients' progress through written documentation such as flow charts, forms, and treatment notes. The treatment teams also verbally informed each other of patients' progress. Each facility was asked questions regarding handling patients who were combative or who demonstrated decreased performance. In most cases with a combative patient, the therapist or group leader removed that patient from the group until the patient interacted more appropriately. If a patient had decreased performance, the therapist either moved the patient to a lowerlevel group or switched the patient solely to individual physical therapy. After a patient was discharged from a group, he or she was either placed into a more advanced group if remaining in the rehabilitation facility or sent to the appropriate location (eg, home, extended care facility, outpatient rehabilitation) upon discharge.

Patient Incentives

All five clinics reported using verbal praise as a performance incentive for the group members. Three of these clinics specifically stated that this verbal praise can arise from the leader or from the other group members. Two of the facilities noted an incentive for obtaining established goals was placement into more advanced groups or discharge. One clinic also used contests within the group in which the winner received a reward.

Patient Complications

Patient complications within the group, such as isolation, infections, and suctioning, were addressed in several ways. Four of the clinics reported that patients on isolation received individual treatment only. One clinic reported that all patients were able to attend group sessions if appropriate and were encouraged to manage their own needs. Three facilities addressed group treatments with patients who had infections. Two of the three facilities allowed patients to participate if the infection was self contained. The third facility stated that if the infection was not self contained and the physician orders group therapy, the patient would then participate on a mat separate from the other patients. Additional staff members would be added to accommodate patient needs at two of the facilities. Two clinics addressed suctioning needs of patients within the group. One clinic called the nurse to perform suctioning procedures. The other clinic reported that the group leader would complete the suctioning and continue with the group treatment.

Billing

All of the facilities billed according to a group charge. Each facility charged a percentage of its individual charge, one clinic at 100%, one at 65%, two at 50%, and one at 33% of the individual charge.

Group Leaders

A total of 32 physical therapists and physical therapist assistants representing all five clinics answered the group leader questions. Their opinions on group physical therapy as well as many positive (Table 5) and negative (Table 6) aspects of this treatment type were documented. The group leaders most commonly cited the following as advantages to group intervention: (1) groups are enjoyable, (2) groups provide increased interaction/socialization between patients and therapists, (3) patients are adherent to group participation, (4) patients observe others with similar conditions, and (5) patients demonstrate improvement of function. The disadvantages most commonly discussed were: (1) difficulty when leading groups of patients functioning on different levels, (2) less time to individualize sessions, and (3) large group numbers lead to decreased therapist enjoyment.

Leader Absences

Group leaders noted that the procedures for covering therapist absences involved substituting with a replacement therapist, canceling the group, or placing patients into other groups.

Patient Roles

Patient roles within the group were noted by the leaders to include participating in treatments, supporting and encouraging other patients, leading sets of exercise, entertaining the group, and counting during exercises. Upon describing how these roles were developed, 12 therapists reported they were assigned, 7 stated they were acquired, 2 noted both were possible, and 11 could not specifically document a process.

DISCUSSION

Groups are being utilized in rehabilitation clinics across the nation as health care continues to change. A comparison of researcher and published data is presented in Table 7. A 1982 study described an increasing prevalence of group treatments in physical therapy and discussed that often these treatments are considered superior to exclusively one-on-one treatments.7 Groups are also documented as an effective supplement to clinician care, allowing patients to receive individual treatment in conjunction with group therapy sessions during their daily rehabilitation.1,7 Some facilities choose to treat patients in either a group or individual treatment session, but do not utilize both treatment options.6,8 In four of the five facilities visited, patients received oneon-one therapy each day in addition to supplemental group therapy, whereas one clinic utilized groups only on weekends. By utilizing groups as an adjunct to individual treatments, the patient receives the psychosocial benefits of group intervention, while still receiving appropriate individual treatments to maintain quality of care. Many of the group leaders stated that group physical therapy was a good adjunct to individual therapy because using groups as a supplemental therapy allowed group treatments to focus on completing exercises and strengthening, whereas the primary focus of the patient's individual therapy was on functional activities.

The group sizes in the five facilities visited correlate to effective sizes stated in the literature. Nishimoto and Schunk6 state there should be one staff member per 4 group participants and a maximum of 12 patients per group to be effective. Feeneys agrees that groups are effective with no more than 6 to 12 members. For occupational therapy activity groups, fewer than 10 patients per group is optimal.3 Effective small groups of 6 to 10 members29 seem to maintain the quality of care by allowing time for individual attention when necessary.22 The facilities we visited used group sizes of 3 to 12 patients. This group size allows patients to maintain their identity, which can be lost in a large group setting.

Patients should be evaluated and assigned according to their impairments. Goal achievement is more difficult in a group setting when patients are at different functioning levels.b Duncombe and Howe3 agree that activities are effective in a group setting when functional levels and goals are similar. In all facilities except one, a physical therapist evaluated the patients and placed them into an appropriate group.

The dependency on others to bring patients to the treatment sometimes hinders the use of groups.34 Duncombe and Howe3 describe a group session that is scheduled for 60 minutes, with 30 to 40 minutes for activity time and the remaining time for patient transport. In all five rehabilitation settings, the person who transported the patient depended on where the patient was before the group session. None of the clinics reported scheduling transportation time as part of the group session.

