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

Quality of life and mood disorders of mild to moderate stroke survivors in the early post-hospital discharge phase: a cross-sectional survey study

BACKGROUND

Exploring sociodemographic and disease characteristics that contribute to patient-reported outcomes can inform targeting of strategies to support recovery and adaptation to stroke. This study aimed to examine among a sample of stroke survivors at three months post-hospital discharge: (1) self-reported physical and mental health quality of life scores; (2) self-reported depressive and anxiety symptoms; and (3) sociodemographic and clinical predictors of these outcomes.

METHODS

This cross-sectional survey study recruited stroke survivors from eight hospitals in one Australian state. Adult survivors recently discharged from hospital stroke wards (within 3 months) were mailed a study information package and invited to complete a pen-and paper survey. Survey items assessed: quality of life (SF12v2), depression (PHQ-9), anxiety (GAD-7) and sociodemographic and clinical characteristics. Predictors were examined using multiple linear regression analysis.

RESULTS

Of the 1161 eligible patients who were posted a recruitment pack, 401 (35%) returned a completed survey. Participants reported a mean SF-12v2 Physical Composite Score (PCS) quality of life score of 44.09 (SD = 9.57); and a mean SF-12v2 Mental Composite Score (MCS) quality of life score of 46.84 (SD = 10.0). Approximately one third of participants (34%; n = 132) were classified as depressed (PHQ-9 ≥ 10); and 27% (n = 104) were classified as anxious (GAD-7 ≥ 8). Lower PCS was associated with being female, not employed and having a comorbid diagnosis of diabetes and atrial fibrillation. Lower MCS was associated with a history of transient ischemic attack (TIA). Males and those with higher levels of education, had greater odds of having lower depression severity; those with a history of TIA or diabetes had lower odds of having lower depression severity. Males had greater odds of having lower anxiety severity; those with a history of TIA had lower odds of having lower anxiety severity.

CONCLUSION

Sub-groups of stroke survivors may be at-risk of poorer quality of life and psychological morbidity in the early post-discharge phase. These findings support the role of early identification and prioritisation of at-risk survivors at discharge, as they may require modifications to standard hospital discharge processes tailored to their level of risk.

Relationships between Self-Efficacy and Post-Stroke Activity Limitations, Locomotor Ability, Physical Activity, and Community Reintegration in Sub-Saharan Africa: A Cross-Sectional Study

Stroke self-efficacy is under-investigated in sub-Saharan Africa. In particular, studies focusing on the relationship between self-efficacy and post-stroke functional outcomes are scarce. This cross-sectional study aimed to explore the association between self-efficacy and post-stroke activity limitations, locomotor ability, physical activity, and community reintegration in Benin, a sub-Saharan African country. To achieve this purpose, a selection of stroke patients was made from the admission registers of the physiotherapy clinics (rehabilitation units) of three reference hospitals in Benin from January to April 2018. Stroke patients who were still continuing their rehabilitation sessions were informed by direct contact. Those who had already finished their sessions were informed by telephone. Sixty stroke patients of those contacted gave their consent and were recruited for this study. The sample consisted of 44 men and 16 women with a mean age of 56.7 ± 10.4 years. Activity limitations, locomotor ability, physical activity, community reintegration, and self-efficacy were self-reported using ACTIVLIM-Stroke, Abiloco-Benin, the Africa francophone version of the International Physical Activity Questionnaire (IPAQ-AF), the Reintegration to Normal Living Index (RNLI), and a French version of the Stroke Self-efficacy Questionnaire (SSEQ-F), respectively. Spearman's rank correlation coefficients (ρ) were calculated to characterize the relationship between self-efficacy and activity limitations, locomotor ability, physical activity, and community reintegration. According to the results, self-efficacy showed a moderate correlation with physical activity (ρ = 0.65; p < 0.001) and high correlations with activity limitations (ρ = 0.81; p < 0.001), locomotor ability (ρ = 0.72; p < 0.001), and community reintegration (ρ = -0.84; p < 0.001). Thus, self-efficacy emerges as an important factor associated with the functional recovery of stroke patients in sub-Saharan Africa.

