Stroke patients’ and informal carers’ experiences with life after stroke: an overview of qualitative systematic reviews

Exploring the personal stroke and rehabilitation experiences of older adults with chronic stroke during the COVID-19 pandemic: a qualitative descriptive study

PURPOSE

The purpose of this study was to explore the personal stroke and rehabilitation experiences of older adults with chronic stroke living in a mid-sized Northwestern Ontario city in Canada during the COVID-19 pandemic.

METHODS

A qualitative descriptive approach with a constructivist worldview was used. In addition, a semi-structured interview guide was used to gather the participants' perspectives on their experiences throughout stroke recovery. Ten participants were interviewed, including six males and four females. The interviews were completed, transcribed, and analysed using inductive and deductive content analysis. Multiple steps were taken to enhance data trustworthiness.

RESULTS

Six main themes and eight related subthemes emerged. These included: getting help is complex, the effects of stroke are multifaceted, losing rehabilitation services during the COVID-19 pandemic, overcoming hardships but not alone, "If you don't use it, you lost it": rehabilitative success is based on one's actions, and "look at me now": the importance of taking pride in one's successes.

CONCLUSIONS

One unique finding was that the participants used this study as an opportunity to teach and advocate for future stroke survivors which is not often seen in qualitative stroke rehabilitation research. Future stroke research should place emphasis on both the positive and negative experiences of this population.

The experiences of cardiac arrest survivors and their key supporters following cardiac arrest: A systematic review and meta-ethnography

AIM

To review qualitative studies on the experience of sudden cardiac arrest survival from the perspective of both survivors and their key supporters, including family/close friends.

METHODS

A seven-step meta-ethnography and synthesis of qualitative evidence was undertaken, informed by the Meta-Ethnography Reporting Guidelines (eMERGe). Four major databases were searched (Medline, EMBASE, CINAHL, PsycINFO; January 1995-January 2022, updated July 2023) for qualitative studies exploring survivors' and/or key supporters' experiences of cardiac arrest survival. The Critical Appraisal Skills Programme checklist and Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual) were applied to evaluate the overall confidence in research findings. Constructs were identified from each paper, informing theme and sub-theme development.

RESULTS

From 15,917 unique titles/abstracts and 196 full-text articles, 32 met the inclusion criteria. Three themes captured the survivors' experiences: 1) Making sense of my cardiac arrest; 2) Learning to trust my body and mind; and 3) Re-evaluating my life. A further three themes reflected key supporters' experiences: 1) Emotional turmoil; 2) Becoming a carer: same person but different me; and 3) Engaging with a new and unknown world. However, limited data and some methodological weaknesses in included studies reduced confidence in several themes. The findings were conceived within the overarching concept of 'negotiating a new normal'.

CONCLUSIONS

The enduring psychosocial and physical sequelae of cardiac arrest survival substantially impacts the lives of survivors and their key supporters, requiring negotiation of their 'new normality'. The need for sense-making, physical and psychological recovery, and the new roles for key supporters should be strong considerations in the development of future interventions.

Stroke disease-specific quality of life trajectories and their associations with caregivers' anxiety, depression, and burden in stroke population: a longitudinal, multicentre study

AIMS

The aims of this study were to: (i) test if there are clusters of stroke survivors who experience distinct trajectories of quality of life (QOL) from hospital rehabilitation discharge to 12-month follow-up; (ii) test if any sociodemographic or clinical variables predict this class membership; and (iii) examine the associations between the clusters of stroke survivors' and their caregivers' trajectories of anxiety, depression, and burden over time.

METHODS AND RESULTS

A total of 415 stroke survivors and their caregivers were recruited in Italy for this 1-year, longitudinal, multicentre prospective study, filling out a survey at five time points. We found two distinct trajectories of change in stroke survivors' psychological QOL (i.e. Memory, Communication, Emotion, and Participation). The first trajectory (86% of the survivors) included those who started with greater levels of QOL and improved slightly to markedly in all psychological domains, while the second trajectory (14% of the survivors) comprised those who started with lower overall levels of psychological QOL and experienced a worsening or no changes at all in these dimensions up to 12-month follow-up. Very few clinical and sociodemographic variables at baseline predicted class membership. Finally, caregivers of those patients who experienced no change or a worsening in psychological QOL reported greater distress and burden over time.

CONCLUSION

Our results highlight the need for more tailored interventions to improve patients' psychological QOL and consequently their caregivers' well-being. This requires a shift from a stroke survivor-centred approach to a stroke survivor- and caregiver-centred one.

The ethical pathway of individuals with stroke-A follow-up study

AIM

To analyse the ethical pathway as perceived by individuals with stroke (IwS) in the first three post-stroke months. In the novel concept of ethical pathway, dignity, privacy, and autonomy are considered as dimensions of the ethical pathway while the pathway illustrates their potential change in the post-stroke time. Furthermore, the focus of interest was on whether the perceived realisation of values is associated with the life situational factors of symptoms diminishing functioning, social environment, and self-empowerment.

METHODOLOGICAL DESIGN AND JUSTIFICATION

A follow-up study with a descriptive correlational design was used to capture the changes in the perceived realisation of values.

ETHICAL ISSUES AND APPROVAL

The study followed the ethical principles of research involving human participants. The study was approved by the ethics committee of the university and one of the university hospitals following national standards. Permission to conduct the study was obtained from the university hospitals.

RESEARCH METHODS AND INSTRUMENT

Data were collected from IwS after the onset of stroke and 3 months post-stroke with the Ethical Pathway of Individuals with Stroke instrument and background questions and were analysed statistically.

RESULTS

Thirty-six participants completed the questionnaire at both measurement points. Wide variety in the ethical pathway was detected. IwS' perceived dignity decreased and autonomy increased. Privacy did not change significantly. Of the life situational factors, IwS perceived less symptoms diminishing functioning and stronger self-empowerment while social environment was perceived as rather stable. Only one association was detected between the dimensions of the ethical pathway and life situational factors: autonomy had a low negative correlation with social environment of health care professionals.

CONCLUSIONS AND STUDY LIMITATIONS

The results provide preliminary evidence of the dynamic nature of the ethical pathway. The ethical pathway was incompletely realised for most participants and requires special attention and improvement in health care. The sample size is small and the results are therefore not generalisable.

Recovery needs and psychosocial rehabilitation trajectory of stroke survivors (PReTS): A qualitative systematic review of systematic reviews

OBJECTIVE

Stroke has a major impact on a person's life. While much research exists on stroke prevention and treatment, explorations into psychosocial recovery needs are lacking. This review critically consolidates the challenges and needs of stroke survivors and develops a trajectory that encapsulates their journey from illness to recovery.

DATA SOURCES

Six major databases were searched, including Academic Search Premier, CINAHL, Global Health, Medline, PsycArticles, and PsycINFO.

METHODS

This review adhered to the PRISMA guidelines and employed the PICo (population, phenomena of interest, context) framework to screen for relevant qualitative reviews published between 1 January 2010 and 31 August 2023. Following full-text screening and the assessment of methodological quality using a modified version of the Assessment of Multiple Systematic Reviews scale, a total of 17 reviews were included for thematic synthesis.

RESULTS

Included reviews referenced 400 qualitative primary studies involving more than 5623 stroke survivors. Data synthesis revealed 18 themes that were further organized into six conceptual categories: (1) The unfamiliar body, (2) compassionate healthcare system, (3) holistic rehabilitation, (4) intrapersonal strength, (5) interpersonal relations, and (6) thriving forward to form the psychosocial rehabilitation trajectory of stroke survivor (PReTS) model. The model recognizes the losses that can occur after a stroke and emphasizes the essentiality of addressing psycho-socio-emotional and spiritual needs alongside physical impairments.

CONCLUSION

The PReTS model is the first to highlight stroke survivors' losses, recovery journeys, and psychosocial needs. The conceptualization serves to inform and advance stroke rehabilitation practices with holistic and wellness recovery research.

"Coming home was a disaster, I didn't know what was going to happen": a qualitative study of survivors' and family members' experiences of navigating care post-stroke

PURPOSE

Understanding navigational barriers and facilitators has the potential to advance equitable stroke care delivery. The aim of this study was to explore, using a qualitative study, the experiences of stroke survivors and their families as they journey through the stroke care system, both before and during the COVID-19 pandemic.

METHODS

In-depth semi-structured interviews were conducted with 18 stroke survivors and 12 family members during 2021 and 2022. Participants were recruited through voluntary organisations, social media, and stroke support groups. Data analysis followed a systematic process guided by the framework method with steps including familiarisation, coding, framework development, and charting and interpretation.

RESULTS

The experiences of navigating stroke care were particularly challenging following discharge from hospital into the community. Barriers to stroke care continuity included insufficient appropriate services and information, unsatisfactory relationships with healthcare professionals and distressed mental health. There were particular navigational challenges for survivors with aphasia. Facilitators to effective navigation included having prior knowledge of the health system, harnessing support for care co-ordination, and being persistent.

CONCLUSION

Greater support for patient navigation, and person-centred referral pathways, particularly during times of increased pressure on the system, have the potential to improve access to services and wellbeing among stroke survivors.

