Self-efficacy and self-management after stroke: a systematic review

"The Other Thousand Hours": A Spinal Cord Injury Self-Management Program Qualitative Analysis

People with spinal cord injury experience secondary health conditions (SHCs) at a high rate which impacts life expectancy and functional performance. Self-management (SM) is an evidence-based approach to reduce the negative effects of SHCs, but prior SM programs have not been successful for the spinal cord injury (SCI) population. We sought to describe the experiences of participants completing a group-based telehealth program that is tailored to the SCI population: The Spinal Cord Injury Self-Management (SCISM) Program. We conducted interviews using Interpretive Phenomenological Analysis to examine participants' experiences. Twenty-two participants completed the interviews. Four themes ("A Sense of Community," "Being Held Accountable," "I'm Still Learning," and "Being Proactive Instead of Reactive") emerged. People with SCI require continued support throughout the chronic stage of SCI particularly at the community level to address mental health as well as the learning and application of SM skills through tailored interventions that foster community and accountability.

Stroke survivors' health literacy is not associated with caregiver burden: a cross-sectional study

Caregivers to stroke survivors often experience a multifaceted strain defined as caregiver burden. Low health literacy among caregivers may contribute to increased caregiver burden but there is limited research specifically examining the association between stroke survivors' health literacy and caregiver burden. Therefore, the aim here is to explore if there is an association between stroke survivors' health literacy and caregiver burden one year after stroke. Participants were 50 caregivers and 50 stroke survivors who were followed up in a longitudinal study on care transitions after stroke. Data were collected one year after the stroke survivors' discharge from hospital and analysed using ordinal logistic regression. Most of the caregivers, median age 71 years, reported being satisfied with their lives (85%) and a low caregiver burden (74%). Stroke survivors' health literacy was not associated with caregiver burden. However, lower needs of assistance in daily activities, lower levels of depression, higher levels of participation and increased age in stroke survivors were associated with lower caregiver burden. In conclusion, stroke survivors' health literacy was not associated with caregiver burden one year after stroke. Future studies with larger samples, focusing on populations with lower functioning after stroke and higher caregiver burden, are recommended.

Satisfaction, user experiences, and initial efficacy of a technology-supported self-management intervention (iSMART) to improve post-stroke functioning: a remoted randomized controlled trial

BACKGROUND

Self-management interventions empower individuals to manage their chronic conditions and daily life after stroke. However, traditional in-person self-management interventions often face transportation and geographical barriers. Digital interventions may offer a solution to address this gap.

OBJECTIVES

This pilot randomized controlled trial (RCT) aimed to examine treatment satisfaction, user experiences, and the initial effect of the interactive Self-Management Augmented by Rehabilitation Technologies (iSMART) intervention in stroke survivors to improve post-stroke functioning.

METHODS

Participants (N = 24) with mild-to-moderate chronic stroke completed a parallel, 2-arm, nonblinded, remote RCT. They were randomly assigned to either a 12-week iSMART or a control intervention (post-stroke information). iSMART was a technology-based self-management intervention involving skill-building education, human coaching, and text messaging. Participants completed a battery measuring treatment satisfaction, use experiences, and function and participation outcomes at baseline and post-intervention.

RESULTS

iSMART participants expressed greater satisfaction with their treatment (r = 0.387), healthcare environment (r = 0.454), relationships with providers (r = 0.374), and higher expectations for positive treatment outcomes (r = 0.328) than control participants, with medium effect sizes. The iSMART group rated the overall program and its coaching, skill-building, and text messaging components as helpful. iSMART participants showed a medium effect in improving overall post-stroke functioning, but control participants showed a small effect. Moreover, iSMART participants showed moderate-to-large effects in improving hand function (r = 0.699), mobility (r = 0.499), memory and thinking (r = 0.436), communication (r = 0.416), social participation (r = 0.307), community reintegration (r = 0.652), and perceived recovery (r = 0.545).

CONCLUSIONS

Our results provide initial evidence that iSMART supports stroke survivors in managing chronic conditions and enhancing post-stroke functioning.

The feasibility of the adapted H-GRASP program for perceived and actual daily-life upper limb activity in the chronic phase post-stroke

PURPOSE

Assessing feasibility and initial impact of the Home-Graded Repetitive Arm Supplementary Program combined with in-home accelerometer-based feedback (AH-GRASP) on perceived and actual daily-life upper limb (UL) activity in stroke survivors during the chronic phase with good UL motor function but low perceived daily-life activity.

MATERIAL AND METHODS

A 4-week intervention program (4 contact hours, 48 h self-practice) encompassing task-oriented training, behavioral techniques, phone-based support, monitoring, and weekly feedback sessions using wrist-worn accelerometery was implemented using a pre-post double baseline repeated measures design. Feasibility, clinical assessments, patient-reported outcomes, and accelerometer data were investigated.

RESULTS

Of the 34 individuals approached, nineteen were included (recruitment rate 56%). Two dropped out, one due to increased UL pain (retention rate 89%). Seven (41%) achieved the prescribed exercise target (120 min/day, six days/week). Positive patient experiences and improvements in UL capacity, self-efficacy, and contribution of the affected UL to overall activity (p < 0.05, small to large effect sizes) were observed. Additionally, seven participants (41%) surpassed the minimal clinically important difference in perceived UL activity.

CONCLUSIONS

A home-based UL exercise program with accelerometer-based feedback holds promise for enhancing perceived and actual daily-life UL activity for our subgroup of chronic stroke survivors.

Designing studies and reviews to produce informative, trustworthy evidence about complex interventions in rehabilitation: a narrative review and commentary

According to Cochrane Rehabilitation's recently published definition for research purposes, rehabilitation is inherently complex. Rehabilitation teams frequently implement multiple strategies concurrently, draw on input from a range of different health professionals, target multiple outcomes, and personalize therapeutic plans. The success of rehabilitation lies not only in the specific therapies employed, but also in how they are delivered, when they are delivered, and the capability and willingness of patients to engage in them. In 2021, the UK Medical Research Council (MRC) and the National Institute of Health Research (NIHR) released the second major update of its framework for developing and evaluating complex interventions. This framework has direct relevance to the development and implementation of evidence-based practice in the field of rehabilitation. While previous iterations of this framework positioned complex interventions as anything that involved multiple components, multiple people, multiple settings, multiple targets of effect, and behavior change, this latest framework expanded on this concept of complexity to also include the characteristics and influence of the context in which interventions occur. The revised MRC-NIHR framework presents complex intervention research as comprising the following four inter-related and overlapping phases: 1) development or identification of the intervention; 2) feasibility; 3) evaluation; and 4) implementation, with different methods and tools required to address each of these phases. This paper provides an overview of the MRC-NIHR framework and its application to rehabilitation, with examples from past research. Rehabilitation researchers are encouraged to learn about the MRC-NIHR framework and its application. Funders of rehabilitation research are also encouraged to place greater emphasis on supporting studies that involve the right design to address key uncertainties in rehabilitation clinical practice. This will require investment into a broader range of types of research than simply individual-level randomized controlled trials. Rehabilitation research can both learn from and contribute to future iterations of the MRC-NIHR framework as it is an excellent environment for exploring complexity in clinical practice.

Construct validity, responsiveness, minimal detectable change, and minimal clinically important difference of the stroke self-efficacy questionnaire in individuals receiving stroke rehabilitation

PURPOSE

To assess the clinimetric properties of the Stroke Self-Efficacy Questionnaire (SSEQ) and estimate the minimal detectable change (MDC) and minimal clinically important difference (MCID) from the database of our randomized controlled trials (RCT) of individuals receiving stroke rehabilitation.

METHODS

We retrieved the pre- and post-intervention scores of the SSEQ and Stroke Impact Scale (SIS) from 80 stroke survivors. The analysis of clinimetric properties was performed using: (1) confirmatory factor analysis and item response theory modeling (IRT) for construct validity; (2) standardized response mean and Glass's delta for responsiveness; (3) MDC based on the standard deviation (SD) or standard error of measurement (SEM) of the SSEQ change scores; (4) MCID determined by the external anchor-SIS; (5) conditional MDC (cMDC) derived from the IRT analysis.

RESULTS

There was a bi-factorial construct with excellent model-data fit and marked responsiveness. The MDC determined by the SD and SEM were 1.5 and 3.0, respectively, and the MCIDs were 3.3 and 3.7.

CONCLUSIONS

This study confirmed that SSEQ is a valid and reliable assessment tool for patients receiving stroke rehabilitation. We also provided practical threshold values, especially demonstrating the benefit of using individualized cMDC, to help clinicians better interpret the change in the SSEQ scores.

Riding waves to improve functioning: a quantitative evaluation of a Surf Week in individuals with chronic phase brain injury with six months follow-up

PURPOSE

Environmental enrichment seems to enable people in the chronic phase of acquired brain injury (ABI) to experience new functional abilities and motor/coping strategies and consequently to become more adaptable which might prevent/reverse functional decline. This study describes the influence of a five-days Surf Week program on participants on physical function, self-efficacy, functional balance performance and self-perceived recovery.

MATERIALS AND METHODS

A multiple-baseline single-case design was used. Adults participating in the Surf Week in chronic phase of ABI were eligible to participate. Participants completed a battery of tests monitoring physical function, self-efficacy, functional balance performance and self-perceived recovery. This battery was repeated 5 times over a 1-year period, two times pre-Surf Week, three times post-Surf Week. Visual data inspection with two non-overlap methods were used to determine if patients showed sustained improvement in outcomes post-intervention.