The HEADS: UP Development Study: Working with Key Stakeholders to Adapt a Mindfulness-Based Stress Reduction Course for People with Anxiety and Depression after Stroke

BACKGROUND

Following stroke, rates of mood disorder are and remain high at five years (anxiety 34.4%; depression 23%). Structured mindfulness-based stress reduction (MBSR) courses are effective in a range of health conditions, but stroke survivors find adherence challenging. We aimed to adapt a standard MBSR course specifically for people affected by stroke.

METHODS

We recruited stroke survivors and family members with symptoms of anxiety and/or depression to take part in a co-development study comprising two rounds of MBSR 'taster' sessions, followed by focus groups in which views were sought on the practices sampled. Data were collected in October 2017 and May 2018 and were analysed using framework analysis, informed adaptations to mindfulness materials and delivery.

RESULTS

Twenty-eight stroke survivors and seven family members participated. Nineteen (76%) stroke survivors had anxiety; 15 (60%) had depression. Five (71.4%) family members reported anxiety; n = 4 (57.1%) depression. Thirty participants attended the first round of taster sessions and focus groups; twenty (66%) the second and three (10%) were unable to attend either round. Framework analysis informed adaptations to course delivery, practices, and materials, ultimately resulting in a stroke-specific MBSR course, HEADS: UP (Helping Ease Anxiety and Depression after Stroke).

CONCLUSIONS

HEADS: UP may provide a feasible, appropriate, and meaningful self-management intervention to help alleviate symptoms of mood disorder.

Promoting adherence to stroke secondary prevention behaviours by imparting behaviour change skills: protocol for a single-arm pilot trial of Living Well After Stroke

INTRODUCTION

Survivors of stroke have an elevated risk of recurrent stroke. Prompt intervention to support healthy lifestyle modification following an initial stroke is crucial for effective secondary prevention of stroke. However, many patients do not receive adequate postdischarge support for secondary prevention, particularly if not referred to inpatient rehabilitation. Living Well After Stroke is a health promotion programme based on the health action process approach (HAPA), which is designed to support this underserviced group to improve and self-manage secondary prevention behavioural performance (eg, diet, exercise, medication-adherence) by equipping participants with a toolkit of theory-based and evidence-based behaviour change strategies and techniques that are transferable to different behavioural contexts.

METHODS AND ANALYSIS

The target sample is 118 adults living in Queensland, Australia, with stroke or transient ischaemic attack not referred to inpatient rehabilitation. Adopting a prospective single-arm trial design, the intervention comprises five behaviour change sessions over an 8-week period. Participants will receive a mix of individual-based and group-based assessments and interventions, based on the HAPA theoretical framework, delivered via telehealth or in-person (eg, public library). Measures of primary (ie, goal behaviours 1 and 2) and secondary outcomes (intention, outcome expectancy, risk perception, self-efficacy, planning, action control, subjective well-being) will be taken at 2 weeks, 4 weeks, 8 weeks and 16 weeks. The primary outcomes of the trial will be behavioural performance and transferability of behaviour change skills at 16 weeks.

ETHICS AND DISSEMINATION

The study has received ethical approval from the Griffith University Human Research Ethics Committee (Ref no: 2022/308). Informed consent is obtained via telephone prior to data collection. Findings will be presented in the form of peer-reviewed journal articles, industry reports and conference presentations, and will be used to inform the continued development and refinement of the programme for testing in a future fully powered trial.

The feasibility of a self-management programme (My Life After Stroke; MLAS) for stroke survivors

PURPOSE

An evidence-based, theory-driven self-management programme "My Life After Stroke" (MLAS) was developed to address the longer-term unmet needs of stroke survivors.This study's aim was to test the acceptability and feasibility of MLAS as well as exploring what outcomes measures to include as part of further testing.

METHODS

Stroke registers in four GP practices across Leicester and Cambridge were screened, invite letters sent to eligible stroke survivors and written, informed consent gained. Questionnaires including Southampton Stroke Self-Management Questionnaire (SSSMQ) were completed before and after MLAS.Participants (and carers) attended MLAS (consisting of two individual appointments and four group sessions) over nine weeks, delivered by two trained facilitators. Feedback was gained from participants (after the final group session and final individual appointment) and facilitators.