Building Bridges between People with Stroke, Families, and Health Professionals: Development of a Blended Care Program for Self-Management

Evidence-informed interventions for stroke self-management support can influence functional capability and social participation. People with stroke should be offered self-management support after hospital discharge. However, in Portugal, there are no known programs of this nature. This study aimed to develop a person-centered and tailored blended care program for post-stroke self-management, taking into account the existing evidence-informed interventions and the perspectives of Portuguese people with stroke, caregivers, and health professionals. An exploratory sequential mixed methods approach was used, including qualitative methods during stakeholder consultation (stage 1) and co-production (stage 2) and quantitative assessment during prototyping (stage 3). After ethical approval, recruitment occurred in three health units. Results from a literature search led to the adaptation of the Bridges Stroke Self-Management Program. In stage one, 47 participants were interviewed, with two themes emerging: (i) Personalized support and (ii) Building Bridges through small steps. In stage two, the ComVida program was developed, combining in-person and digital approaches, supported by a workbook and a mobile app. In stage three, 56 participants evaluated prototypes, demonstrating a strong level of quality. Understandability and actionability of the developed tools obtained high scores (91-100%). The app also showed good usability (A-grade) and high levels of recommendation (5 stars).

In search of self after stroke: a longitudinal qualitative study in the context of client-centred rehabilitation

PURPOSE

The aim was to illuminate the experiences of stroke survivors returning to everyday life in the year following stroke, in the context of client-centred rehabilitation.

METHODS

Four men who participated in a client-centred rehabilitation program were followed during the first year after stroke. Semi-structured interviews were conducted, allbut the first in the participants' home. The data were analysed using a grounded theory approach.

RESULTS

The results revealed a process with the overarching core category; The "new" self becomes reality through challenging everyday experiences, and five main categories driving the process: 1) Striving for structure in a "new" chaotic world, 2) Homecoming an ambiguous experience, 3) Reaching the "new" self through reflections of self-understanding, 4) Socialising in new circumstances, and 5) Realising a new reality.

CONCLUSIONS

While in hospital, stroke survivors can have unrealistic expectations. When at home they can begin to realise their actual capacity . To find a "new" self after a stroke can involve time-consuming and taxing processes of reflections of self-understanding. Engagement in self-selected meaningful and valued activities can support stroke survivors' reconstruction of the "new" self but not all stroke survivors may succeed in finding their "new" self during the first year after stroke.

Living with stroke during the first year after onset: an instrumental case study exploring the processes that influence adjustment

PURPOSE

The purpose of the study was to explore the experiences of an individual navigating life in the first year after stroke, with attention to the influence of health professionals on adjustment.

METHOD

In-depth interviews were completed at regular intervals with an individual in rural Australia. This longitudinal approach supported the exploration of views over time. Interview transcripts were coded and analysed using strategies consistent with constructivist grounded theory methods. Findings are presented as an instrumental case study.

RESULTS

The experience of stroke was one of adjustment to a new reality and of an altered and evolving concept of self: captured within the themes of fragmentation, loss, and reconstruction. Self-efficacy emerged as a driver in the adjustment process. Interactions with health professionals influenced adjustment and impacted on conceptualisations of self and self-efficacy.

CONCLUSIONS

Adjustment to stroke necessitated a reconceptualization of self. Relationships and interactions with others emerged as potential facilitators. For health professionals working with people after stroke, knowledge of the adjustment process and attention to practices that affirm personhood and enhance self-efficacy have the potential to facilitate long term outcomes. Processes linked to adjustment are represented visually to guide conceptual understandings and facilitative actions.

IMPLICATIONS FOR REHABILITATIONAll interactions with health professionals, including casual or ad hoc interactions, have the potential to influence adjustment after stroke.Health professionals who interact in ways that recognise personhood may have an especially positive influence on processes linked to adjustment.Giving time to listen to personal narratives and reflections may assist with sense-making and support the process of reconceptualising self after stroke.Through bidirectional sharing of experience and ideas, health professionals can facilitate the experience of self-efficacy.

Thoracoabdominal aortic aneurysm life-altering events following endovascular aortic repair in the Vascular Quality Initiative

OBJECTIVE

Endovascular aortic aneurysm repair has lower rates of postoperative mortality and morbidity when compared with open repair. However, endovascular repair still carries the risk of postoperative dialysis, paralysis, and stroke. This study examined the rates of postoperative mortality and morbidity stratified by type of endovascular aortic aneurysm repair.

METHODS

All patients who underwent endovascular aortic aneurysm repair in the Vascular Quality Initiative registry from January 2011 - May 2022 were identified. Patients were stratified by repair type: infrarenal endovascular aortic repair (EVAR), complex EVAR, thoracic endovascular aortic repair (TEVAR), extent I-III thoracoabdominal aortic aneurysm (TAAA) repair, or aortic arch repair. The primary outcome was postoperative thoracoabdominal aortic aneurysm life-altering events (TALE) across the different treatment groups. TALE was defined as a composite outcome of postoperative mortality, dialysis, paralysis, and/or stroke. Mixed effect logistic regression modeling was used to identify procedural and anatomic factors that were independently associated with TALE.

RESULTS

A total of 52,592 EVARs, 3,768 complex EVARs, 3,899 TEVARs, 1,139 extent I-III TAAA repairs, and 479 arch repairs were identified. TALE was observed in 1.2% of EVARs, 4.8% of complex EVARs, 6.0% of TEVARs, 10% of extent I-III TAAA repairs, and 14% of arch repairs. More proximal landing zone was associated with higher odds of TALE after complex EVAR (OR 1.9 [1.2-3.1]; p=.008), TEVAR (OR 2.2 [1.4-3.5]; p=.001), and extent I-III TAAA repair (OR 2.7 [1.5-4.9]; p=.001). Aortic diameter >65mm was associated with higher odds of TALE after infrarenal EVAR (OR 1.8 [1.4-2.3]; p<.001), complex EVAR (OR 1.6 [1.1-2.3]; p=.010), TEVAR (OR 2.7 [2.0-3.8]; p<.001), and arch repair (OR 2.4; [1.3-4.4]; p=.007). The use of parallel grafting technique (chimney/snorkel/periscope) during extent I-III TAAA repair was also associated with higher odds of TALE (OR 1.8 [1.1-3.2]; p=.032). Preoperative chronic kidney disease was also associated with higher odd of TALE after infrarenal EVAR (OR 4.3 [3.0-5.7]; p<.001), complex EVAR (OR 5.2 [3.3-8.2]; p<.001), TEVAR (OR 4.5 [2.8-7.1]; p<.001), and extent I-III TAAA repair (OR 3.2 [1.6-6.7]; p=.001).

CONCLUSION

While TALE was originally described for thoracoabdominal aortic aneurysm repairs, TALE may occur after complex EVAR, TEVAR, and arch repairs as well. Therefore, TALE and its component parts should be used to evaluate the efficacy of all aortic repairs and for preoperative counseling. Additionally, surgeons should be aware of anatomic and procedural characteristics that are associated with higher odds of TALE. The anticipated need for such interventions during aortic repair should be factored into preoperative risk assessment of patients.

Living losses in stroke caregiving: A qualitative systematic review of systematic reviews on psycho-socio-emotional challenges and coping mechanisms

BACKGROUND

Stroke compromises the quality of life and wellbeing of stroke survivors and families as a whole. The unexpected caregiving responsibilities often cause psychological distress, overwhelming emotions, living losses and grief, and relational conflicts with stroke survivors. Despite the increasing research to better understand their needs, empirically sound and holistic psychosocial interventions for stroke caregivers are lacking.

AIMS

This study aims to consolidate psycho-socio-emotional needs and challenges in the existing systematic reviews and offer potential directions for psychosocial interventions to better support caregivers at a psycho-socio-emotional level.

METHODS

This systematic review adhered to the PRISMA guideline and employed the PICo (population, phenomena of interest, context) framework to screen for relevant systematic reviews for analysis. Six major databases were searched, including Academic Search Premier, CINAHL, Global Health, Medline, PsycArticles, and PsycInfo between 2010 and 2020. Ten systematic reviews were selected for full-text analysis using thematic synthesis.

SUMMARY OF REVIEW

Data synthesis revealed eight themes with sixteen sub-themes, all together organized into two main theme categories. The psycho-socio-emotional challenges included disruptions to (1) psychological homeostasis, (2) role equilibrium, (3) familial connection, and (4) caregiving empowerment. The psycho-socio-emotional coping mechanisms, which could be adopted to buffer against the identified challenges, involved (1) recalibration of normality and balance, (2) psychosocial support and caregiver relief, (3) relational reorientation and dyadic coping, and (4) institutional holistic care and support.

CONCLUSION

The findings accentuate the importance of addressing living losses and grief emerging from the caregiving journey, as well as facilitating meaning reconstruction to safeguard caregivers' wellbeing. Clinical implications and future research directions are discussed.