RESULTS

A moderate to strong indication for improvements on physical function, functional balance performance and self-perceived recovery exists till six months follow-up. No indication was observed on self-efficacy till six months follow-up.

CONCLUSIONS

A five-days Surf Week is a physically, cognitively and socially intensive stimulating activity that can positively challenge individuals after ABI and seems to improve physical functioning, functional balance performance and self-perceived recovery.

Translation and validation of the Persian version of the Stroke Self-Efficacy Questionnaire in stroke survivors

BACKGROUND

The Stroke Self-Efficacy Questionnaire (SSEQ) is a self-report scale that measures stroke survivors' self-efficacy and covers specific domains of functioning after stroke.

OBJECTIVES

We aimed to determine the validity and reliability of the Persian version of the SSEQ.

METHODS

This descriptive cross-sectional study included 124 stroke patients in the sub-acute phase (between 2 weeks and 3 months of stroke onset). The original SSEQ was translated to Persian and back-translated to English. Demographic, neurologic examination, 'Persian Stroke Self-Efficacy Questionnaire (SSEQ-P)', and 'General Self-Efficacy Scale' (GSE-10) data were collected. The reliability of the questionnaire was evaluated by test-retest assessment among 30 people with stroke at an interval of two weeks. Factor analysis was used to assess the validity of SSEQ-P. Cronbach's alpha assessed internal consistency in all participants. Statistical analysis was performed by SPSS software version 23 and SmartPLS version 3.

RESULTS

In this study, the mean of SSEQ scores was 87.99 ± 37.09. Content Validity Ratio (CVR) and Content Validity Index (CVI) were favorable. Convergent validity of the questionnaire was reported (r = 0.669) using GSE. Factor loadings of items in SSEQ ranged from 0.41 to 0.92. Validity indices (AVE = 0.75, SRMR = 0.07) showed that the single-factor model of the present study owns a favorable fit. Test-retest reliability and Cronbach's alpha values of SSEQ in the present study were calculated at 0.80 and 0.97, respectively.

CONCLUSIONS

The Persian version of the SSEQ depicted acceptable reliability and validity and can be utilized to evaluate the self-efficacy of patients with stroke.HIGHLIGHTSStroke Self-Efficacy Questionnaire (SSEQ) is a self-report scale that measures stroke survivors' self-efficacy.The Persian version of the SSEQ demonstrated acceptable reliability and validity and can be used in stroke patients.

Self-management Programs Within Rehabilitation Yield Positive Health Outcomes at a Small Increased Cost Compared With Usual Care: A Systematic Review and Meta-analysis

OBJECTIVE

To determine if self-management programs, supported by a health professional, in rehabilitation are cost effective.

DATA SOURCES

Six databases were searched until December 2023.

STUDY SELECTION

Randomized controlled trials with adults completing a supported self-management program while participating in rehabilitation or receiving health professional input in the hospital or community settings were included. Self-management programs were completed outside the structured, supervised therapy and health professional sessions. Included trials had a cost measure and an effectiveness outcome reported, such as health-related quality of life or function. Grading of Recommendations, Assessment, Development, and Evaluations was used to determine the certainty of evidence across trials included in each meta-analysis. Incremental cost-effectiveness ratios were calculated based on the mean difference from the meta-analyses of contributing health care costs and quality of life.

DATA EXTRACTION

After application of the search strategy, two independent reviewers determined eligibility of identified literature, initially by reviewing the title and/or abstract before full-text review. Using a customized form, data were extracted by one reviewer and checked by a second reviewer.

DATA SYNTHESIS

Forty-three trials were included, and 27 had data included in meta-analyses. Where self-management was a primary intervention, there was moderate certainty of a meaningful positive difference in quality-of-life utility index of 0.03 units (95% confidence interval, 0.01-0.06). The cost difference between self-management as the primary intervention and usual care (comprising usual intervention/therapy, minimal intervention [including education only], or no intervention) potentially favored the comparison group (mean difference=Australian dollar [AUD]90; 95% confidence interval, -AUD130 to AUD310). The cost per quality-adjusted life year (QALY) gained for self-management programs as a stand-alone intervention was AUD3000, which was below the acceptable willingness-to-pay threshold in Australia per QALY gained (AUD50,000/QALY gained).

CONCLUSIONS

Self-management as an intervention is low cost and could improve health-related quality of life.

Self-efficacy and resilience in severe aphasia - an exploratory cross-sectional study of two psychosocial factors and their relation to functional communication

PURPOSE

Self-efficacy and resilience are important for various aspects of rehabilitation outcome after stroke. However, little is known about how these factors are affected and related to communication outcome in stroke survivors with aphasia. The purpose was to investigate self-efficacy and resilience, and associations to language and functional communication, in people with severe post-stroke aphasia.

MATERIALS AND METHODS

37 participants with severe aphasia rated their self-efficacy and resilience, using adapted versions of the existing instruments DLSES and CD-RISC. In addition, linguistic ability, executive function and functional communication were assessed.

RESULTS

Participants rated their self-efficacy and resilience as expected based on reports in the literature; somewhat lower than general populations and at similar levels as clinical populations. There were no association between self-efficacy, resilience and linguistic ability. In the sample as a whole, there were no associations between self-efficacy, resilience and functional communication. However, when results were stratified by executive function, associations emerged in the group with stronger executive function.

CONCLUSIONS

People with severe aphasia have decreased self-efficacy and resilience compared to general populations, but not necessarily in proportion to their language impairment. Among participants with relatively spared executive functions there were indications of an association between self-efficacy, resilience and functional communication.

Predictive utility of self-efficacy in early stroke rehabilitation

INTRODUCTION

A biopsychosocial approach entailing person-centered factors provides valuable insight to post-stroke rehabilitation potential. The consideration of an individual's belief in their capabilities, known as self-efficacy, may prove especially informative in the inpatient rehabilitation setting where motor learning often occurs.

OBJECTIVE

To assess the predictive utility of self-efficacy in functional independence status change during inpatient rehabilitation.

METHODS

Individuals with stroke admitted to an inpatient rehabilitation facility (IRF) completed an assessment battery near IRF admission and discharge involving motor assessments, participant-reported self-efficacy (Stroke Self-Efficacy Questionnaire), and functional independence status evaluation (sum of self-care and mobility Quality Indicators (QI) from the IRF-Patient Assessment Instrument). Linear regression was performed to determine the predictive performance of self-efficacy on QI change during IRF stay while accounting for age, time post-stroke, and IRF length of stay. Regression procedures were repeated for separate subgroups based on initial motor impairment level.

RESULTS

Thirty individuals with stroke (14 females, age = 67.0 ± 9.80 years, 10.4 ± 3.46 days post-stroke) were enrolled. Self-efficacy at IRF admission explained a significant percentage of variance in QI Change for the cohort (R2 = 30.7%, p = .001) and for the moderate to severe motor impairment subgroup (n = 12; R2 = 49.9%, p = .010). After accounting for confounders, self-efficacy remained a significant predictor for the cohort (n = 30) model.

DISCUSSION

Findings generated from this work support the predictive utility of self-efficacy in early post-stroke motor recovery. The inclusion of self-efficacy in a multi-faceted evaluation framework may therefore optimize rehabilitation outcomes by providing therapists with additional knowledge to better tailor an individual's care.

Treatment expectations of patients and clinicians: a cross-sectional study

Importance

Understanding treatment expectations of patients and their clinicians is of great importance in improving personalized medical services and enhancing patient safety systems.

Objective

To investigate treatment expectations of patients and their clinicians and compare differences between both, by using a pair of validated structured assessment tools covering three key aspects/dimensions of clinical interests.

Design setting and participants

This single-center cross-sectional study was conducted at Peking Union Medical College Hospital in China. The study enrolled patients aged 16 years and older receiving inpatient care and their clinicians. Patient recruitment was conducted from March 2023 to November 2023.

Assessments

In addition to demographic and clinical characteristics, this study employed two validated structured assessment tools to evaluate treatment expectations among patients and their clinicians: the Hospitalized Patients' Expectations for Treatment Scale-Patient version (HOPE-P) and its counterpart, the Hospitalized Patients' Expectations for Treatment Scale-Clinician version (HOPE-C).

Results

A total of 233 patients (mean [SD] age, 52.3 [15.1] years; 108 [46.4%] female) along with their clinicians, who numbered 75 in total were enrolled in this study. The distribution of total scores for HOPE-P and HOPE-C displayed similar patterns, with most scores concentrated in the higher range (above 50% of the full score). The mean HOPE-P total score was higher than that of HOPE-C (mean [SD] score, 38.78 [4.86] vs 37.49 [4.32]; t = 3.12, P = 0.002). In Dimension 2, the HOPE-P score was higher than HOPE-C (23.67 [3.20] vs 21.72 [3.03]; t = 6.98, P < 0.001). However, in Dimensions 1 and 3, HOPE-P scored lower than HOPE-C (13.37 [2.44] vs 13.84 [1.73]; t = -2.384, P < 0.018; 1.74 [1.14] vs 1.94 [1.00]; t = -2.00, P = 0.047). Certain demographic and clinical characteristics led to variations in patients' treatment expectations, including marital status, monthly family income, and smoking history.

Conclusions and relevance

This cross-sectional study revealed significant differences between patients' and doctors' treatment expectations. Notably, it highlighted the need for clinicians to focus on rationalizing patients' expectations concerning treatment outcomes.

Trial Registration Chinese Clinical Trial Registry Identifier

ChiCTR2300075262.

A scoping review of factors associated with self-management in young adults with stroke

PURPOSE

To synthesize the available evidence on factors associated with self-management behavior in young stroke patients.