Rising costs in health care can influence the utilization of groups. Duncombe and Howe3 concur that group therapy is a cost-effective treatment alternative that maximizes staff productivity. Groups have been shown to decrease labor costs by one third over individual therapy.1 Another study identified an average savings of 17% when using group therapy.6 However, a survey of occupational therapy professionals revealed that 55% of the survey respondents said no difference existed in the cost between the two treatment styles.3 Three of the five facilities we visited cited cost-effectiveness and efficient use of staff as advantages to the utilization of groups. In the five facilities we visited, one charged 100% of individual therapy billing for group sessions. one charged 65%, two charged 50%, and one charged 33%. Thus, 80% of the five facilities provided a decreased cost for third-party payers when using group therapy versus individual therapy.

The definition of a group varied among the clinics we visited. Duncombe and Howe3 describe informal group sessions in which several patients are being treated at one time. Each patient acquires various functions within the group such as leading, comic, and inquisitive roles.29 When patients participate in these interactions, they assume responsibility and understanding of their own part within the larger group, which ultimately leads to their function within society.25,29 Many groups observed during data collection involved each patient performing an individual exercise program or task simultaneously. Other groups used treatments, such as follow-the-leader, circuit training, and obstacle courses, which increased patient interactions as well as other psychosocial benefits. Many of the group leaders stated that group physical therapy was a good adjunct to individual therapy because using groups as a supplemental therapy allowed group treatments to focus on completing exercises and strengthening, whereas the primary focus of the patient's individual therapy could be on functional activities. Therefore, physical therapy groups allowed for cost-efficiency while indirectly adding the psychosocial benefits of group interaction.

Subjective comments by group leaders are also supported by the literature (Table 7). Payne28 discusses spinal cord injury group intervention in physical therapy educational studies. She expands upon psychological and social outcomes secondary to group treatments, including motivation, decreased feelings of isolation, sharing and learning among group members, and hope.28 Leaders at all five facilities we visited reported that groups provided increased interaction and socialization between patients and therapists. In all of the clinics, therapists noted that the patients appeared to enjoy the groups and seemed to be motivated by each other. The literature supports the idea that groups should have patients of similar functional levels to be effective.3,6 One disadvantage listed by several group leaders was having patients within a group who required more assistance. This disadvantage seemed to compromise the benefit and effectiveness of the group format.

We recognize that there are several limitations in the design and implementation of this study. The small sample size limits the application of the data to the general use of groups in physical therapy. The data collection instrument was not tested for reliability. It was designed to guide us in obtaining the same information from all the areas listed from all five facilities. We had occasional difficulty retrieving sections of the instrument from therapists who chose to complete them after the therapist visit. Lastly, due to the paucity of documentation in current literature regarding the utilization of groups in physical therapy, a descriptive analysis of existing physical therapy groups at five midwestern facilities provides the initial data to spawn further research. Suggestions for future research include: (1) specific physical therapy group analyses, (2) a comprehensive overview of group programs at the nation's leading rehabilitation centers, and (3) a national survey of group therapy perceptions from group coordinators.

CONCLUSION

In view of the fact that health care is changing so rapidly, many facilities have felt the need to utilize group intervention within their settings. In the five midwestern clinics we visited, each facility designed their own groups to meet the needs of their patients. Overall, therapists seemed to enjoy physical therapy groups. Groups were found to provide increased social interaction and motivation for patients during therapy. Group leaders frequently stated that using group treatments was a very effective adjunct to individual treatment sessions, allowing more flexibility for both therapist and patient scheduling. Using groups also allowed for the individual treatment sessions to emphasize performance of functional activities.

We have presented many aspects of group intervention in this article. Therapists can see that there are many advantages and disadvantages and must weigh the cost and feasibility of whether to implement or not to implement physical therapy groups. Group intervention is a viable option to the demands placed on therapists with shortened lengths of stay and current trends of decreased reimbursement.

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Kristi L Gelsomino, MSPT Lisa A Kirkpatrick, MSPT

Rebecca R Hess, MSPT Julie E Gahimer, PT, HSD

Mrs Gelsomino is a 1998 graduate of the Krannert School of Physical Therapy, University of Indianapolis, and is currently a registered physical therapist in Illinois. Ms Kirkpatrick is a 1998 graduate of the Krannert School of Physical Therapy and is currently a registered physical therapist in Indiana, where she provides services to infants and toddlers enrolled in Indiana's First Steps Program. Ms Hess is a 1998 graduate of the Krannert School of Physical Therapy and is currently a registered physical therapist in Florida. This study was completed in partial fulfillment of the requirements for Mrs Gelsomino's, Ms Kirkpatrick's, and Ms Hess' Master of Science in Physical Therapy degree from the Krannert School of Physical Therapy. Dr Gahimer is Associate Professor of Physical Therapy, Krannert School of Physical Therapy, University of Indianapolis, 1400 E Hanna Ave, Indianapolis, IN 46227-3697.

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