Contributing Factors to the Burden on Primary Family Caregivers of Stroke Survivors in South Korea

The purpose of this study is to identify the factors associated with the burden on primary family caregivers of stroke patients at home without care services. For this study, the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) data were used. Of the total 8010 caregivers, 1133 family caregiver burden was assessed with the shortened Caregiver Burden Inventory (CBI) 3 months after stroke. Patient and caregiver-related factors affecting the heavier burden of caregivers were identified by comparing the heavier caregiver burden group and the lighter caregiver burden group, which divided according to the CBI scores. The 719 (63.5%) family caregiver cared for patients at home without care services. Logistic regression analysis showed that four or more comorbidities (p = 0.002), neurological impairment at early onset (p < 0.001), dependence on daily life (p < 0.001), aphasia (p = 0.024), and depression(p < 0.001) were associated with a heavier burden of care. According to the shortened CBI, caregivers tended to be concerned more about psychological stress than physical strain. The findings suggest the importance of proactively guiding the emotional support services to caregivers who are at high risk of the heavier burden of patient care.

Information, involvement, self-care and support-The needs of caregivers of people with stroke: A grounded theory approach

BACKGROUND

Globally, stroke is a leading cause of death and disability, with most care undertaken by caregivers who are generally family and friends without prior experience of care. The lack of experience or unpreparedness results in feelings of uncertainty, burnout, anxiety, burden, etc. Hence, it is necessary to identify the needs of caregivers to better support them in their caregiving journey and improve the quality of care delivered.

METHODS

The study employed a grounded theory methodology that utilizes information gathered from literature reviews and social media to represent the needs and create a storyline visually. The storyline is further refined and evaluated using an online survey of 72 participants recruited through online stroke caregiving communities.

RESULTS

The study identified four core categories of needs: (i) Information: sufficient information delivered in layman's terms based on the individual situation of the caregiver and survivor through oral and hands-on demonstrations, (ii) Involvement: inclusion in the decision-making processes at different stages of recovery through face-to-face communication at the hospital, (iii) Self-care: ability to engage in work and leisure activities, (iv) Support: receive support in the form of resources, services and finances from different other stakeholders.

CONCLUSIONS

There is a need to create a caregiver-centered approach in stroke recovery to ensure limited obstruction to care and reduced uncertainty in stroke recovery. Moreover, through the inclusion of caregivers in stroke recovery, it may be possible to reduce the burden of care to the caregiver and ensure the satisfaction of the healthcare system throughout stroke recovery.

Types and associated methodologies of overviews of reviews in health care: a methodological study with published examples

OBJECTIVES

To provide a descriptive insight into the different types of research questions/objectives and associated methodologies of overviews of reviews, supplemented by representative examples from the health care literature.

STUDY DESIGN AND SETTING

We searched in methodological articles for information on types and methodologies used in overviews and we explored the typology of reviews to identify similar types in literature of overviews. We categorized the types of overviews based on the research question/objective and the methodological approach used. Indicative examples for each category were selected from a sample of 2,121 overviews that were retrieved between 2000 and 2022 from MEDLINE, Scopus, and Cochrane Database of Systematic Reviews.

RESULTS

Based on type of research question, overviews were classified as overviews of reviews of interventions, associations, prediction, diagnostic accuracy, prevalence/incidence, experiences/views, economic evaluation, and measurement properties. Based on the methodological approach, we identified a variety of methods (systematic, living, rapid, scoping, evidence mapping, framework, and methodological) used in overviews.

CONCLUSION

The proposed classification and examples provide an essential starting point for future theory-building research on typologies and study designs of overviews of reviews. It is important for methodologists to make vigorous effort to create consensus-based methodological and reporting guidelines to cover these diverse types and key methodological challenges.

Co-Design of an Educational Resource with Female Partners of Male Stroke Survivors to Support Physical Activity Participation

Many male stroke survivors find it challenging to meet the recommended physical activity (PA) guidelines for health benefits. The spouse/partner is an important source of self-management for stroke survivor PA participation; however, they feel unsupported by health professionals. This study aimed to co-design an educational resource prototype to guide and empower female partners in supporting male stroke survivors' participation in PA. We used a participatory action research (PAR) methodology. Thirteen support persons of male stroke survivors from Canterbury, New Zealand participated in four PAR cycles. The data were collected using individual interviews and focus groups and analyzed inductively using the general inductive approach. Three themes were reflected in the data and informed the prototype content: (1) managing an unwanted and challenging new life, (2) inconsistent access to meaningful information, and (3) considerations for successful stroke survivor PA participation. If partners are to be an essential source in supporting stroke survivors' self-management of PA, they require resources that are meaningful and credible to enhance their confidence and self-efficacy. Further research is needed to explore the acceptability and usability of the educational resource with a wider audience and evaluate the co-design process. An inclusive and collaborative approach where support persons were valued for their expertise was essential in co-designing a meaningful resource intended to support stroke survivors and support persons' self-management of their PA.

Post-Stroke Experiences and Rehabilitation Needs of Community-Dwelling Chinese Stroke Survivors: A Qualitative Study

Stroke survivors encounter significant limitations in daily life activities and face increased risk of health complications such as stroke recurrence. Considering the escalating demand for personalised community rehabilitation services, this qualitative study was conducted to understand the current recovery experiences, needs, and expectations of community-dwelling stroke survivors. Fifty stroke survivors were recruited from two tertiary teaching hospitals and community centres in two provinces in mainland China. Semi-structured interviews were carried out, and participants were asked to describe their experiences of stroke, current lifestyles, exercise habits, and rehabilitation needs and expectations. Resulting data were thematically analysed. The majority of participants were first-time stroke survivors (80%) and lived with their family or caregivers (92%). Four main themes and twelve sub-themes emerged from the data: (1) shifts in social life, (2) shaken sense of self and perceived helplessness, (3) complex rehabilitation needs, and (4) perceptions and patterns of physical activity. Findings suggest that though survivors recognised their need for further rehabilitation, their demands remained unmet due to a combination of personal and external factors such as limited mobility and the absence of supportive companions and accessible facilities. The enhancement and diversification of home rehabilitation strategies are therefore necessary to make community rehabilitation more accessible and equitable.

Uncertainty among families of patients with cerebrovascular diseases in Japan: association with quality of life and background characteristics

Purpose

To determine the relationship between family uncertainty and family quality of life (QOL) during the recovery period of patients with cerebrovascular disease in Japan, and the factors that influence family uncertainty.

Methods

Data were collected from copies of patient medical files and interviews with family members of 85 patients admitted to two rehabilitation wards in Japan. Family uncertainty was measured using the Japanese version of the Managing Uncertainty in Illness Scale–Family Member form (MUIS-FM) and family QOL using the World Health Organization Five Well-Being Index (WHO-5). Multiple linear regression analysis was applied to investigate associated factors.

Results

WHO-5 score was significantly negatively associated with MUIS-FM score (β =  − 0.236, p = 0.03); other factors associated with MUIS-FM score were the Care Shared Decision-Making Questionnaire for care providers score (β =  − 0.384, p < 0.001), Short Intolerance of Uncertainty Scale score (β = 0.296, p = 0.001), and history of surgical treatment (β = 0.199, p = 0.032).

Conclusions

Family QOL could be improved by reducing family uncertainty. It is also suggested that promoting shared decision-making between healthcare providers and patients’ families may help reduce family uncertainty. It is necessary to take into account not only family intolerance of uncertainty but also uncertainty that varies by type of acute care provided.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-022-02254-1.

Patient and public involvement in stroke research: a scoping review protocol

Background: Growing consensus supports public and patient involvement (PPI) in research as the lived experience of patients, family carers and users of health and social care services bring unique insights to healthcare research. The impact and burden of stroke present ongoing challenges for those living with its consequences and could potentially limit PPI activity. This review aims to explore PPI in published stroke research to identify and describe the extent, nature and design of PPI activities, the type/s of studies involved and the profile of PPI participants engaged in stroke research. Methods: This systematic scoping review, guided by the Arksey & O’Malley five step framework, will be reported according to the PRISMA-ScR reporting guidelines. PPI is embedded at each stage of this proposed scoping review from conceptualisation, participation, contribution and collaboration. The Population, Concept, Context (PCC) structure defines the research question which asks - How is PPI in stroke research currently being conducted and how do the study authors report their PPI activities and its impact? A comprehensive range of electronic databases including PubMed, CINAHL, EMBASE, PsychINFO and the Cochrane Database of Systematic Reviews will generate a broad range of studies. Grey literature (e.g. OpenGrey, Lenus) and internationally recognised stroke organisation websites will be searched for additional research reports. Data extraction will adhere to the Joanna Briggs Institute guidelines, with results collated and mapped to the research cycle stage/s. Conclusions: The outlined scoping review protocol will comprehensively identify and map the existing scientific literature that reports PPI in stroke research. Findings will be presented in relation to PPI conceptualisation, participant profiles and activities in stroke research, volume, type and range of approaches. Knowledge gaps may be identified thereby offering opportunities and recommendations for future priorities for PPI in stroke research.