METHODS

The methodological guidelines for scoping reviews developed by the Joanna Briggs Institute and the PRISMA-scR-checklist for scoping reviews were used. A total of 5586 studies were identified through bibliographic searches of the scientific databases Medline (OVID), Embase (OVID), CINAHL (EBSCO), and PsycINFO, limited to the period 2000-2023. Studies were independently assessed for inclusion and exclusion criteria by two reviewers. Quantitative observational data and qualitative studies were extracted, mapped, and summarized to provide a descriptive summary of trends and considerations for future research.

RESULTS

Nine papers were finally selected to answer the research question. Young patients' self-management was mainly influenced by demographic factors (age, gender, income, education, and stroke knowledge), disease-related factors (functionality and independence, duration of stroke diagnosis, cognitive function, and poststroke fatigue), and psychosocial factors (hardiness, spiritual self-care, self-efficacy, and social support).

CONCLUSION

Further research is needed to determine the trajectory of poststroke self-management over time and its potential predictors, which should lead to the development of specific stroke rehabilitation and stroke self-management support programs for young people (considering factors that influence return to work in young stroke patients' self-management).

PRACTICE IMPLICATIONS

Healthcare providers can design more efficient interventions to improve the quality of life of young stroke patients after discharge. Gaining an in-depth understanding of the factors that influence self-management can help achieve this.

Discharge intervention to improve outcomes and web-based portal engagement after stroke and transient ischaemic attack: A randomised controlled trial

OBJECTIVES

Web-based interventions may assist in post-discharge stroke care. However, strategies for maximising uptake and engagement are needed.

AIMS

To determine the: (1) effectiveness of a discharge support intervention (EnableMe web-based portal and strategies to encourage use) in improving quality of life and reducing depression (primary outcome); anxiety and unmet needs of survivors of stroke and transient ischemic attack (TIA); and (2) EnableMe use and acceptability.

MATERIALS AND METHODS

An open, parallel-group, multi-centre randomised controlled trial (RCT) of the intervention compared to usual care for survivors of stroke/TIA and their support persons. Participants recruited from eight hospitals completed questionnaires at baseline, 3 and 6 months. Outcomes included quality of life, depression, anxiety and unmet needs.

RESULTS

98 survivors (n=52 intervention, n=47 control) and 30 support persons (n=11 intervention, n=19 control) enrolled in the RCT. Bayesian analyses showed substantial evidence of an intervention effect on survivors' quality of life scores at 3 months. There was moderate-to-strong evidence of a treatment effect on depression scores and strong evidence that intervention participants had fewer unmet needs at 3 and 6 months. 45 % of intervention group survivors and 63 % of support persons self-reported using EnableMe. 64 % of survivors and 84 % of support persons found it helpful.

CONCLUSION

Substantial evidence for the discharge support intervention was found, with a difference between groups in survivor quality of life, depression, and unmet needs. Acceptability was demonstrated with largely positive attitudes towards EnableMe. Future research should explore different engagement strategies to improve uptake of online stroke resources.

Use of standardized patients in patient education practices of senior nursing students: A mixed-methods study

BACKGROUND

There is a need for innovative teaching practices in nursing education due to many factors, such as global changes, the rapid development of technology, the increasing number of students, and the recent pandemic.

OBJECTIVES

This research was conducted using standardized patients to evaluate the attitudes and skills of senior nursing students toward patient education practices following the implementation of a patient education training program.

DESIGN

Mixed-methods design.

SETTINGS

The study was conducted at a nursing faculty.

PARTICIPANTS

The sample of the study consisted of 47 senior nursing students.

INTERVENTION

The students participating in the study were given a four-hour patient education training that included the preparation of patient education, preparation of materials, and effective presentation.

METHODS

A descriptive information form prepared by the researchers, the Patient Education Implementation Scale (PEIS), the Turkish version of the Patient Education Materials Assessment Tool for Printable Materials (PEMATTR-P), and the presentation skill evaluation form (PSEF) were used to collect quantitative data. Semi-structured interview forms were utilized to collect qualitative data. SPSS for Windows v. 25.0 and MAXQDA20 were used for the data analyses. Results with a p value of <0.05 were considered statistically significant.

RESULTS

The post-test mean PEIS scores of the students increased in the total scale and in all subdimensions. A significant difference was found in the understandability and actionability of patient education materials evaluated with PEMATTR-P (p < 0.05). The mean PSEF score of the students was 85.14 ± 9.25 points. Within the scope of the research, two main themes, namely emotions and efficacy, were determined.

CONCLUSIONS

This study confirms that structured patient education training, including the use of standardized patients, is important for supporting and developing nursing senior students' attitudes and skills toward patient education.

The Treatment Expectation Questionnaire Tool: A Cross-Cultural Adaptation and Psychometric Evaluation in Turkey

Patients' general treatment expectations are an important indicator of the outcomes of the various treatments they will receive. There is a need for valid and reliable assessment tools that measure the expectations of patients receiving rehabilitation services. This study aimed to translate and validate the Treatment Expectations Questionnaire (TR.TEX-Q) in Turkish patients to assess their treatment-specific expectations. 150 physiotherapy patients were enrolled in the study. The original version of the Treatment Expectation Questionnaire was translated into Turkish. Cronbach's α was used to investigate internal consistency. Intraclass correlation coefficients were used to assess test-retest reliability. Pearsons's correlation was used to calculate convergent and divergent validity. Principal component analysis produced a 15-items scale which had a 6-factors structure. Cronbach's α values ranged from .649 to .879. Test-retest reliability was high for total score and for all subscales. The ICC was between .622 and .852, p < .001. TR.TEX-Q showed good convergent validity, a moderate correlation was found between the Positivity Scale (rho = .45, p < .001). For divergent validity, low to moderate correlation was found between the TR.TEX-Q and the HADS scores. The Turkish version of Treatment Expectation Questionnaire has good reliability and validity data in terms of evaluating the treatment expectations of patients who will receive physiotherapy.

Rehabilitation at Home With the Development of a Sustainable Model Placing the Person's Needs and Environment at Heart: Protocol for a Multimethod Project

BACKGROUND

Each year, more than 1.5 million people in Europe have a stroke, and many experience disabilities leading to activity and participation restrictions. Home-based rehabilitation is the recommended approach for stroke rehabilitation, in line with the international shift to integrated care. Despite this, rehabilitation often focuses on the person's physical functions, not the whole life situation and opportunities to live an active life. Given that rehabilitation today is often provided in the person's home, there is a need to develop new models that consider the rehabilitation process as situated in the everyday living environment of persons with stroke. This project is grounded in experiences from our ongoing research, where we study the importance of the home environment for health and participation among persons with stroke, rehabilitated at home. This research has shown unmet needs, which lead to suboptimal rehabilitation outcomes. There is a need for studies on how to use environmental resources to optimize stroke rehabilitation in the home setting.

OBJECTIVE

The overarching objective of the project is to develop a new practice model for rehabilitation where the needs of the person are the starting point and where the environment is considered.

METHODS

The project will be conducted in partnership with persons with stroke, significant others, health care professionals, and care managers. Results from a literature review will form the base for interviews with the stakeholders, followed by co-designing workshops aiming to create a new practice model. Focus groups will be held to refine the outcome of the workshops to a practice model.

RESULTS

This 4-year project commenced in January 2023 and will continue until December 2026. The results of the literature review are, as of April 2024, currently being analyzed. The ethics application for the interviews and co-design phase was approved in October 2023 and data collection is ongoing during spring 2024. We aim to develop a practice model with stakeholders and refine it together with care managers and decision makers. The outcome is a new practice model and implementation plan, which will be achieved in autumn 2026.

CONCLUSIONS

The project contributes with a prominent missing puzzle to optimize the rehabilitation process by adding a strong focus on user engagement combined with integrating different aspects of the environment. The goal is to improve quality of life and increase reintegration in society for the large group of people living with the aftermath of a stroke. By co-designing with multiple stakeholders, we expect the model to be feasible and sustainable. The knowledge from the project will also contribute to an increased awareness of the importance of the physical environment for sustainable health care. The findings will lay the foundation for future upscaling initiatives.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56996.

Perceived social support, self-management, perceived stress, and post-traumatic growth in older patients following stroke: Chain mediation analysis

Stroke is a potentially traumatic event that can lead to both positive changes associated with post-traumatic growth (PTG) and enduring mental distress. This study aimed to investigate the association between perceived stress and PTG among older postsurvivors, as well as to explore the potential mediating role of perceived social support and self-management in this relationship. A cross-sectional study was conducted to recruit 354 older poststroke survivors from 2 tertiary hospitals in Shenyang, China, between January 2022 and October 2023. Various multidimensional scales were utilized to measure perceived stress, perceived social support, self-management, and PTG. Structural equation modeling was employed by Amos 24.0 to analyze the mediating pathways. The average score of PTG was 50.54 ± 22.69 among older poststroke patients. Pearson analysis revealed significant associations between perceived stress, perceived social support, self-management, and PTG (all P < .01). The mediation model showed that perceived stress could both direct influence PTG (Effect = -0.196, 95% CI = [-0.259, -0.129]), and indirectly impact PTG through perceived social support (Effect = -0.096, 95% CI = [-0.157, -0.044]), through self-management (Effect = -0.033, 95% CI = [-0.064, -0.012]), and sequentially through perceived social support and self-management (Effect = -0.007, 95% CI = [-0.017, -0.002]), accounting for 58.9%, 28.8%, 9.9%, and 2.1% of the total effect, respectively. These findings confirmed the mediating roles of perceived social support and self-management between perceived stress and PTG among older poststroke survivors. This provides valuable insights into developing targeted social intervention programs to improve stroke management among older survivors.