RESULTS

Seventeen of 36 interested stroke survivors participated alongside seven associated carers. 15/17 completed the programme and attendance ranged from 13-17 per session. A positive change of 3.5 of the SSSMQ was observed. Positive feedback was gained from facilitators and 14/15 participants recommended MLAS (one did not respond).

CONCLUSIONS

MLAS was a feasible self-management programme for stroke survivors and warrants further testing as part of the Improving Primary Care After Stroke (IPCAS) cluster randomised controlled trial.IMPLICATIONS FOR REHABILITATIONMy Life After Stroke is a self-management programme developed for stroke survivors living in the community.MLAS is feasible and acceptable to stroke survivors.MLAS could be considered to help address the unmet educational and psychological needs of stroke survivors.

Association between self-efficacy and self-management behaviours among individuals at high risk for stroke: Social support acting as a mediator

AIMS AND OBJECTIVES

To explore the association between self-efficacy and self-management by modelling three types of social support as mediators among stroke high-risk populations.

BACKGROUND

Self-efficacy and social support (i.e. objective support, subjective support and support utilisation) are important for self-management among stroke high-risk populations. Self-efficacy activates three types of social support, and the effect of social support on self-management varies by types among chronic patients. Therefore, social support may act as a mediator between self-efficacy and self-management, and the mediating role may vary by types of social support. Disentangling the role of these different types of social support can guide tailored interventions.

DESIGN

A cross-sectional study.

METHODS

This study was conducted among 448 Chinese adults at high risk for stroke. Self-efficacy, self-management and social support were assessed using the Self-Efficacy Scale, the Stroke Self-management Scale and the Social Support Rating Scale respectively. The PROCESS SPSS Macro version 3.3, model 4 was used to explore the mediating role of different types of social support in the relationship between self-efficacy and self-management. This study followed STROBE checklist for cross-sectional studies (Appendix S1).

RESULTS

Self-efficacy improved three types of social support, and subjective support and support utilisation promoted self-management, but objective support hindered self-management. The specific indirect effect of objective support and subjective support was significant but not that of support utilisation. Objective support, subjective support and support utilisation attenuated the total effect of self-efficacy on self-management by -23.8%, 23.8% and 7.7% respectively.

CONCLUSIONS

Mediating effect of social support in the relationship between self-efficacy and self-management varies by type, and the positive effect of subjective support is offset by the detrimental effect of objective support.

RELEVANCE TO CLINICAL PRACTICE

Among stroke high-risk populations, interventions should target objective support and subjective support as well as self-efficacy to efficiently improve their self-management.

Hausa translation, cross-cultural adaptation, and assessment of psychometric properties of the Stroke Self-Efficacy Questionnaire

BACKGROUND

Self-efficacy has been defined as "people's beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives." In stroke survivors, impairments in motor, sensory/perceptual, and cognitive functions greatly reduce self-efficacy.

AIM

To translate and cross-culturally adapt the Stroke Self-Efficacy Questionnaire (SSEQ) into Hausa language.

METHOD

Two independent experts who are fluent in Hausa and English languages did the forward and backward translations, respectively. A group of experts reviewed the translation according to Beaton's guidelines. The English and the final Hausa versions were administered to 75 patients with stroke once and twice, respectively (on the first day and a week later). Construct validity between the English and the Hausa version, and internal consistency and structural validity of the Hausa version were assessed using Spearman's correlation coefficient, kappa statistics, and Rasch analysis, respectively.

RESULTS

There was a significant correlation (r = 0.96, p < .001) between the Hausa version of the SSEQ and the original English version. The scale also demonstrated an excellent test-retest reliability (r = 0.99, p < .001) on two different administrations. The Hausa version also demonstrated an excellent internal consistency on two different administrations, Cronbach alpha, 0.99. Similarly, the two versions were found to be perfect fit, having the same measure of construct [infit and outfit mean-square (MNSQ) and standardized (ZSTD) fit statistics values for the Hausa version and the English version of SSEQ were (1.00, Z = -0.2)].

CONCLUSION

Hausa version of SSEQ is valid and reliable at assessing self-efficacy among Hausa-speaking stroke survivors.