A protocol to evaluate the impact of embedding Public and Patient Involvement in a structured PhD program for stroke care

Background

Embedding Public and Patient Involvement (PPI) in postgraduate research has been recognized as an important component of post-graduate training, providing research scholars with an awareness and a skillset in an area which prepares them for future roles as healthcare researchers. Improving Pathways for Acute STroke And Rehabilitation (iPASTAR) is a structured PhD training program [Collaborative Doctoral Award (CDA)] which aims to design a person-centered stroke pathway throughout the trajectory of stroke care, to optimize post-stroke health and wellbeing. PPI is embedded at all stages.

Purpose

The iPASTAR research programme was strongly informed by a round-table PPI consultation process with individuals who experienced stroke and who provided broad representation across ages, gender, geographical locations (urban and rural) and the PhD themed areas of acute care, early supported discharge and lifestyle-based interventions after stroke. Four PhD scholars taking part in the CDA-iPASTAR now work collaboratively with four stroke champions, supported by a wider PPI advisory panel.

Methods

This study will evaluate the process and impact of embedding PPI during a PhD program. We will conduct a longitudinal mixed-methods evaluation, conducting focus groups at 24, 36, and 48 months to explore the experiences of the key stakeholders involved. The participants will include PhD scholars, PPI partners (PPI Advisory Group and PPI Champions), PhD supervisors and a PPI manager. An independent researcher will conduct the evaluation. We will include focus groups, individual interviews and participant reflections. Qualitative data will be analyzed using thematic and content analysis, quantitative data will be analyzed using descriptive statistics.

Discussion

PPI and patient voice initiatives bring together researchers, family, and people with health care issues into meaningful dialogue and allow the development of a patient-voice learning network. Embedding PPI training within a PhD program can build meaningful capacity in PPI partnerships in stroke research.

Psychological experience and social reintegration needs of young stroke patients: a systematic review and meta-aggregation of qualitative studies

BACKGROUND

The visible physical dysfunction and invisible psychological effects after stroke prevent young patients from returning to their pre-stroke roles and social activities.

PURPOSE/AIM

To comprehensively analyze the psychological experience and social reintegration needs of young stroke patients, which may be beneficial for improving quality of life and social reintegration after stroke.

METHODS

We conducted a comprehensive literature search of 10 databases. The screening and quality assessment of the included articles were performed by the Qualitative Assessment and Review Instrument (QARI). Meta-aggregation was conducted to synthesize the findings of the included studies. We summarized the certainty of confidence using the Confidence in Evidence from Reviews of Qualitative Research (CERQual) approach.

RESULTS

A total of 5506 studies were screened, of which 12 were included. Data synthesis suggested two new themes: (a) the self-growth process from denial of stroke to accepting stroke (high CERQual confidence), and (b) desire to regain pre-stroke normality, but having difficulty in the social reintegration process (high CERQual confidence).

CONCLUSION

Stroke, as a traumatic event, disrupts the life structure of young patients, and their needs of reintegration are not adequately considered. Interventions based on the principle of individuation should focus on this issue to restore continuity in life after stroke.

Living with the aftermaths of a stroke in the era of the COVID-19 pandemic; the significance of home and close surroundings

Stay-at-home recommendations to reduce the spread of the COVID-19 virus have had a major impact on people's everyday lives. However, while the evidence indicates that such recommendations have caused distress, anxiety, and fear among the public, little is known about how persons living with complex health conditions, e.g., disability after stroke, have experienced and handled the situation. We interviewed fourteen participants (7 women, 7 men) aged 61–91 years living in ordinary housing during summer 2020 to explore how people who recovered after a stroke experienced their everyday lives in their homes and close surroundings during the COVID-19 pandemic recommendations. Three intertwined themes were constructed from the narrative data and the iterative thematic analysis: (1) Places within and out of reach, (2) Upholding activities–strategies and structures, and (3) Adapting to new circumstances. The findings suggest that places within reach were important to maintain activities and provide structure in daily life. The participants seemed to make use of their previous experiences of adjusting to new circumstances after stroke when adapting to living under the stay-at-home recommendations. In addition, feeling that they now shared the restrictions with all other people in society seemed to ease their situations. Access to nature and spaces in the close surroundings was essential for staying socially connected and receiving support in daily life. The significance of the home and the neighbourhood for health experiences among people who recently have had a stroke should inform rehabilitation interventions both during and after pandemics and environmental planning.

Co-creating Digital Stories With UK-Based Stroke Survivors With the Aim of Synthesizing Collective Lessons From Individual Experiences of Interacting With Healthcare Professionals

Background

Stroke survivor narratives can provide valuable insight into experiences of healthcare and beyond. There is need to further understand collective lessons from stroke survivor narratives, yet prior studies utilizing digital storytelling tend to not synthesize lessons from individual experiences. This study aims to develop a novel method to co-create digital stories with stroke survivors that will aim to synthesize and portray important collective lessons from individual stroke survivors' experiences of interacting with healthcare professionals.

Methods

This study follows-up a qualitative study conducted with 30 stroke survivors exploring factors that help or hinder survivors to positively reconfigure their identity post-stroke. Five co-creation workshops were conducted with a subset of UK-based stroke survivors from this previous study. Participants were invited to join through: online workshops, an online bulletin board, and as an advisor. A four-stage workshop framework was developed through the integration of UK Design Council's Double Diamond method, digital storytelling strategies and the Behavior Change Wheel (BCW) framework for developing behavioral change interventions.

Findings

Six online workshop participants (three male, three female; aged 33–63; time since stroke 2–16 years) co-created digital stories that share six collective lessons aimed at increasing empathy and encouraging behavior change in healthcare professionals (HCPs) working with stroke survivors. Online bulletin board participants (n = 1) and advisors (n = 5) supported the co-creation process. Collective lessons identified were: (1) Stroke has a variety of symptoms that must all be considered; (2) Stroke can affect anyone of any age and not just the elderly; (3) Assumptions should not be made about a survivor's lifestyle or habits; (4) It is important to acknowledge the person behind the stroke and ensure that they are communicated with and listened to; (5) Stroke survivors can often feel unprepared for the reality of life after stroke; (6) Adapting to life after stroke is a long-term process requiring long-term support.

Conclusion

Stroke survivor stories highlighted preconceptions, attitudes and behaviors embedded within healthcare that negatively impacted their experiences and recovery. The novel methodology employed in this study enabled these stories to be synthesized into collective lessons to bring about improvements in these behaviors in future.

Transitional care for patients with acute stroke-A priority-setting project

Background

The scope of this priority‐setting process is communication and collaboration in transitional care for patients with acute stroke. Actively involving persons with stroke and their family caregivers is important both in transitional care and when setting priorities for research. Established priority‐setting methods are time‐consuming and require extensive resources. They are therefore not feasible in small‐scale research. This article describes a pragmatic priority‐setting process to identify a prioritized top 10 list of research needs regarding transitional care for patients with acute stroke.

Methods

A pragmatic priority‐setting approach inspired by the James Lind Alliance was developed. It involves establishing a user group, identifying the research needs through an online survey, analysing and checking the research needs against systematic reviews, culminating in an online prioritization of the top 10 list.

Results

The process was completed in 7 months. A total of 122 patients, family caregivers, health personnel and caseworkers submitted 484 research needs, and 19 users prioritized the top 10 list. The list includes the categories ‘patients and caregivers’ needs and health literacy’, ‘health personnel's common understanding’, ‘information flow between health personnel and patients and caregivers’, ‘available interventions and follow‐up of patients and caregivers’, ‘interaction and collaboration between health personnel and caseworkers across hospital and primary healthcare’ and ‘disabilities after stroke’.

Conclusion

This paper outlines a pragmatic approach to identifying and prioritizing users' research needs that was completed in 7 months. The top 10 list resulting from this priority setting process can guide future research relating to communication and collaboration during the transition from hospital to the community for patients with stroke.

Patient and Public Contribution

Members of three stroke organizations participated in the advisory group. They gave feedback on the scope and the process, distributed the surveys and prioritized the top 10 list. Persons with stroke and their caregivers submitted research needs in the survey.

Development and psychometric evaluation of a questionnaire for assessing self-management behaviors in stroke survivors

OBJECTIVES

To develop and examine the psychometric properties of the Stroke Self-management Behaviors Performance Scale (SSBPS).

MATERIALS AND METHODS

This is a cross-sectional descriptive correlational study. An 11-item SSBPS was developed. Its content validity was reviewed by an expert panel, and it was piloted among six stroke survivors. Participants completed the SSBPS and four additional measures, namely Stroke Self-Efficacy Questionnaire, Stroke Specific Quality of Life Scale, Geriatric Depression Scale and Reintegration to Normal Living Index, at baseline and the SSBPS again after four weeks. Principal component factor analysis was performed to examine the factor structure. Internal consistency, convergent validity and test-test reliability were evaluated.

RESULTS

128 stroke survivors completed the SSBPS and additional measures. Thirty-four of them completed the SSBPS again after four weeks. A two-factor structure of "Psychosocial management" and "Medical management" consisting of nine items was identified and accounted for 62% of the total variance. The SSBPS had acceptable internal consistency (Cronbach's alpha=0.65-0.88) and test-retest reliability (Intra-class correlation coefficient=0.57-0.73). The SSBPS total score was significantly correlated with the Stroke Self-Efficacy Questionnaire total (r=0.63, p<0.01), Reintegration to Normal Living Index total and subscales (r=0.60-0.69, p<0.01), Stroke Specific Quality of Life Scale total and all domains (r=0.19-0.61, p<0.05), and Geriatric Depression Scale total (r=-0.50, p<0.01) scores.