Restricted health service utilization and subsequent positive self-care behavior during the early COVID-19 pandemic in China

Background

The reallocation of health resources, epidemic prevention and control measures during the COVID-19 pandemic triggered widespread restricted health service utilization, some residents and patients tried positive self-care behavior to maintain their health, yet the efficacy of this intervention remains unclear.

Object

Based on the reasoned action approach (RAA) theory, this study aimed to investigate the correlation between self-care behavior and restricted health service utilization among adults in China, trying to discover the vulnerable groups and external and intrinsic factors that affect self-care behavior among Chinese adults.

Methods

Data on demographics, socioeconomic, health status, and self-care behavior were collected in "The Early China COVID-19 Survey," a cross-sectional anonymous online survey of the general population in China. Self-care behavior was measured by four indicators: weight control (WC), physical activity (PA), prevention behavior (PB), and online medical consultation (OMC). The multiple linear models and binary logistic regression were used to examine whether restricted health service utilization (RHSU) is associated with self-care behaviors; also, adjusted multivariate logistic regression was used to analyze subgroup heterogeneity.

Results

In total, 8,428 adult participants completed the survey, the mean OMC score was 1.51 (SD 1.34), the mean PB score was 18.17 (SD 3.44), and the proportion of participants who engaged in WC and PA was 42.30 and 62.57%, respectively. According to the multiple regression model, the RHSU was significantly positively correlated with all four indicators of self-care (WC: OR = 1.34, p < 0.001, PA: OR = 1.34, p < 0.05, MC: OR = 1.30, p < 0.001, PB: coef = 0.16, p < 0.05). We also observed some significant differences in the intensity of this relationship by subgroup analysis, precisely, OMC (high vs. moderate vs. low infection-risk level: OR = 1.48; 1.41; 1.19, p < 0.1), PA (male vs. female: OR = 1.27;1.06; p < 0.05, high vs. Moderate and low infection-risk level: OR = 1.51; 1.17; 1.02, p < 0.05), PB (Chronic disease groups vs. no: coef = 0.46; 0.1, p < 0.05).

Conclusion

Restricted health service utilization predicts more positive self-care behavior, and the intensity of partial correlation was significantly different in the subgroups of sex, actual infection risk level of the living area, and chronic diseases. These findings highlight the urgent demand for self-care behavior among Chinese adults during the pandemic and provide new insights for developing self-care and reducing the burden on the healthcare system in the long term.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Socially Assistive Robot for Stroke Rehabilitation: A Long-Term in-the-Wild Pilot Randomized Controlled Trial

Socially assistive robots (SARs) have been suggested as a platform for post-stroke training. It is not yet known whether long-term interaction with a SAR can lead to an improvement in the functional ability of individuals post-stroke. The aim of this pilot study was to compare the changes in motor ability and quality of life following a long-term intervention for upper-limb rehabilitation of post-stroke individuals using three approaches: 1) training with a SAR in addition to usual care; 2) training with a computer in addition to usual care; and 3) usual care with no additional intervention. Thirty-three post-stroke patients with moderate-severe to mild impairment were randomly allocated into three groups: two intervention groups - one with a SAR (ROBOT group) and one with a computer (COMPUTER group) - and one control group with no intervention (CONTROL group). The intervention sessions took place three times/week, for a total of 15 sessions/participant; The study was conducted over a period of two years, during which 306 sessions were held. Twenty-six participants completed the study. Participants in the ROBOT group significantly improved in their kinematic and clinical measures which included smoothness of movement, action research arm test (ARAT), and Fugl-Meyer upper-extremity assessment (FMA-UE). No significant improvement in these measures was found in the COMPUTER or the control groups. 100% of the participants in the SAR group gained improvement which reached - or exceeded - the minimal clinically important difference in the ARAT, the gold standard for upper-extremity activity performance post-stroke. This study demonstrates both the feasibility and the clinical benefit of using a SAR for long-term interaction with post-stroke individuals as part of their rehabilitation program. Trial Registration: ClinicalTrials.gov NCT03651063.

Effect of hospital-community online management on medication management of elderly patients with peritoneal dialysis during COVID-19

INTRODUCTION

The study aimed to explore feasibility and effect of hospital-community online management on the medication management of elderly peritoneal dialysis (PD) patients with end-stage renal disease (ESRD) during COVID-19.

METHODS

A total of 160 patients receiving PD were randomly divided into the control (n = 80, outpatient follow-up management mode) and observation (n = 80, hospital-community online management mode) groups. The self-efficacy (General Self-Efficacy Scale [GSES]), medication adherence (8-item Morisky medication adherence scale [MMAS-8]), quality of life (kidney disease quality of life short form [KDQOL-SF]), and degree of depression (beck depression inventory [BDI]) before and after the intervention were compared.

RESULTS

After the intervention, the scores of GSES (4.20 ± 0.46 vs. 3.09 ± 0.33), MMAS-8 (5.82 ± 0.92 vs. 5.13 ± 1.25), and KDQOL-SF were significantly higher, whereas the BDI score (9.50 ± 2.86 vs. 12.08 ± 2.95) was significantly lower in the observation group than in the control group (p < 0.05).

CONCLUSION

Hospital-community online management presents good effects in the medication management of PD patients with ESRD.

Use of the Capability, Opportunity and Motivation Behaviour model (COM-B) to Understand Interventions to Support Physical Activity Behaviour in People with Stroke: An Overview of Reviews

OBJECTIVE

Physical activity in people with stroke remains low despite considerable research. This overview aimed to provide high-level synthesis and aid clinical decision-making. The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to classify interventions to understand which components improve physical activity behaviour in people with stroke.

DATA SOURCES

CINAHL, Cochrane Database, MEDLINE, PEDro, PsychINFO, SPORTDiscus.

REVIEW METHODS

A systematic search was conducted (November 2023) to identify reviews of interventions to improve physical activity in people with stroke. Results were screened and assessed for eligibility. Participant characteristics, intervention classification using COM-B, and effect of intervention were extracted. Quality was assessed using AMSTAR2, and Corrected Cover Analysis for study overlap. Narrative synthesis was used to understand components of interventions to improve physical activity behaviour.

RESULTS

1801 references were screened and 29 full-text references assessed for eligibility. Twenty reviews were included. Quality ranged from critically low (n = 3) to high (n = 10). Study overlap calculated using corrected cover area indicated slight overlap (0.028) and minimal reporting bias.The majority of participants were mobile with mild stroke and community dwelling. Twenty-three interventions were classified using COM-B. Three of twelve interventions classified to one aspect of the COM-B were effective. Fourteen of sixteen effective interventions combined at least two COM-B elements, ten of these combined capability and motivation.

CONCLUSION

Interventions including at least two elements of the COM-B are most likely to improve physical activity in mobile stroke survivors. Further research is needed to understand physical activity behaviour in those with moderate to severe stroke.

Relationships between mediolateral step modulation and clinical balance measures in people with chronic stroke

BACKGROUND

Many people with chronic stroke (PwCS) exhibit walking balance deficits linked to increased fall risk and decreased balance confidence. One potential contributor to these balance deficits is a decreased ability to modulate mediolateral stepping behavior based on pelvis motion. This behavior, hereby termed mediolateral step modulation, is thought to be an important balance strategy but can be disrupted in PwCS.

RESEARCH QUESTION

Are biomechanical metrics of mediolateral step modulation related to common clinical balance measures among PwCS?

METHODS

In this cross-sectional study, 93 PwCS walked on a treadmill at their self-selected speed for 3-minutes. We quantified mediolateral step modulation for both paretic and non-paretic steps by calculating partial correlations between mediolateral pelvis displacement at the start of each step and step width (ρSW), mediolateral foot placement relative to the pelvis (ρFP), and final mediolateral location of the pelvis (ρPD) at the end of the step. We also assessed several common clinical balance measures (Functional Gait Assessment [FGA], Activities-specific Balance Confidence scale [ABC], self-reported fear of falling and fall history). We performed Spearman correlations to relate each biomechanical metric of step modulation to FGA and ABC scores. We performed Wilcoxon rank sum tests to compare each biomechanical metric between individuals with and without a fear of falling and a history of falls.

RESULTS

Only ρFP for paretic steps was significantly related to all four clinical balance measures; higher paretic ρFP values tended to be observed in participants with higher FGA scores, with higher ABC scores, without a fear of falling and without a history of falls. However, the strength of each of these relationships was only weak to moderate.

SIGNIFICANCE

While the present results do not provide insight into causality, they justify future work investigating whether interventions designed to increase ρFP can improve clinical measures of post-stroke balance in parallel.

Are Clinical Prediction Rules Used in Spinal Cord Injury Care? A Survey of Practice

Background

Accurate outcome prediction is desirable post spinal cord injury (SCI), reducing uncertainty for patients and supporting personalized treatments. Numerous attempts have been made to create clinical prediction rules that identify patients who are likely to recover function. It is unknown to what extent these rules are routinely used in clinical practice.

Objectives

To better understand knowledge of, and attitudes toward, clinical prediction rules amongst SCI clinicians in the United Kingdom.

Methods

An online survey was distributed via mailing lists of clinical special interest groups and relevant National Health Service Trusts. Respondents answered questions about their knowledge of existing clinical prediction rules and their general attitudes to using them. They also provided information about their level of experience with SCI patients.

Results

One hundred SCI clinicians completed the survey. The majority (71%) were unaware of clinical prediction rules for SCI; only 8% reported using them in clinical practice. Less experienced clinicians were less likely to be aware. Lack of familiarity with prediction rules was reported as being a barrier to their use. The importance of clinical expertise when making prognostic decisions was emphasized. All respondents reported interest in using clinical prediction rules in the future.