The Risk Factors of Self-Management Behavior among Chinese Stroke Patients

BACKGROUND

Stroke is associated with a high number of disability-adjusted life years globally, so long-term care is necessary and important for those survivors, so self-management is becoming a more significant concept in stroke rehabilitation.

METHODS

Ischemic stroke patients (n = 354) were enrolled from the outpatient department of Neurology in West China Hospital from September 2018 to December 2019. The general demographic and disease-related data of stroke patients were collected. The stroke self-efficacy questionnaire (SSEQ), the brief cognition questionnaire (BIPQ), and the stroke self-management scale (SSMS) were used to collect data on self-efficacy, disease cognition, and self-management behavior separately. The chi-square test, Fisher exact test, independent sample t-test, and Mann-Whitney U test were used for comparison among groups. The logistic regression analysis was used to explore the independent risk factors of the different levels of self-management behavior in stroke patients.

RESULTS

The score of self-management among Chinese stroke patients was 151.07 ± 18.53. Multivariate analysis showed that the way of paying medical expenses (OR = 3.215, 95% CI (1.130, 7.769)), self-management efficacy (OR = 2.467, 95% CI (1.534, 3.968)), health education before discharge (OR = 2.354, 95% CI (1.457, 3.802)), age (elder) (OR = 2.060, 95% CI (1.265, 3.355)), educational level (OR = 1.869, 95% CI (1.169, 2.988)), and mRS score (OR = 1.850, 95% CI (1.129, 3.031)) were statistically significant (P  <  0.05).

CONCLUSIONS

The self-management behavior of Chinese stroke patients was at the middle level. Patients with medical insurance, high self-efficiency of management, and better limb function may have better self-management behavior. Besides, patients with a high educational level who accept health education before discharge may also have better self-management behavior. For patients, it is important to know this disease in the right way and set up the faith to take care of themselves independently gradually. For medical staff, it is necessary and important to give all patients health education about self-management before discharge. It is urgent to call for attention to this disease, and the government and all of society should give more support to stroke patients.

Self-management to promote physical activity after discharge from in-patient stroke rehabilitation: a feasibility study

OBJECTIVES

To investigate the feasibility of a self-management program aimed at increasing physical activity in community-dwelling ambulators after stroke in a middle-income country with high income inequality.

METHODS

A Phase 1, pre-post intervention study was conducted with 20 sub-acute stroke participants. The self-management program was delivered in six home-based sessions over 3 months. Feasibility of recruitment, intervention, and measurement was determined. Physical activity, cardiovascular risk, depression, walking speed, self-efficacy for exercise, participation, and quality of life were measured at baseline, 3, and 6 months.

RESULTS

16% of eligible participants were recruited. 90% completed the program and were measured at 3 months, and 65% at 6 months. The most common reasons for withdrawal were return to work, lack of interest/motivation and surgery. 92% of the sessions were delivered for 59 (SD 23) minutes per session. Participants did not increase physical activity at 3 months (MD 364 steps/day, 95% CI -282 to 1010) or 6 months (MD 312 steps/day, 95% CI -881 to 1504). Post-hoc analysis showed that sedentary participants increased their step count at 3 months by 1,300 (95% CI 152 to 2447) and at 6 months by 1,701 (95% CI -556 to 3959) more steps than non-sedentary participants.

CONCLUSIONS

A Phase 2 study of the self-management program appears to be feasible in a middle-income country with high income inequality and has the potential to increase physical activity levels in sedentary individuals with mild disability after stroke.

TRIAL REGISTRATION

RBR-6bdmsk.

Physical Activity, Psychological and Functional Outcomes in Non-Ambulatory Stroke Patients during Rehabilitation-A Pilot Study