CONCLUSIONS

The desirable psychometric properties of the SSBPS provide evidence that the scale may be reliable and valid for assessing stroke survivors' performance of self-management behaviors. It would inform the development of effective strategies to promote positive self-management behavioral performance for optimal recovery.

Improving physical mobility is critical for wellbeing in people with severe impairment after an acquired brain injury: a qualitative study

OBJECTIVES

1) Understand the experience, and personal significance, of mobility skills for people with severe mobility impairment after brain injury 2) Determine how these evolve over time.

DESIGN

Longitudinal qualitative study.

PARTICIPANTS

Ten adults, unable to walk at 8 weeks post-injury.

METHODS

Participants were interviewed up to three times, at three-month intervals. Semi-structured interviews were transcribed and coded independently by two researchers, then themes developed. Codes were then reviewed longitudinally.

RESULTS

Initial analysis derived six themes: I lost everything overnight; It feels frustrating; Walking is absolutely the most important; I need help; I'm making progress; I can start doing things that I used to be able to do. Participants described overwhelming losses, with loss of mobility affecting many aspects of life. All participants described progress other than walking that was critical for their wellbeing, including assisted standing and transfers without a lifter. Themes from longitudinal analyses: My losses softened by progress; Walking means freedom; Control helps adjustment happen; Challenges keep coming. Over time, participants valued greater control within their lives and progress with mobility was key.

CONCLUSION

Participants saw mobility as crucial to recovering control of life. Mobility achievements other than independent walking matter to individuals after brain injury.

[Satisfaction of Rehabilitation Patients on Social Media Websites and Online Rating Portals]

PURPOSE

Patients increasingly express themselves about their medical rehabilitation stay, evaluate health service providers with star ratings, and write reviews on the internet. So far, no results are available regarding online patient satisfaction for inpatient medical rehabilitation in Germany. For the first time, this study conducted a systematic analysis of rehabilitation patient satisfaction on social media websites and hospital rating portals.

METHODS

We collected reviews of medical rehabilitation on the portal Klinikbewertungen.de and the social network Facebook for 8 indication groups (orthopedics, psychosomatics/psychotherapy, oncology, cardiology, neurology, internal medicine, pulmonology/dermatology, gastroenterology) with a full data extraction over 3 survey years (October 2014-September 2017) and for rehabilitation clinics with main bed occupancy of retirement insurance (N=497). The star ratings, aggregated according to indication groups, were evaluated to determine patient satisfaction (Pearson's chi-square test, Fisher's exact test, Phi coefficient).

RESULTS

A total of 97.2% of the rehabilitation clinics were represented, with 24,806 ratings on Klinikbewertungen.de. The most frequently evaluated indication groups were orthopedics (38.5%) and psychosomatics/psychotherapy (27.1%). Facebook ratings (N=4,127) were collected for rehabilitation clinics with one department (38.6%) in order to ensure an indication group assignment. Almost the same number of ratings were determined on official (48.7%) and unofficial Facebook pages (51.3%), with no significant correlation between website management and overall satisfaction (p>0.05). On the Facebook pages of the rehabilitation clinics, 49.1% of the ratings were written by women (38.5% by men; 12.4% not assignable). Sociodemographic information on Klinikbewertungen.de was based solely on the status of the insured (89.1% of those with statutory insurance). Overall, 95.4% of the reviews were written by patients and 4.0% by relatives, with 77.5% of patients recommending the clinic to other users (relatives: 37.2%). Most patient ratings were positive. However, there were differences in overall satisfaction between the indication groups. Patients in oncology (77.9%) were more satisfied than those in neurology (59.0%).

CONCLUSIONS

Online ratings of inpatient medical rehabilitation were collected to a considerable extent. These were mostly positive. The results are comparable to standardized surveys. Despite restrictions in the use of social media data, the results indicated that the publicly available real-time online feedback from patients can provide useful information for the quality management of clinics as well as for patients in exercising their right to choose a rehabilitation clinic.

Patient and public involvement in stroke research: a scoping review protocol

Background: Growing consensus supports public and patient involvement (PPI) in research as the lived experience of patients, family carers and users of health and social care services bring unique insights to healthcare research. The impact and burden of stroke present ongoing challenges for those living with its consequences and could potentially limit PPI activity. This review aims to explore PPI in published stroke research to identify and describe the extent, nature and design of PPI activities, the type/s of studies involved and the profile of PPI participants engaged in stroke research. Methods: This systematic scoping review, guided by the Arksey & O’Malley five step framework, will be reported according to the PRISMA-ScR reporting guidelines. PPI is embedded at each stage of this proposed scoping review from conceptualisation, participation, contribution and collaboration. The Population, Concept, Context (PCC) structure defines the research question which asks - How is PPI in stroke research currently being conducted and how do the study authors report their PPI activities and its impact? A comprehensive range of electronic databases including PubMed, CINAHL, EMBASE, PsychINFO and the Cochrane Database of Systematic Reviews will generate a broad range of studies. Grey literature (e.g. OpenGrey, Leanus) and internationally recognised stroke organisation websites will be searched for additional research reports. Data extraction will adhere to the Joanna Briggs Institute guidelines, with results collated and mapped to the research cycle stage/s. Conclusions: The outlined scoping review protocol will comprehensively identify and map the existing scientific literature that reports PPI in stroke research. Findings will be presented in relation to PPI conceptualisation, participant profiles and activities in stroke research, volume, type and range of approaches. Knowledge gaps and future priorities for PPI in stroke research will be identified.

Seeking healthcare services post-stroke: a qualitative descriptive study exploring family caregiver and stroke survivor perspectives in an asian setting

Aim

Exploration of the healthcare journey post-stroke is incomplete without acknowledging the crucial role of family caregivers. With limited literature documenting the role of caregivers in the healthcare journey post-stroke, we aimed to describe the healthcare experiences of family caregivers and stroke survivors across different caregiver identities in Singapore.

Methods

We conducted a qualitative descriptive study involving semi-structured interviews with transcripts analysed using thematic analysis. 26 stroke survivors and 35 family caregivers purposively sampled from multiple settings.

Results

Findings were summarized into seeking care and experience of healthcare encounters. Seeking care comprised of the following themes: factors influencing seeking care, decision to seek care and role of caregiver in seeking care. Experience of healthcare encounters comprised of the following themes: service around the patient, service with care and role of caregiver in healthcare encounters.

Conclusion

Multi-dimensional role of caregivers in healthcare experience emerged as a major finding. Unique to our Asian context, as per the participants’ accounts, family caregivers seemed to be central in healthcare decision-making for stroke survivors, with adult-child caregivers commonly reported being engaged in collaborative decision-making. While spousal caregivers preferred a relational healthcare experience, adult-child caregivers preferred a transactional one. Practical implications include equipping caregivers with skillset to make healthcare decisions, provision of supportive decision-making environment for caregivers and reinforcing communication aspects in the medical, nursing and allied healthcare curriculum to improve healthcare experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02463-7.

Examining components of community psychosocial stroke interventions using concept mapping

BACKGROUND

Stroke impacts psychosocial well-being and engagement in occupation. Psychosocial interventions reduce depression and anxiety but may not impact occupation. Knowledge of key processes and components of community psychosocial stroke interventions can inform future intervention development.

AIM/OBJECTIVE(S)

To determine the essential elements common to three psychosocial interventions for stroke survivors.

MATERIAL(S) AND METHOD(S)

Concept maps were created for three community psychosocial stroke interventions based on published literature and communication with researchers who tested the intervention with stroke survivors. The concept maps were then compared to identify common elements. Ongoing communication with researchers ensured accurate representation of each respective intervention.

RESULTS

Similarities in intervention processes and components included support for autonomy; individualized information exchange; coping, life skill development and adaptation support; competence development; and the incorporation of goals. Differences included intervention delivery (individual versus group), and the avenues in which psychosocial needs are addressed (occupation versus dialogue).

CONCLUSIONS

Concept mapping identified similarities among the three interventions that can be best understood using self-determination theory. Clinicians may utilize findings revealed in the process to inform evidence-based psychosocial stroke interventions.

SIGNIFICANCE

Knowledge of key 'active ingredients' for psychosocial community stroke interventions, can be used to guide clinical reasoning and inform development of interventions.

Effectiveness of information and communications technology interventions for stroke survivors and their support people: a systematic review

PURPOSE

To examine the effectiveness of self-directed, off-the-shelf information and communications technology (ICT)-based interventions in improving the quality of life, physical and psychosocial outcomes of community-dwelling stroke survivors and their support persons (SP).

METHODS

Medline, EMBASE, CINAHL and Cochrane databases were searched (2006-19th June 2020) for randomized controlled trials, controlled trials, controlled before and after studies, or interrupted time series studies that met the eligibility criteria. The quality of included studies was assessed. Interventions effectiveness was narratively synthesized, as was participant adherence and acceptability.