Conclusion

The results show widespread lack of awareness of clinical prediction rules amongst SCI clinicians in the United Kingdom. However, clinicians were positive about the potential for clinical prediction rules to support decision-making. More focus should be directed toward refining current rules and improving dissemination within the SCI community.

A Digital Intervention to Promote Self-Management Self-Efficacy Among Community-Dwelling Individuals With Stroke: Pilot Randomized Controlled Trial

BACKGROUND

Digital interventions provided through smartphones or the internet that are guided by a coach have been proposed as promising solutions to support the self-management of chronic conditions. However, digital intervention for poststroke self-management is limited; we developed the interactive Self-Management Augmented by Rehabilitation Technologies (iSMART) intervention to address this gap.

OBJECTIVE

This study aimed to examine the feasibility and initial effects of the iSMART intervention to improve self-management self-efficacy in people with stroke.

METHODS

A parallel, 2-arm, nonblinded, randomized controlled trial of 12-week duration was conducted. A total of 24 participants with mild-to-moderate chronic stroke were randomized to receive either the iSMART intervention or a manual of stroke rehabilitation (attention control). iSMART was a coach-guided, technology-supported self-management intervention designed to support people managing chronic conditions and maintaining active participation in daily life after stroke. Feasibility measures included retention and engagement rates in the iSMART group. For both the iSMART intervention and active control groups, we used the Feasibility of Intervention Measure, Acceptability of Intervention Measure, and Intervention Appropriateness Measure to assess the feasibility, acceptability, and appropriateness, respectively. Health measures included the Participation Strategies Self-Efficacy Scale and the Patient-Reported Outcomes Measurement Information System's Self-Efficacy for Managing Chronic Conditions.

RESULTS

The retention rate was 82% (9/11), and the engagement (SMS text message response) rate was 78% for the iSMART group. Mean scores of the Feasibility of Intervention Measure, Acceptability of Intervention Measure, and Intervention Appropriateness Measure were 4.11 (SD 0.61), 4.44 (SD 0.73), and 4.36 (SD 0.70), respectively, which exceeded our benchmark (4 out of 5), suggesting high feasibility, acceptability, and appropriateness of iSMART. The iSMART group showed moderate-to-large effects in improving self-efficacy in managing emotions (r=0.494), symptoms (r=0.514), daily activities (r=0.593), and treatments and medications (r=0.870), but the control group showed negligible-to-small effects in decreasing self-efficacy in managing emotions (r=0.252), symptoms (r=0.262), daily activities (r=0.136), and treatments and medications (r=0.049). In addition, the iSMART group showed moderate-to-large effects of increasing the use of participation strategies for management in the home (r=0.554), work (r=0.633), community (r=0.673), and communication activities (r=0.476). In contrast, the control group showed small-to-large effects of decreasing the use of participation strategies for management in the home (r=0.567), work (r=0.342, community (r=0.215), and communication activities (r=0.379).

CONCLUSIONS

Our findings support the idea that iSMART was feasible to improve poststroke self-management self-efficacy. Our results also support using a low-cost solution, such as SMS text messaging, to supplement traditional therapeutic patient education interventions. Further evaluation with a larger sample of participants is still needed.

TRIAL REGISTRATION

ClinicalTrials.gov 202004137; https://clinicaltrials.gov/study/NCT04743037?id=202004137&rank=1.

Needs Assessment of Self-Management for Individuals With Chronic Spinal Cord Injury/Disease

Since the 1980s, survivorship for persons with spinal cord injury/disease (SCI/D) has significantly improved; however, life expectancy remains lower than the general population due to secondary health conditions (SHCs) that lead to decreased function and death. This study explored (1) facilitators and barriers to engaging in self-management (SM) for persons with SCI/D and (2) stakeholder perspectives on potential SM program components and content for intervention development. Around 38 participants with SCI/D responded to this cross-sectional study and needs assessment conducted at the University of Missouri, Columbia. Responses were analyzed to determine descriptive statistics. Participants indicated barriers to SM include transportation/distance, presence of SHCs, and a lack of local resources. Participants noted that virtual SM programs with strong psychological health/coping components were preferred. These findings should guide the development of an SM program tailored to SCI/D to reduce the prevalence and impact of SHC on the SCI/D population.

Characterizing the impact of multiple chronic conditions on return to participation in chronic stroke survivors

BACKGROUND

Each year, 795,000 Americans experience a stroke. As stroke mortality declines, more individuals are in the chronic phase of recovery (>6 months post-stroke). Over 80% of stroke survivors have multiple, chronic health conditions (MCC). While the relationship between MCC and mortality and function during acute recovery has been explored, less is known about how MCC burden affects participation in chronic stroke survivors.

OBJECTIVE

This study investigated whether MCC burden is related to participation in those with chronic stroke.

METHODS

Two hundred and sixty-six participants with chronic (≥6 months) stroke were included in this cross-sectional and retrospective analysis. Participants had a mean age of 62.2 ± 12.8 years, and time since stroke (TSS) of 36.0 ± 44.6 months (114F/152 M). Participants completed the 6-minute Walk Test (6MWT), Activities-Specific Balance Confidence Scale (ABC), Modified Cumulative Illness Rating Scale (MCIR) to quantify the presence and severity of chronic illness across 14 body systems, and the Stroke Impact Scale - Participation subscale (SIS-P). Participation (SIS-P) was the dependent variable. Independent variables were entered into a sequential regression model in three blocks: demographic variables, physical capacity (6MWT distance) and balance self-efficacy (ABC), and MCC burden (MCIR).

RESULTS

After adjusting for age, sex, and time since stroke, physical capacity and balance self-efficacy explained 31.4% (p < 0.001), and the MCC burden explained 2.0% (p = 0.004). Higher participation was related to lower MCC burden.

CONCLUSIONS

MCC burden is a significant contributor to variance in participation in chronic stroke survivors, above and beyond demographics, physical capacity, and self-efficacy, and therefore should be considered when creating rehabilitation programs to improve participation.

Effectiveness of self-management interventions during the peri-hospitalization period in patients with stroke: A systematic review and meta-analysis

OBJECTIVE

To synthesize the evidence of the effectiveness of self-management interventions during the peri-hospitalization period.

DATA SOURCES

Three databases (i.e. PubMed, Web of Science, and Scopus) were systematically searched.

REVIEW METHODS

Full-text randomized controlled studies that assessed the effects of self-management interventions initiated during the peri-hospitalization period in patients with stroke were included. Two independent reviewers performed data extraction. A third reviewer was available for discrepancies. The methodological quality was evaluated using version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB-2). Data were pooled and a meta-analysis was performed.

RESULTS

Eight studies comprising 1030 participants were included. The self-management interventions showed considerable heterogeneity in their protocols, although most of them included an individualized plan based on the patient's needs. The meta-analysis was performed with data from the self-efficacy domains. The pooled results showed a trend towards the self-management intervention on quality of life (1.07, 95% confidence interval [CI] 0.52 to 1.63; P = 0.0002) but neither in dependence (0.80, 95% CI -0.14 to 1.74; P = 0.10) nor in self-efficacy (0.77, 95% CI -0.44 to 1.98; P = 0.21).

CONCLUSION

Most of the studies reviewed suggest that self-management interventions had an impact on dependency, quality of life and self-efficacy when compared with usual care, written materials about stroke, or post-discharge rehabilitation recommended by a physician. However, the evidence in this review neither supports nor refutes self-management interventions used in addition to usual care, or other interventions, to improve dependency, quality of life and/or self-efficacy in patients' post-stroke.

Occupational therapists' experiences of using a new internet-based intervention - a focus group study

BACKGROUND

Research is limited about how the introduction of new ways of delivering and conducting occupational therapy, in accordance with expected changes in health care, is experienced by occupational therapists (OTs).

AIM

To explore how OTs experienced use of a new internet-based intervention, 'Strategies for Empowering activities in Everyday life' (SEE), focusing on supporting client resources to manage an active everyday life after stroke.

MATERIAL AND METHODS

A focus group study with periodical repeated discussion was designed. Four sessions during a period of 22 months were conducted with a total of four OTs.

RESULT

Overall, the results reflected that the OTs experienced that the use of SEE for persons with stroke was a valuable complement to existing rehabilitation. The process of introducing SEE included a multifaceted transition involving context, intervention process and delivery that renewed occupational therapy.

CONCLUSION

These results indicate how the use of new internet-based interventions such as SEE can influence and support renewal of occupational therapy that extends beyond the particular intervention. Continued research is needed to explore more aspects of SEE feasibility.

Co-creation of self-management support during inpatient stroke rehabilitation

Objective

This study aimed to identify priority self-management skills and behaviours in partnership with stroke survivors, and to co-create approaches to support self-management during inpatient stroke rehabilitation.

Methods

Three stroke survivors and two communication partners participated in the three-stage Participatory Action Research project with embedded co-design processes after undertaking inpatient rehabilitation at a metropolitan tertiary hospital.

Results

Participants identified key factors influencing self-management during inpatient rehabilitation including motivation, emotional well-being, and fatigue. Three approaches to support people to self-manage post-stroke were co-created. (1) A health professional concierge and early family meeting. (2) A peer support person. (3) Adapting the hospital environment.

Conclusion

Findings suggest post-stroke self-management support should commence during inpatient rehabilitation to optimise its research-informed benefits. This support should focus on empowering stroke survivors and their key support people through active involvement in decision-making, and provision of multi-modal individualised education. The impact of hospital environments on emotional-wellbeing and self-management post-stroke also requires further investigation.