Despite the extensive literature on stroke rehabilitation, there are few studies that comprehensively show non-ambulatory stroke patients. The aim of the study was to explore the dynamics of the change in physical activity (PA), psychological and functional outcomes, and the correlation between them in non-ambulatory patients during early in-patient post-stroke rehabilitation. Measurements were taken on 21 participants at the beginning of and 6 weeks post-conventional rehabilitation with the Barthel Index (BI), Berg Balance Scale (BBS), Trunk Control Test (TCT), Stroke Impact Scale (SIS), General Self-Efficacy Scale, Stroke Self-Efficacy Questionnaire (SSEQ), the original scale of belief in own impact on recovery (BiOIoR), Hospital Anxiety and Depression Scale, Acceptance of Illness Scale and when the patient could walk—Time Up & Go and 6 Minute Walk Test. Daily PA was assessed over 6 weeks using a Caltrac accelerometer. Only outcomes for BI, BBS, TCT, SIS, and SSEQ significantly improved 6 weeks post-rehabilitation. PA energy expenditure per day significantly increased over time (p < 0.001; effect size = 0.494), but PA only increased significantly up to the third week. PA change was correlated with BiOIoR post-treatment. Self-efficacy in self-management mediated improvement in SIS. The BiOIoR and confidence in self-management could be important factors in the rehabilitation process.

A mixed-methods feasibility study of a new digital health support package for people after stroke: the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) intervention

BACKGROUND

Evidence for digital health programmes to support people living with stroke is growing. We assessed the feasibility of a protocol and procedures for the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) trial.

METHODS

We conducted a mixed-method feasibility study. Participants with acute stroke were recruited from three hospitals (Melbourne, Australia). Eligibility: Adults with stroke discharged from hospital to home within 10 days, modified Rankin Score 0-4 and prior use of Short Message System (SMS)/email. While in hospital, recruited participants contributed to structured person-centred goal setting and completed baseline surveys including self-management skills and health-related quality of life. Participants were randomised 7-14 days after discharge via REDCap® (1:1 allocation). Following randomisation, the intervention group received a 12-week programme of personalised electronic support messages (average 66 messages sent by SMS or email) aligned with their goals. The control group received six electronic administrative messages. Feasibility outcomes included the following: number of patients screened and recruited, study retainment, completion of outcome measures and acceptability of the ReCAPS intervention and trial procedures (e.g. participant satisfaction survey, clinician interviews). Protocol fidelity outcomes included number of goals developed (and quality), electronic messages delivered, stop messages received and engagement with messages. We undertook inductive thematic analysis of interview/open-text survey data and descriptive analysis of closed survey questions.

RESULTS

Between November 2018 and October 2019, 312 patients were screened; 37/105 (35%) eligible patients provided consent (mean age 61 years; 32% female); 33 were randomised (17 to intervention). Overall, 29 (88%) participants completed the12-week outcome assessments with 12 (41%) completed assessments in the allocated timeframe and 16 also completing the satisfaction survey (intervention=10). Overall, trial participants felt that the study was worthwhile and most would recommend it to others. Six clinicians participated in one of three focus group interviews; while they reported that the trial and the process of goal setting were acceptable, they raised concerns regarding the additional time required to personalise goals.

CONCLUSION

The study protocol and procedures were feasible with acceptable retention of participants. Consent and goal personalisation procedures should be centralised for the phase III trial to reduce the burden on hospital clinicians.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618001468213 (date 31/08/2018); Universal Trial Number: U1111-1206-7237.

Patients' experience of and participation in a stroke self-management programme, My Life After Stroke (MLAS): a multimethod study

OBJECTIVE

A self-management programme, My Life After Stroke (MLAS), was developed to support stroke survivors. This evaluation reports patients' experience.

DESIGN

Multimethod, involving interviews and questionnaires.

SETTING

23 general practices in the intervention arm of a cluster randomised controlled trial in East of England and East Midlands, UK.

PARTICIPANTS

People on the stroke registers of participating general practices were invited to attend an MLAS programme.

INTERVENTIONS

MLAS comprises one-to-one and group-based sessions to promote independence, confidence and hope.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was uptake of the programme. Participants who declined MLAS were sent a questionnaire to ascertain why. Attendees of four programmes completed evaluation forms. Attendees and non-attendees of MLAS were interviewed. Ad-hoc email conversations with the lead author were reviewed. Thematic analysis was used for qualitative data.

RESULTS

141/420 (34%) participants (mean age 71) attended an MLAS programme and 103 (73%) completed 1. 64/228 (28%) participants who declined MLAS gave reasons as: good recovery, ongoing health issues, logistical issues and inappropriate. Nearly all attendees who completed questionnaires felt that process criteria such as talking about their stroke and outcomes such as developing a strong understanding of stroke had been achieved.