RESULTS

Seventeen studies were eligible. Three studies were rated as low risk of bias across all methodological review criteria. Nine studies reported on interventions delivered using self-directed computer programs, two studies utilized internet or web-based support programs and six studies used mobile phone interventions. Few studies reported on intervention acceptability or adherence. Those that did generally reported good acceptability, although adherence was variable. Fifteen studies reported significant positive effects for at least one outcome examined including stroke-specific outcomes, physical outcomes, behavioural outcomes and health service use. No studies found an effect for psychosocial wellbeing.

CONCLUSION

ICT-based interventions are likely to provide benefit to stroke survivors and their SPs. However, there is a need for further robustly designed intervention studies that include larger sample sizes, longer follow-up, and outcomes for SPs.Implications for RehabilitationICT-based interventions with minimal clinician supervision are likely to provide some benefits to stroke survivors and their SPs.There is insufficient evidence to allow recommendations to rehabilitation professionals regarding the type, length and intensity of ICT-based interventions for specific targeted outcomes.Rehabilitation professionals should use professional judgement prior to recommending ICT-based interventions to stroke survivors and their SPs.

Determinants of life satisfaction among stroke survivors 1 year post stroke

ABSTRACT

Stroke is the major leading cause of death and severe long-term disability worldwide. The consequences of stroke, aside from diminished survival, have a significant impact on an individual's capability in maintaining self-autonomy and life satisfaction (LS). Thus, this study aimed to assess LS and other specific domains of LS in stroke survivors following their first-ever stroke, and to describe the relationship using socio-demographic and stroke-related variables.This study recruited 376 stroke survivors (244 men and 132 women, mean age: 57 years) 1 year following stroke. Data on participants' LS (measured using the Life Satisfaction Questionnaire [LiSat-11]), socio-demographics, and stroke-related variables were collected.Univariate analysis showed that LS and the 10 specific domains were not associated with the patients' gender or stroke type; however, age at onset, marital status, and vocational situation were significantly associated with some domains in LiSat-11 (Spearman's rho = 0.42-0.87; all P < 0.05). Logistic regression revealed that verbal and cognitive dysfunction were the most negative predictors of LS (odds ratio 4.1 and 3.7, respectively).LS is negatively affected in stroke survivors 1 year post onset. The results indicate that recovering social engagement is a positive predictor of higher LS in stroke survivors. More importantly, the findings revealed that cognitive and verbal dysfunctions were the most prominent negative predictors of the overall gross level of LS. Multidisciplinary rehabilitation for stroke survivors is therefore critical.

Developing and implementing an exercise-based group for stroke survivors and their carers: the Carers Count group

PURPOSE

Guidelines recommend that carers of stroke survivors should be engaged early in rehabilitation. There has been limited research implementing exercise programs that include carers. The aims of this study were to develop, facilitate, and evaluate an intervention, the Carers Count group, an exercise-based group for stroke survivors and their carers.

METHODS

Over a 5-month period, a staged approach was used to design the intervention and implementation strategies which would maximise the chances of embedding the intervention within an inpatient stroke ward. Implementation strategies included planning, educating, restructuring, financing, and managing quality. Following development and facilitation of the intervention, outcomes were evaluated through collecting data about therapy time, surveys (n = 30) and interviews (n = 18) with participants, and a focus group with staff.

RESULTS

Thirty stroke survivors and their carers participated in the Carers Count group. Analysis of time spent in therapy showed that participation led to increased dose of physiotherapy time (service outcome). Survey and interview data suggested that participation in the group was a rewarding and engaging experience for participants (client outcomes).

CONCLUSION

Using multifaceted strategies, a group designed to include carers was implemented on a stroke rehabilitation ward. The intervention provided positive outcomes in terms of increased therapy dose and satisfaction according to participant feedback.

CLINICAL TRIALS REGISTRATION NUMBER

ANZCTR12620000708954Implications for rehabilitationIt is possible to develop modes of delivery in rehabilitation that include the carers of stroke survivors and these interventions are considered enjoyable and beneficial.Health professionals should consider interventions that are engaging and fun for stroke survivors and their carers.Health professionals should carefully plan and utilise appropriate implementation strategies when aiming to introduce a new intervention into an established health service.Health professionals should ensure stroke survivors and their carers have an understanding of recovery following stroke and how to maximise outcomes through increasing amount of practice.

Stroke survivors' experiences with rebuilding life in the community and exercising at home: A qualitative study

Aim

This study aimed to explore how stroke survivors deal with stroke‐related impairments when rebuilding their lives in the community and their experiences of exercising at home.

Design

An explorative and descriptive qualitative study.

Methods

A purposive sample of ten stroke survivors residing at home was recruited to explore experiences of rebuilding their lives in the community and exercising at home. One focus group interview was conducted followed by semi‐structured interviews. Data were analysed using thematic analysis.

Results

Three main themes were identified: “Framing exercise within the context of everyday life” describes how stroke survivors integrate exercise in everyday activities with varying success and the social importance of exercising; “Managing the challenges of physical impairment” describes the taxing undertakings in daily living, loss of concentration and identity; “Long‐term challenges of everyday life” describes how the stroke survivors manage depression and live with a sense of uncertainty.

Recovering is about living my life, as it evolves: perspectives of stroke survivors in remote northwest Queensland

PURPOSE

Recovering from stroke in remote Australia has rarely been considered, even though rehabilitation services are generally scarce. The primary purpose of this study was to explore stroke recovery, from the perspective of stroke survivors in remote northwest Queensland (NWQ), to explicate the lens through which they view recovering. The secondary purpose was to explore the role of technology to support stroke survivors in remote locations along their recovery journey.

METHODS

A qualitative study was undertaken using elements of constructivist grounded theory for data collection and analysis. Semi-structured interviews were conducted with fifteen stroke survivors and two partners living, working or travelling in remote NWQ.

RESULTS

From the participants' perspective, recovering in a remote area after stroke is about living my life, as it evolves by endeavouring to recover my way and navigating my recovery in my world. Technology was only considered helpful when it supported participants to recover their way in their world.

CONCLUSION

Recovering from stroke from the perspective of stroke survivors in remote NWQ is about living their life, as they want it to be, and as it unfolds within their own context. Technology only has a place when it can support them to recover their way in their world. These findings reinforce the importance of health professionals listening, learning about, and enabling stroke survivors along their recovery journey, within their remote context and support network.Implications for RehabilitationRecovering from the perspective of stroke survivors is about living their life as it evolves.To support stroke survivors from remote areas, health professionals need to listen to and learn from each stroke survivor about what matters to them, what works for them, and about their world; including the challenges (e.g., switching between services) and enablers (e.g., community support) as the stroke survivor perceives them.Finding ways to utilise the strengths within and around them, may improve the recovery process for the stroke survivor in a remote area, ensuring they can access care that meets their needs in their world.Working together with stroke survivors, health professionals need to consider how technology could help them to live their life, while recovering their way and in their world.

"Just that four letter word, hope": stroke survivors' perspectives of participation in an intensive upper limb exercise program; a qualitative exploration

Background: Less than half of stroke survivors will be able to use their arm at 6 months post-stroke. Guidelines recommend the use of intensive upper limb exercise programs to optimize recovery; however, there has been limited research exploring experiences of participation in intensive programs. Aim: To identify factors influencing adherence to an intensive upper limb exercise program in people with stroke.Methods: Qualitative design. Semi-structured interviews were conducted with 20 stroke survivors who had participated in an intensive upper limb program. Perspectives of participation, including perceived barriers and enablers to program adherence were explored. Interviews were audio-recorded, transcribed, and imported into NVivo for analysis. Two authors mapped themes to the Capability, Opportunity, Motivation-Behavior (COM-B) behavior change model to identify barriers and enablers to adherence.Results: Enablers influencing adherence included: 1) routine practice times (Motivation - automatic); 2) accountability to staff (Motivation - reflective); and 3) social support (Opportunity - social). Barriers to adherence included: 1) exercises being too difficult (Capability - physical); 2) reliance on others to help (Capability - physical); and 3) difficulty 'fitting it in' (Motivation - reflective).Conclusion: Findings will inform recommendations for the delivery of intensive upper limb exercise programs to improve adherence and assist services to provide rehabilitation in a manner that enables self-directed practice by stroke survivors.

Nursing Home Care Intervention Post Stroke (SHARE) 1 year effect on the burden of family caregivers for older adults in Brazil: A randomized controlled trial

The purpose of this study is to evaluate the effect of home-care nursing intervention on the burden of family caregivers for older adults surviving a stroke. A randomised clinical trial blinded for outcome evaluation. Forty-eight family caregivers of older adults surviving a stroke took part in the study. The intervention group (IG) received three home visits by nurses in 1 month after hospital discharge for guidance on the disease and care activities for the elderly people. The control group (CG) relied on the service network that had access. The Caregiver Burden Scale was applied to assess the burden outcome 1 week, 60 days and 1 year after hospital discharge. The caregivers of the intervention and CGs had no difference regarding baseline data. There was an interaction effect between the CG and the IG in the isolation domain (p = 0.037) and in the emotional involvement domain (p = 0.003) over time. These findings provide support for strengthening a care line for the elderly people after a stroke, with adequate discharge planning, indicating the importance of integrating care network services such as primary care, home care and hospital care with a view to achieving an effective care transition. It is also necessary to construct a specific instrument to evaluate other outcomes, such as the knowledge and learning of caregivers in relation to the care activities taught. This study is registered in the Clinical Trials with name Nursing Home Care Intervention Post Stroke (SHARE) and under number NCT02807012.