Innovation

The identification of a health professional concierge as a co-designed solution to the current challenges with self-management support is an innovative recommendation for practice. The findings support changes to the traditional processes of rehabilitation towards a consumer and family-led practices.

Interventions for improving self-efficacy in patients after stroke based on self-efficacy-related principles of Bandura's cognition theory: a systematic review and meta-analysis

BACKGROUND

Interventional approaches based on Bandura's cognition theory are effective in improving self-efficacy poststroke. However, a systematical investigation for identifying effectives therapeutic components of the intervention has not yet been conducted.

OBJECTIVE

This meta-analysis was conducted to systematically investigated the effects of interventions with different principles on improving self-efficacy after stroke.

METHODS

Searches were conducted in PubMed, EMBASE, CINAHL, PsycINFO, MEDLINE, Cochrane Library, and two randomized controlled trials registration websites for randomized controlled trials from inception to 18th January 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The meta-analysis was performed using Review Manager and Stata software.

RESULTS

In total, 36 RCTs were included. Interventions using any one of the self-efficacy principles - principle 1 (Mastery), principle 2 (Modeling), principle 3 (Social persuasion), and principle 4 (Understanding), were more effective in improving self-efficacy in patients with stroke at post-training and follow-up, compared with the control group. Psycho-educational interventions might significantly improve self-efficacy in both post-intervention and follow-up stages, compared with control group. Meta-regression revealed time since stroke onset was significantly associated with effect sizes.

CONCLUSION

Interventions developed based on Bandura's cognition theory are beneficial to the improvement of self-efficacy. This review highlights principles of Bandura's cognition theory are worth considering to be integrated to interventions targeted at improving self-efficacy. The application of self-efficacy principles with Bandura's cognitive theory could be encouraged in clinical practice in the future.

PROTOCOL REGISTRATION NUMBER

PROSPERO CRD42020154984.

Cross-cultural Adaptation and Validation of the Arabic version of Stroke Self-Efficacy Questionnaire for Patients with Stroke

BACKGROUND

Self-efficacy has an important impact on rehabilitation outcomes in stroke. The Stroke Self-Efficacy Questionnaire assesses performance in daily functional activities and self-management following a stroke.

PURPOSE

To translate and cross-culturally adapt the Stroke Self-Efficacy Questionnaire (SSEQ) into the Arabic language and to assess its psychometric properties among patients with stroke.

METHODS

SSEQ was translated into Modern Arabic and then translated back into English. An expert review panel produced a pre-final version of SSEQ-AR, which was followed by a pilot test with a sample of 15 patients with stroke. The psychometric properties of the final version of the SSEQ-AR were evaluated in 135 patients with stroke.

DATA ANALYSIS

Cronbach's alpha and ICC were calculated to describe the internal consistency and test-retest reliability, respectively. Short-Form Survey (SF-12) physical and mental subscales and Fall Efficacy Scale International were used to determine the construct validity.

RESULTS

The total score of the SSEQ-AR and subscales showed a strong to very strong (ICC2,1 0.89-0.92), and acceptable internal consistency for two subscales (Cronbach's alpha = 0.81 to 0.94) and total (Cronbach's alpha = 0.93). The SSEQ-AR subscales showed a good correlation with physical component subscales of SF-12 (r = 0.64-0.72) and excellent correlation with FES-I in total (r = 0.82) and with subscales (r = 0.75-0.79).

CONCLUSION

This study shows that SSEQ-AR is a reliable and valid instrument that assesses the level of self-efficacy for patients with stroke in Arabic-speaking countries.

Variables associated with oral health-related self-efficacy - results of a cross-sectional study

BACKGROUND

Oral health-related self-efficacy (OH-SE) is pivotal for oral health and is associated with other oral-health related variables, such as dental fear and anxiety (DF/A) and dental hygiene behaviors (DHB). This study attempts to analyze associations between OH-SE and oral healthrelated variables in a German population to extend previous research by analyzing whether OH-SE can be predicted by these variables, as this might contribute to the development of treatment interventions.

METHODS

OH-SE, DF/A, oral health-related quality of life (OHRQoL), self-perceived dental condition, satisfaction with general health, DHB, and socioeconomic status were assessed as a part of the Saxon Longitudinal Study in an adult sample (n = 309, 56.3% female, all Saxon secondary school 8th graders in 1987). The associations of OH-SE with these variables were examined by means of correlation, multiple linear regression analyses, and group comparisons. Significance (p), standardized regression coefficients (β), and effect size (Cohen's d) were calculated.

RESULTS

The correlation analyses revealed increased OH-SE to be accompanied by low levels of DF/A, high levels of OHRQoL, high levels of self-perceived dental condition, increased satisfaction with general health and socioeconomic status (all r ≥ 0.142; all p ≤ 0.013). In the regression analysis, OH-SE was mainly predicted by self-perceived dental condition and satisfaction with general health (R2 = 0.157) as well as by daily frequency of toothbrushing, OHRQoL, and socioeconomic status on a trend-level basis. In the group comparisons OH-SE was lower in participants with moderate for manifest DF/A and higher in individuals with higher OHRQoL, better self-perceived dental condition, increased satisfaction with general health, increased daily frequency of toothbrushing, more dental appointments, and above-average socioeconomic status (trend level; all t ≥ 1.57; p ≤ 0.059).

CONCLUSIONS

In this cross-sectional study, high levels of OH-SE were mainly predicted by general health as well as self-perceived dental condition. It was also associated with decreased DF/A, increased DHB, higher OHRQoL, and higher socioeconomic status. Future research should analyze these associations in longitudinal designs to address whether interventions focusing on adherence to good DHB improve (dental) health and thus OH-SE. This might be a promising approach, particularly in relation to the treatment of DF/A.

Lifetime and Acute Stress Predict Functional Outcomes Following Stroke: Findings From the Longitudinal STRONG Study

BACKGROUND

Stroke is a sudden-onset, uncontrollable event; stroke-related stress may impede rehabilitation and recovery. Lifetime stress may sensitize patients to experiencing greater stroke-related stress and indirectly affect outcomes. We examine lifetime stress as predictor of poststroke acute stress and examine lifetime and acute stress as predictors of 3- and 12-month functional status. We also compare acute stress and baseline National Institutes of Health Stroke Scale as predictors of poststroke functional status.

METHODS

Between 2016 and 2020 the STRONG Study (Stroke, Stress, Rehabilitation, and Genetics) enrolled adults with new radiologically confirmed stroke 2 to 10 days poststroke onset at 28 acute care US hospitals. Participants were interviewed 3 times: acute admission (acute stress; Acute Stress Disorder Interview), 3 months (Fugl-Meyer Upper Extremity motor impairment [Fugl-Meyer Upper Arm Assessment; N=431], modified Rankin Scale [3 months; N=542], Stroke Impact Scale-Activities of Daily Living [3 months; N=511], Lifetime Stress Exposure Inventory), and 12 months (modified Rankin Scale, N=533; Stroke Impact Scale 3.0 Activities of Daily Living; N=485; Telephone Montreal Cognitive Assessment; N=484) poststroke. Structural equation models examined whether acute stress predicted 3- and 12-month functional outcomes, and mediated an association between lifetime stress and outcomes controlling for demographics and initial National Institutes of Health Stroke Scale. Standardized betas are reported.

RESULTS

Sample (N=763) was 19 to 95 years old (mean=63; SD=14.9); 448 (58.7%) were male. Acute stress scores ranged from 0 to 14 (mean, 3.52 [95% CI, 3.31-3.73]). Controlling for age, gender, baseline National Institutes of Health Stroke Scale, and race and ethnicity, higher lifetime stress predicted higher acute stress (β=0.18, P<0.001), which predicted lower 3-month Fugl-Meyer Upper Arm Assessment scores (β=-0.19, P<0.001), lower Stroke Impact Scale 3.0 Activities of Daily Living scores at 3 months (β=-0.21, P<0.001) and 12 months (β=-0.21, P<0.001), higher modified Rankin Scale scores at 3 months (β=0.23, P<0.001) and 12 months (β=0.22, P<0.001), and lower 12-month Telephone Montreal Cognitive Assessment scores (β=-0.20, P<0.001). Acute stress predicted 12-month tMoCA (χ2[1]=5.29, P=0.022) more strongly, 3-month and 12-month modified Rankin Scale and SIS scores as strongly (all Ps>0.18), but Fugl-Meyer scores (χ2[1]=7.01, P=0.008) less strongly than baseline National Institutes of Health Stroke Scale.

CONCLUSIONS

Lifetime stress/trauma is associated with more poststroke acute stress, which is associated with greater motor and cognitive impairment and disability 3 and 12 months poststroke. Poststroke interventions for acute stress may help mitigate stroke-related disability.

Effects of Virtual Reality-Based Cognitive Rehabilitation in Stroke Patients: A Randomized Controlled Trial

During the process of recovering functional ability after damage caused by a stroke, it is important to restore cognitive function via cognitive rehabilitation. To achieve successful rehabilitation, it is important for patients to have a sense of efficacy in their ability to manage their disease well. Therefore, a virtual reality-based cognitive rehabilitation program based on self-efficacy theory was developed, and its effects were compared with conventional and computer-assisted cognitive rehabilitation. The virtual reality-based cognitive rehabilitation program consisted of sessions lasting 30 min each five days a week for eight weeks. After applying the virtual reality-based cognitive rehabilitation program, there were significant differences in group-by-time interactions regarding stroke self-efficacy, cognitive function, visual perception, activities of daily living, and health-related quality of life. In addition, there were significant group differences among the three groups in terms of stroke self-efficacy and health-related quality of life. In conclusion, our virtual reality-based cognitive rehabilitation program developed based on self-efficacy theory is effective for inpatients with stroke and improves their stroke self-efficacy, cognitive function, visual perception, activities of daily living, and health-related quality of life.