Effect of a tailored multidimensional intervention on the care burden among family caregivers of stroke survivors: study protocol for a randomised controlled trial

INTRODUCTION

Caring for stroke survivors creates high levels of care burden among family caregivers. Previous initiatives at alleviating the care burden have been unsuccessful. The proposed study aims to evaluate the effect of a tailored multidimensional intervention on the care burden among family caregivers of stroke survivors. Based on the perceived needs of family caregivers, this intervention takes into account scientific recommendations to combine three different approaches: skill-building, psychoeducation and peer support.

METHODS AND ANALYSIS

Using a prospective, randomised, open-label, parallel-group design, 110 family caregivers will be enrolled from Dakahlia Governorate, Egypt between December 2019 and May 2020, and randomly assigned to either the intervention group or the control group. The tailored multidimensional intervention will be administered for 6 months, including three home visits, six home-based telephone calls and one peer support session. The primary outcome is the care burden as measured using the Zarit Burden Interview. Secondary outcomes include changes in the family caregivers' perceived needs (Family Needs Questionnaire-Revised), coping strategies (Brief-Coping Orientation to Problems Experienced) and quality of life (WHO Quality of Life-BREF). Outcomes evaluation will be conducted at baseline (T0), month 3 (T1) and month 6 (T2). Independent t-test will be performed to compare the mean values of study variables between the two groups at both T1 and T2. After adjusting for confounding variables, analysis of covariance will be used to assess the effect of the intervention. In addition, repeated measures analysis of variance will be conducted to assess changes in effect over time.

ETHICS AND DISSEMINATION

This study was approved by the Research Ethics Committee of the Faculty of Nursing, Mansoura University, Mansoura, Egypt (P.0195). The results will be published in a scientific peer-reviewed journal, and findings will be disseminated at the local and international levels.

TRIAL REGISTRATION NUMBER

NCT04211662.

Quickly home again: patients' experiences of early discharge after minor stroke

BACKGROUND

Patients with minor stroke experience some of the same issues as patients experiencing stroke of increased severity such as fatigue, anxiety and cognitive symptoms. It is current practice that patients with minor stroke receive accelerated treatment and care, yet studies indicate that patients find it difficult to return to their everyday lives after being discharged. We aimed to explore how patients with minor stroke experience the transitional period from the hospital through the first 2-4 weeks after an accelerated care pathway with discharge within 72 hours after stroke onset.

METHODS

A qualitative study consisting of semi-structured interviews with 11 patients experiencing first-time stroke 2-4 weeks after discharge.

RESULTS

The patients struggled to identify themselves as having had a stroke. They strived to find a new everyday life, but were challenged by existential concerns, mental fatigue and the fear of having a stroke again. Unresolved questions and misunderstandings arose, and the patients expressed a need for health professionals to support them and discuss unclear issues after discharge. Patients searched for others with similar issues in order to find a new sense of self.

CONCLUSION

Patients with minor stroke struggle with everyday life after discharge. There is a need for support after discharge from healthcare professionals with specialised knowledge of stroke. Patients also requested an opportunity to meet other patients with minor stroke.

Benefits finding among Chinese family caregivers of stroke survivors: a qualitative descriptive study

OBJECTIVES

The caregiving experience includes both caregiver burdens and benefits finding. However, the benefits obtained by family caregivers of stroke survivors in Chinese community dwellings are unknown. The objective of this study was to explore the benefits experienced by family caregivers of stroke survivors in Chinese community dwellings.

DESIGN

A qualitative descriptive design was used, fulfilling the consolidated criteria for the Standards for Reporting Qualitative Research reporting guidelines. Semi-structured interviews were conducted with 20 family caregivers of stroke survivors. The interviews were audiotaped, transcribed and analysed. Thematic analysis was performed to analyse the interview transcripts.

SETTING AND PARTICIPANTS

Home interviews were conducted with family caregivers of stroke survivors in two communities in Zhengzhou, China.

RESULTS

The family caregivers of stroke survivors experienced various benefits from caregiving. There were both internal benefits (increases in knowledge and skills, the development of positive attitudes, and the development of a sense of worthiness and achievement) and external benefits (family growth and gains in social support), which interact to create a healthy lifestyle.

CONCLUSION

Our findings provide a comprehensive perspective in understanding the benefits perceived by family caregivers of stroke survivors. This study provides insights into interventions focused on identifying benefits finding in six domains that may help reduce negative emotions and promote the mental health of caregivers.

The Road to Family Resiliency: A Case Report of a Family's Experiences Following Adolescent Stroke

PURPOSE

This study generated an understanding of familial resiliency following an adolescent's stroke and what resiliency-related outcomes were important to this family.

DESIGN AND METHODS

A qualitative case study design was used to collect data during an in-person interview. The interview was transcribed verbatim and analyzed using thematic analysis.

FINDINGS

Participants' narratives revealed that reengaging and establishing new activities, reconstructing identities, and changing perceptions regarding health and life itself were important resiliency-related outcomes.

CONCLUSIONS

The findings from this case study highlight innovative strategies that can be used to facilitate resiliency during strenuous times in a family's life, such as following an adolescent's stroke.

CLINICAL RELEVANCE

Clinicians and service providers have the opportunity to help facilitate resiliency by identifying which protective factors and positive outcomes are most important to a family following an adolescent's stroke, allowing clinicians to assist in achieving these outcomes. This research illustrates ways for families to convert resources into personally meaningful resiliency-related outcomes. Further research is needed to study familial resiliency as a part of an intervention to promote occupational engagement.

Robot-assisted training compared with an enhanced upper limb therapy programme and with usual care for upper limb functional limitation after stroke: the RATULS three-group RCT

BACKGROUND

Loss of arm function is common after stroke. Robot-assisted training may improve arm outcomes.

OBJECTIVE

The objectives were to determine the clinical effectiveness and cost-effectiveness of robot-assisted training, compared with an enhanced upper limb therapy programme and with usual care.

DESIGN

This was a pragmatic, observer-blind, multicentre randomised controlled trial with embedded health economic and process evaluations.

SETTING

The trial was set in four NHS trial centres.

PARTICIPANTS

Patients with moderate or severe upper limb functional limitation, between 1 week and 5 years following first stroke, were recruited.

INTERVENTIONS

Robot-assisted training using the Massachusetts Institute of Technology-Manus robotic gym system (InMotion commercial version, Interactive Motion Technologies, Inc., Watertown, MA, USA), an enhanced upper limb therapy programme comprising repetitive functional task practice, and usual care.

MAIN OUTCOME MEASURES

The primary outcome was upper limb functional recovery 'success' (assessed using the Action Research Arm Test) at 3 months. Secondary outcomes at 3 and 6 months were the Action Research Arm Test results, upper limb impairment (measured using the Fugl-Meyer Assessment), activities of daily living (measured using the Barthel Activities of Daily Living Index), quality of life (measured using the Stroke Impact Scale), resource use costs and quality-adjusted life-years.

RESULTS

A total of 770 participants were randomised (robot-assisted training, n = 257; enhanced upper limb therapy, n = 259; usual care, n = 254). Upper limb functional recovery 'success' was achieved in the robot-assisted training [103/232 (44%)], enhanced upper limb therapy [118/234 (50%)] and usual care groups [85/203 (42%)]. These differences were not statistically significant; the adjusted odds ratios were as follows: robot-assisted training versus usual care, 1.2 (98.33% confidence interval 0.7 to 2.0); enhanced upper limb therapy versus usual care, 1.5 (98.33% confidence interval 0.9 to 2.5); and robot-assisted training versus enhanced upper limb therapy, 0.8 (98.33% confidence interval 0.5 to 1.3). The robot-assisted training group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale) than the usual care group at 3 and 6 months. The enhanced upper limb therapy group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale), better mobility (as measured by the Stroke Impact Scale mobility domain) and better performance in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the usual care group, at 3 months. The robot-assisted training group performed less well in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the enhanced upper limb therapy group at 3 months. No other differences were clinically important and statistically significant. Participants found the robot-assisted training and the enhanced upper limb therapy group programmes acceptable. Neither intervention, as provided in this trial, was cost-effective at current National Institute for Health and Care Excellence willingness-to-pay thresholds for a quality-adjusted life-year.

CONCLUSIONS

Robot-assisted training did not improve upper limb function compared with usual care. Although robot-assisted training improved upper limb impairment, this did not translate into improvements in other outcomes. Enhanced upper limb therapy resulted in potentially important improvements on upper limb impairment, in performance of activities of daily living, and in mobility. Neither intervention was cost-effective.

FUTURE WORK

Further research is needed to find ways to translate the improvements in upper limb impairment seen with robot-assisted training into improvements in upper limb function and activities of daily living. Innovations to make rehabilitation programmes more cost-effective are required.

LIMITATIONS

Pragmatic inclusion criteria led to the recruitment of some participants with little prospect of recovery. The attrition rate was higher in the usual care group than in the robot-assisted training or enhanced upper limb therapy groups, and differential attrition is a potential source of bias. Obtaining accurate information about the usual care that participants were receiving was a challenge.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN69371850.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 54. See the NIHR Journals Library website for further project information.

Supported cognitive-behavioural therapy self-help versus treatment-as-usual for depressed informal caregivers of stroke survivors (CEDArS): feasibility randomised controlled trial

Demands placed on informal caregivers can result in an increased likelihood of experiencing common mental health difficulties that may affect their ability to undertake the caring role. Currently, however, few evidence-based interventions have been specifically developed for informal caregivers and available interventions are difficult to access. The Improving Access to Psychological Therapies (IAPT) programme aims to improve access to evidence-based psychological therapies for all groups and may therefore present an opportunity to meet informal caregiver needs. Located within the MRC Complex Intervention Framework, a Phase II feasibility randomised controlled trial (RCT) examines key methodological, procedural and clinical uncertainties associated with running a definitive Phase III RCT of an adapted written cognitive behavioural therapy (CBT) self-help intervention for informal caregivers of stroke survivors. Recruitment was low despite different recruitment strategies being adopted, highlighting significant challenges moving towards a Phase III RCT until resolved. Difficulties with study recruitment may reflect wider challenges engaging informal caregivers in psychological interventions and may have implications for IAPT services seeking to improve access for this group. Further attempts to develop a successful recruitment protocol to progress to a Phase III RCT examining effectiveness of the adapted CBT self-help intervention should be encouraged.

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Feasibility of ActivABLES to promote home-based exercise and physical activity of community-dwelling stroke survivors with support from caregivers: A mixed methods study

Background

Technical applications can promote home-based exercise and physical activity of community-dwelling stroke survivors. Caregivers are often able and willing to assist with home-based exercise and physical activity but lack the knowledge and resources to do so. ActivABLES was established to promote home-based exercise and physical activity among community-dwelling stroke survivors, with support from their caregivers. The aim of our study is to investigate the feasibility of ActivABLES in terms of acceptability, demand, implementation and practicality.

Methods

A convergent design of mixed methods research in which quantitative results were combined with personal experiences of a four-week use of ActivABLES by community-dwelling stroke survivors with support from their caregivers. Data collection before, during and after the four-week period included the Berg Balance Scale (BBS), Activities-Specific Balance Confidence Scale (ABC), Timed-Up-and-Go (TUG) and Five Times Sit to Stand Test (5xSST) and data from motion detectors. Semi-structured interviews were conducted with stroke survivors and caregivers after the four-week period. Descriptive statistics were used for quantitative data. Qualitative data was analysed with direct content analysis. Themes were identified related to the domains of feasibility: acceptability, demand, implementation and practicality. Data was integrated by examining any (dis)congruence in the quantitative and qualitative findings.

Results

Ten stroke survivors aged 55–79 years participated with their informal caregivers. Functional improvements were shown in BBS (+ 2.5), ABC (+ 0.9), TUG (− 4.2) and 5xSST (− 2.7). More physical activity was detected with motion detectors (stand up/sit down + 2, number of steps + 227, standing + 0.3 h, hours sitting/lying − 0.3 h). The qualitative interviews identified themes for each feasibility domain: (i) acceptability: appreciation, functional improvements, self-initiated activities and expressed potential for future stroke survivors; (2) demand: reported use, interest in further use and need for follow-up; (3) implementation: importance of feedback, variety of exercises and progression of exercises and (4) practicality: need for support and technical problems. The quantitative and qualitative findings converged well with each other and supported the feasibility of ActivABLES.

Conclusions

ActivABLES is feasible and can be a good asset for stroke survivors with slight or moderate disability to use in their homes. Further studies are needed with larger samples.

Validation of Bakas Caregiving Outcome Scale for brazilian portuguese

Objective:

to analyze the psychometric properties of the adapted version of Bakas Caregiving Outcome Scale for Brazilian Portuguese.

Method:

this is a cross-sectional methodological study conducted with 151 informal caregivers of people with cerebral vascular accident sequelae enrolled in Family Health Units. To assess reliability, Cronbach’s alpha was used. Construct validity was verified through exploratory factor analysis, confirmatory factor analysis and correlation with measures of instruments that evaluate correlated constructs.

Results:

Cronbach’s alpha for the total BCOS score was 0.89. Factor and exploratory analysis generated a one-factor structure, which was confirmed by confirmatory factor analysis. Construct validity was supported by the high positive correlations with Negative Affect (r = 0.51) and Negative Experience (r = 0.47) of the Well-being Scale and the Depression Anxiety and Stress Scale -21 (r = 0.53) and negative correlations with Positive Affect (r =-0.47) and Positive Experience (r = -0.17) of the Well-being scale.

Conclusion:

Bakas Caregiving Outcome Scale shows evidence of satisfactory reliability and validity in family caregivers of cerebral vascular accident survivors.

Experiences of quality of life the first year after stroke in Denmark and Norway. A qualitative analysis

Purpose: This study aims to explore quality of life (QOL) during the first year of recovery after stroke in North Norway and Central Denmark. Method: Individual in-depth interviews with 11 stroke survivors were performed twelve months after stroke onset. An interpretative, inductive approach shaped the interview process and the processing of data. Results: We found that QOL reflected the individuals' reconstruction of the embodied self, which was identified by three intertwined and negotiating processes: a familiar self, an unfamiliar self, and a recovery of self. Further, we found that reconstruction of the embodied self and QOL could be framed as an ongoing and interrelated process of "being, doing, belonging and becoming". Enriching social relations, successful return to work, and continuity and presence in professional support during recovery enhanced the experience of QOL. Fatigue and sustained reduced function hindered participation in meaningful activities and influenced the perceived QOL negatively. Conclusions: The two countries differed in descriptions of continuity and support in the professional follow-up during the recovery process, influencing the degree of encouragement in reconstructing the embodied self. Reconstruction of the embodied self is a means of understanding stroke survivors' QOL during the first year of recovery, supporting an individualized and tailored rehabilitation practice.

A psychosocial intervention for stroke survivors and carers: 12-month outcomes of a randomized controlled trial

Background and Purpose: Stroke can have a devastating impact on the mental and physical health of stroke survivors and their carers. We aimed to evaluate the effectiveness of a novel psychosocial intervention designed to improve health outcomes in both groups.Methods: We conducted a randomized controlled trial of a personalized psychosocial intervention (eight 1-hour weekly sessions plus one booster) compared to usual care for adult stroke survivors and carers. Participants recruited from hospital services and community referrals completed questionnaires at baseline, 3, 6, and 12 months. Primary outcomes were quality of life and self-efficacy; secondary outcomes were depressive and anxiety symptoms, coping, illness perception, work and social adjustment, carer strain, and carer satisfaction. Mixed-effect model repeated measures analysis between groups and across time was conducted.Results: Of the 173 participants recruited (89 stroke survivors; 84 carers), a total of 137 participants - 73 stroke survivors (intervention n = 42; usual care n = 31) and 64 carers (intervention n = 35; usual care n = 29) - underwent analysis up to 12 months. No statistically significant differences were found in the primary outcomes between groups over time, though a significant improvement in carer satisfaction was found at 6 months in the intervention group compared to the usual care group.Conclusion: A personalized psychosocial intervention resulted in a significant improvement in carer satisfaction at 6 months but in no other outcomes. A lack of available services and barriers to social engagement may have impeded the effectiveness of this intervention.

"Caregiving is a full-time job" impacting stroke caregivers' health and well-being: A qualitative meta-synthesis

Family caregivers contribute to the sustainability of healthcare systems. Stroke is a leading cause of adult disability and many people with stroke rely on caregiver support to return home and remain in the community. Research has demonstrated the importance of caregivers, but suggests that caregiving can have adverse consequences. Despite the body of qualitative stroke literature, there is little clarity about how to incorporate these findings into clinical practice. This review aimed to characterise stroke caregivers' experiences and the impact of these experiences on their health and well-being. We conducted a qualitative meta-synthesis. Four electronic databases were searched to identify original qualitative research examining stroke caregivers' experiences. In total, 4,481 citations were found, with 39 studies remaining after removing duplicates and applying inclusion and exclusions criteria. Articles were appraised for quality using the Critical Appraisal Skills Programme (CASP), coded using NVivo software, and analysed through thematic synthesis. One overarching theme, 'caregiving is a full-time job' was identified, encompassing four sub-themes: (a) restructured life, (b) altered relationships, (c) physical challenges, and (d) psychosocial challenges. Community and institution-based clinicians should be aware of the physical and psychosocial consequences of caregiving and provide appropriate supports, such as education and respite, to optimise caregiver health and well-being. Future research may build upon this study to identify caregivers in most need of support and the types of support needed across a broad range of health conditions.