The effect of sequential combination of mirror therapy and robot-assisted therapy on motor function, daily function, and self-efficacy after stroke

Robot-assisted therapy and mirror therapy are both effective in promoting upper limb function after stroke and combining these two interventions might yield greater therapeutic effects. We aimed to examine whether using mirror therapy as a priming strategy would augment therapeutic effects of robot-assisted therapy. Thirty-seven chronic stroke survivors (24 male/13 female; age = 49.8 ± 13.7 years) were randomized to receive mirror therapy or sham mirror therapy prior to robot-assisted therapy. All participants received 18 intervention sessions (60 min/session, 3 sessions/week). Outcome measures were evaluated at baseline and after the 18-session intervention. Motor function was assessed using Fugl-Meyer Assessment and Wolf Motor Function Test. Daily function was assessed using Nottingham Extended Activities of Daily Living Scale. Self-efficacy was assessed using Stroke Self-Efficacy Questionnaires and Daily Living Self-Efficacy Scale. Data was analyzed using mixed model analysis of variance. Both groups demonstrated statistically significant improvements in measures of motor function and daily function, but no significant between-group differences were found. Participants who received mirror therapy prior to robot-assisted therapy showed greater improvements in measures of self-efficacy, compared with those who received sham mirror therapy. Our findings suggest that sequentially combined mirror therapy with robot-assisted therapy could be advantageous for enhancing self-efficacy post-stroke.Trial registration: ClinicalTrials.gov Identifier: NCT03917511. Registered on 17/04/2019, https://clinicaltrials.gov/ct2/show/ NCT03917511.

Housing Accessibility at Home and Rehabilitation Outcomes After a Stroke: An Explorative Study

PURPOSE

To explore if aspects of the physical home environment are related to rehabilitation outcomes among community-living persons poststroke.

BACKGROUND

Research demonstrates that healthcare environments are important for high-quality care and that the design of the physical environment is associated with improved rehabilitation outcomes. However, relevant research focusing on outpatient care settings, such as the home, is sparse.

METHODS

In this cross-sectional study, data on rehabilitation outcomes, physical environmental barriers, and housing accessibility problems were collected during home visits of participants (N = 34), 3 months poststroke. Data were analyzed with descriptive statistics and correlation analysis.

RESULTS

Few participants had adapted their homes, and the relevance of the physical environment was not always discussed with the patient during discharge from the hospital. Accessibility problems were associated with suboptimal rehabilitation outcomes such as worse perceived health and recovery after stroke. Activities most restricted by barriers in the home concerned hand and arm use. Participants who reported one or more falls at home tended to live in houses with more accessibility problems. Perceived supportive home environments were associated with more accessible dwellings.

CONCLUSIONS

Many face problems adapting their home environments poststroke, and our findings highlight unmet needs that should be considered in the rehabilitation practice. These findings could be used by architectural planners and health practitioners for more effective housing planning and inclusive environments.

Barriers and facilitators to implementing self-directed therapy activities in inpatient rehabilitation settings

BACKGROUND

Self-directed therapy activities are not currently part of routine care during inpatient rehabilitation. Understanding patient and clinician perspectives on self-directed therapy is key to increasing implementation. The aim of this study was to investigate barriers and facilitators to implementing a self-directed therapy programme ("My Therapy") in adult inpatient rehabilitation settings.

METHODS

My Therapy was recommended by physiotherapists and occupational therapists and completed by rehabilitation inpatients independently, outside of supervised therapy sessions. Physiotherapists, occupational therapists, and patients were invited to complete an online questionnaire comprising open-ended questions on barriers and facilitators to prescribing and participating in My Therapy. A directed content analysis of free-text responses was undertaken, with data coded using categories of the Capability, Opportunity, and Motivation Model of Behaviour (COM-B model).

RESULTS

Eleven patients and 20 clinicians completed the questionnaire. Patient capability was reported to be facilitated by comprehensive education by clinicians, with mixed attitudes towards the format of the programme booklet. Clinician capability was facilitated by staff collaboration. One benefit was the better use of downtime between the supervised therapy sessions, but opportunities for patients to engage in self-directed therapy were compromised by the lack of space to complete the programme. Clinician opportunity was reported to be provided via organisational support but workload was a reported barrier. Patient motivation to engage in self-directed therapy was reported to be fostered by feeling empowered, engaged, and encouraged to participate. Clinician motivation was associated with belief in the value of the programme.

CONCLUSION

Despite some barriers to rehabilitation patients independently practicing therapeutic exercises and activities outside of supervised sessions, both clinicians and patients agreed it should be considered as routine practice. To do this, patient time, ward space, and staff collaboration are required. Further research is needed to scale-up the implementation of the My Therapy programme and evaluate its effectiveness.

The Pre-Adaptation of a Stroke-Specific Self-Management Program Among Older Adults

Objectives: Managing multimorbidity as aging stroke patients is complex; standard self-management programs necessitate adaptations. We used visual analytics to examine complex relationships among aging stroke survivors' comorbidities. These findings informed pre-adaptation of a component of the Chronic Disease Self-Management Program. Methods: Secondary analysis of 2013-2014 Medicare claims with stroke as an index condition, hospital readmission within 90 days (n = 42,938), and 72 comorbidities. Visual analytics identified patient subgroups and co-occurring comorbidities. Guided by the framework for reporting adaptations and modifications to evidence-based interventions, an interdisciplinary team developed vignettes that highlighted multimorbidity to customize the self-management program. Results: There were five significant subgroups (z = 6.19, p < .001) of comorbidities such as obesity and cancer. We constructed 6 vignettes based on the 5 subgroups. Discussion: Aging stroke patients often face substantial disease-management hurdles. We used visual analytics to inform pre-adaptation of a self-management program to fit the needs of older adult stroke survivors.

Health Professional- and Volunteer-partnered Self-management Support (COMBO-KEY) to Promote Self-efficacy and Self-management Behaviors in People with Stroke: A Randomized Controlled Trial

BACKGROUND

Multiple systematic reviews have reported that self-management interventions are associated with positive impacts on self-efficacy and health-related quality of life (HRQoL) of people with stroke.

PURPOSE

This article reports the effects of an enhanced stroke self-management program.

METHODS

Eligible adults with stroke were recruited from community-based organizations and a support group for a two-arm, assessor-blinded randomized controlled trial. Participants in the control group received usual care, while those in the intervention group also received the 8-week self-management program, Coaching Ongoing Momentum Building On stroKe rEcovery journeY (COMBO-KEY), consisting of four individual home visits and five follow-up phone calls, delivered by healthcare professionals and trained volunteers. Assessments were conducted at baseline and after the intervention, for outcomes of self-efficacy, satisfaction with the performance of self-management behaviors, HRQoL, and community reintegration, which were analyzed using generalized estimating equations (GEEs).

RESULTS

134 Participants were recruited [mean age = 64.1 years, standard deviation (SD) = 12.7]. Over 80% of the participants had a first-ever stroke [mean years after first stroke: 4.2 (SD = 5.1)]. The GEE analysis revealed that the intervention group participants showed significantly greater improvements in self-efficacy, satisfaction with their performance of self-management behaviors, HRQoL, and community reintegration at 8-week follow-up with respect to their baseline levels.

CONCLUSIONS

The COMBO-KEY program showed effective improvements in recovery outcomes of people with stroke. Future research should explore the inclusion of virtual/hybrid sessions, strategies to assess health conditions of people with stroke via online modes, and assessment of goal attainment and actual performance of self-management behaviors.

The use of self-management strategies for stroke rehabilitation: a scoping review

INTRODUCTION

Self-management is generally considered a dynamic and collaborative process by individuals and caregivers to manage a chronic condition. Self-management has recently emerged as a promising strategy for stroke rehabilitation. This scoping review aims to examine and summarize self-management strategies utilized by stroke survivors for stroke rehabilitation.

METHODS

PubMed, Scopus, CINAHL (EBSCO), Embase, and ProQuest were searched for articles published between January 2010 and December 2021. Studies were selected if they were published in English in a peer-reviewed journal, utilized a non-experimental research design, and focused on adult stroke survivors. All relevant information from the included articles was extracted in a systematic way using a pre-developed data extraction form. Two authors performed data extraction and quality evaluation independently. All issues were resolved through discussion among the authors.

RESULTS

We narratively summarized the findings of 15 quantitative, qualitative, and mixed-method studies, including a total of 1,494 stroke survivors. The stroke survivors used a range of self-management strategies for their stroke rehabilitation, including domains related to lifestyle, social support, communication, knowledge and information, and goal-setting. Gender, age, stroke-related disability, fatigue, self-management education, social support, and communication with others were found to be associated with self-management use in stroke rehabilitation.

CONCLUSIONS

This scoping review provides an important overview on stroke survivors' use of self-management strategies and their experience. Their use of self-management strategies is complicated and multifaceted, comprising several domains and involving a diverse range of approaches and personal experiences. However, we identified several gaps in the literature and more research is required.

The Impact of Upper Limb Apraxia on General and Domain-Specific Self-Efficacy in Post-Stroke Patients

BACKGROUND

Upper limb apraxia (ULA) is a neurological syndrome characterized by the inability to perform purposeful movements. ULA could impact individuals' perceptions, including perceived self-efficacy. The aim of this study is to investigate whether ULA is related to general self-efficacy and self-efficacy for managing symptoms in post-stroke patients.

METHODS

A cross-sectional study was conducted involving 82 post-stroke patients. Regression analyses were implemented using a stepwise model including seven dimensions of ULA: imitation (non-symbolic, intransitive, and transitive), pantomime (non-symbolic, intransitive, and transitive), and dimension of apraxic performance in activities of daily living. These dimensions were independent variables, while general self-efficacy and symptom management self-efficacy dimensions were dependent variables.

RESULTS

The findings revealed that intransitive imitation accounted for 14% of the variance in general self-efficacy and 10% of self-efficacy for managing emotional symptoms. Transitive imitation explained 10% of the variance in self-efficacy for managing global symptoms and 5% for social-home integration symptoms. The combination of intransitive imitation, non-symbolic pantomime, and alterations in activities of daily living performance associated with ULA explained 24% of the variance in cognitive self-efficacy.

CONCLUSIONS

Hence, ULA dimensions seem to be related to the levels of general perceived self-efficacy and self-efficacy for managing symptoms among post-stroke patients.

Neurofeedback therapy to improve cognitive function in patients with chronic post-stroke attention deficits: a within-subjects comparison

Introduction

We investigated a slow-cortical potential (SCP) neurofeedback therapy approach for rehabilitating chronic attention deficits after stroke. This study is the first attempt to train patients who survived stroke with SCP neurofeedback therapy.

Methods

We included N = 5 participants in a within-subjects follow-up design. We assessed neuropsychological and psychological performance at baseline (4 weeks before study onset), before study onset, after neurofeedback training, and at 3 months follow-up. Participants underwent 20 sessions of SCP neurofeedback training.

Results

Participants learned to regulate SCPs toward negativity, and we found indications for improved attention after the SCP neurofeedback therapy in some participants. Quality of life improved throughout the study according to engagement in activities of daily living. The self-reported motivation was related to mean SCP activation in two participants.

Discussion

We would like to bring attention to the potential of SCP neurofeedback therapy as a new rehabilitation method for treating post-stroke cognitive deficits. Studies with larger samples are warranted to corroborate the results.

Virtual Reality for Upper Extremity Rehabilitation-A Prospective Pilot Study

Applications related to virtual reality are a rapidly growing area. Thus, these technologies are also increasingly used in the field of medicine and rehabilitation. The primary objective of this prospective pilot study was to investigate the feasibility, user experience and acceptance of a virtual-reality-based system for upper extremity rehabilitation. The study was conducted as a single-center trial over 16 weeks. The eligibility criteria included rehabilitants with upper extremity injuries of at least 18 years of age who were fluent in spoken and written German. After detailed instruction, each participant was asked to complete daily 30 min exercises over 15 training sessions with the virtual reality system consisting of three different training modules. Outcomes were assessed pre-study and post-study using standardized clinical measures. In addition, qualitative interviews with rehabilitants as well as therapists regarding user experience and acceptance were conducted. Six participants were recruited for the pilot study, of which five underwent virtual-reality-based rehabilitation. Overall, the clinical measures showed a positive tendency over the course of the study, even if the results were not significant. Furthermore, the virtual-reality-based training was well accepted by the participants as well as therapists. Given these findings, it will be beneficial to evaluate virtual reality for rehabilitation in further research.

Exploring the self-efficacy and self-care-based stroke care model for risk factor modification in mild-to-moderate stroke patients

Context

The worldwide burden of stroke is projected to grow unless proper stroke education is implemented. Information alone cannot promote patient self-efficacy and self-care and reduce risk factors.

Aim

This trial aimed to test self-efficacy and self-care-based stroke education (SSE) on changes in self-efficacy, self-care, and risk factor modification.

Design setting and participants

This study is a single-center, double-blinded, interventional, two-arm randomized controlled trial with a 1- and 3-month follow-up in Indonesia. Between January 2022 and October 2022, 120 patients were prospectively enrolled from Cipto Mangunkusumo National Hospital, Indonesia. Participants were assigned using a computer-generated random number list.

Intervention

SSE was given before discharge from the hospital.

Primary outcome measure

Self-care, self-efficacy, and stroke risk score was measured 1 month and 3 months after discharge.

Secondary outcome measure

Modified Rankin Scale, Barthel Index, and blood viscosity was measured at 1 month and 3 months after discharge.

Results

A total of 120 patients (intervention n = 60; standard care n = 60) were randomized. In the 1st month, the intervention group showed a more significant change in self-care (4.56 [95% CI: 0.57, 8.56]), self-efficacy (4.95 [95% CI: 0.84, 9.06]), and stroke risk (-2.33 [95% CI:-3.19, -1.47]) compared to the controlled group. In the 3rd month, the intervention group also showed a more significant change in self-care (19.28 [95% CI: 16.01, 22.56]), self-efficacy (19.95 [95% CI: 16.61, 23.28]), and stroke risk (-3.83 [95% CI: -4.65, -3.01]) compared to the controlled group.

Conclusion

SSE may boost self-care and self-efficacy, adjust risk factors, enhance functional outcomes, and decrease blood viscosity.

Clinical trial registration

ISRCTN11495822.

Post-stroke cardiovascular management: Current concepts, integrated care and future developments

After an ischaemic stroke patients often have cardiovascular complications known as stroke-heart syndrome. The cardiovascular management after stroke has a significant impact on life expectancy as well as the quality of life. The development and implementation of management pathways to improve outcomes for patients with stroke-heart syndrome requires a multidisciplinary involvement from health care professionals from primary, secondary and tertiary prevention levels. A holistic, integrated care approach could follow the ABC pathway: A) Appropriate antithrombotic therapy in all stroke/TIA patients in the acute phase as well as recommendations for the longer term treatment regimen are required to avoid recurrent stroke. B) For better functional and psychological status the assessment of post-stroke cognitive and physical impairment, depression, and anxiety as part of routine post-stroke work-up in every patient is necessary. C) Cardiovascular risk factors and comorbidities management further includes cardiovascular work-up, adapted drug therapy, but often also lifestyle changes that are central to the success of integrated care for stroke-heart syndrome. Greater patient and family/caregiver involvement in planning actions and the input and feedback on optimizing stroke care pathways is needed. Achieving integrated care is challenging and highly context dependent on different healthcare levels. A tailored approach will utilize a variety of enabling factors. In this narrative review, we summarize the current evidence and outline potential factors that will contribute to the successful implementation of integrated cardiovascular care for stroke-heart syndrome management.

"My head feels like it has gone through a mixer" - a qualitative interview study on recovery 1 year after aneurysmal subarachnoid hemorrhage

PURPOSE

To describe patients' perceived and expected recovery 1 year after aneurysmal subarachnoid hemorrhage (aSAH).

MATERIALS AND METHODS

Semi-structured interviews were conducted with 16 persons 1 year after aSAH. Inductive manifest qualitative content analysis was used.

RESULTS

The analysis resulted in two categories and seven subcategories. The category "A spectrum of varying experiences of recovery" includes four subcategories describing physical recovery, mental recovery, alterations in social life, and perceived possibilities to return to normality. Some informants felt that life was almost as before, while others described a completely different life, including a new view of self, altered relationships, not being able to return to work, and effects on personal finances. The category "A spectrum of reflections and expectations of recovery" comprises three subcategories depicturing that expectations of recovery were influenced by existential thoughts, describing what they based own expectations of recovery on, and how expectations from others influenced them.

CONCLUSIONS

aSAH was perceived as a life-changing event. The changes impacted on informants' view of self and relationships, and they perceived new barriers in their living conditions. Lack of information on expected recovery was expressed and expectations of recovery were at times unrealistic.IMPLICATIONS FOR REHABILITATIONContracting an aneurysmal subarachnoid hemorrhage (aSAH) is a life-changing event with possible impact on a variety of areas in daily life.There is a need for improved information to aSAH survivors and their significant others on the course of the recovery and possible long-term consequences.aSAH survivors may need assistance to balance unrealistic expectations on recovery.

Diving into Health: A Mixed Methods Study on the Impact of Scuba Diving in People with Physical Impairments

The impacts of scuba diving on people with physical impairments are unknown. Grounded on the social identity approach to health, the aim of this study was to test and describe the relationships between scuba diving social identity, self-efficacy, social health, psychological health, physical health, health-related quality of life (HRQOL), and disability level among recreational scuba divers with physical impairments. A mixed methods explanatory sequential design was employed. The quantitative strand used an 80-item cross-sectional survey, with the data analyzed via a path analysis. The qualitative strand used 1:1 interviews across 3 case study groups; the data were analyzed using deductive and inductive analyses. Mixing occurred via a joint display with meta-inferences. The quantitative results (n = 78) indicated that self-efficacy was a significant predictor of social health, psychological health, physical health, HRQOL, and disability level. The qualitative findings (n = 15) consisted of six themes, whereby participants described scuba as a positive social identity that provides them with meaning, purpose, and belonging. Furthermore, they described scuba diving as a positive contributor to their self-efficacy, social health, psychological health, physical health, and quality of life. During the mixing of data, the quantitative and qualitative results did not match on the influence of scuba diving social identity on self-efficacy, social health, psychological health, physical health, HRQOL, and disability level. A further analysis revealed that the range restriction impaired the conclusive quantitative evidence on the scuba diving social identity variable. The meta-inferences derived from the data integration suggest that scuba diving plays a role in the self-efficacy, health, HRQOL, and disability level among scuba divers with physical impairments. The findings point to the potential of scuba diving as a health promotion recreational activity and rehabilitation modality for people with physical impairments.