CONCLUSIONS

MLAS was a positive experience for participants but many stroke survivors did not feel it was appropriate for them. Participation in self-management programmes after stroke might be improved by offering them sooner after the stroke and providing a range of delivery options beyond group-based, face-to-face learning.

TRIAL REGISTRATION NUMBER

NCT03353519, NIH.

Motivation Theory and Practice in Aphasia Rehabilitation: A Scoping Review

PURPOSE

In the aphasia literature, motivation has been described as potentially influencing rehabilitation outcomes, and there are reports that researchers and clinicians have acted to promote it. However, studies directly investigating the range of beliefs and practices surrounding motivation do not exist currently. The purpose of this scoping review is to develop themes related to the beliefs and practices appearing in the recent aphasia literature.

METHOD

Four databases (CINAHL, PsycINFO, PubMed, and Google Scholar) were searched using keywords aphasia and motivation (including derivatives such as motiv*) for articles published between 2009 and 2020. Searches returned 19,731 articles; after deleting duplicates and applying inclusionary criteria, 365 articles remained. In each article, text surrounding the term motivation was highlighted and thematic analysis was applied to these quotations.

RESULTS

Sixteen themes were developed through thematic analysis and placed into two groups. The first group contained five themes suggesting that researchers believed that motivation should be studied and recognized the value of motivation in person(s) with aphasia when participating in research or clinical activities. The second group contained 11 themes reporting diverse beliefs and practices in how motivation is incorporated in research and clinical activities.

CONCLUSIONS

Results from this scoping review suggest that aphasia researchers, clinicians, and persons with aphasia hold beliefs about motivation that can influence clinical and research decisions. In general, beliefs and decisions related to motivation appeared to be guided by intuition rather than theories of motivation. These themes are discussed within the context of three psychological needs proposed by self-determination theory: competency, autonomy, and relatedness. Applying theories of motivation to future study in aphasia rehabilitation will guide work that can provide empirical support for these beliefs.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Theory-Based Self-Management Interventions for Community-Dwelling Stroke Survivors: A Systematic Review and Meta-Analysis

IMPORTANCE

Self-management is a critical component of stroke rehabilitation. A better understanding of the use of theory and behavior change techniques (BCTs) informs the development of more effective stroke self-management interventions.

OBJECTIVE

To examine what theories and BCTs have been applied in stroke self-management interventions; investigate the extent to which these interventions encourage implementation of behavior changes; and appraise their effectiveness to enhance self-efficacy, quality of life, and functional independence.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, CINAHL, Cochrane Library, and ClinicalTrials.gov were searched from inception to May 26, 2020.

STUDY SELECTION AND DATA COLLECTION

Randomized controlled trials (RCTs) in six databases were reviewed for inclusion and analysis. We included trials that involved community-dwelling adult stroke survivors, assessed the effectiveness of self-management interventions, and explicitly mentioned the use of theory in the development of the intervention. We assessed use of theory and BCTs using the Theory Coding Scheme and BCT taxonomy v1, respectively.

FINDINGS

A total of 3,049 studies were screened, and 13 RCTs were included. The predominant theory and BCT categories were Social Cognitive Theory (7 studies) and goals and planning (12 studies), respectively. Significant and small effect sizes were found for self-efficacy (0.27) and functional independence (0.19).

CONCLUSIONS AND RELEVANCE

Theory-based self-management interventions have the potential to enhance stroke outcomes. Systematic reporting on the use of theory and BCTs is recommended to enhance clarity and facilitate evaluations of future interventions. What This Article Adds: This review supports and guides occupational therapy practitioners to use theory-based self-management intervention as a routine part of stroke rehabilitation to improve stroke survivors' experience in the community.

Self-Perceived ADL/IADL Function is Influenced by Residual Neurological Impairment, Aphasia, and Anxiety

BACKGROUND.

Self-perceptions of performance of activities of daily living (ADL) and instrumental activities of daily living (IADL) are reduced following stroke. Research investigating contributing factors is lacking.

PURPOSE.

We examined the extent to which aphasia status, neurological impairment and poststroke depression, and anxiety contribute to self-perceived ADL/IADL function.

METHOD.

Seventy-six community-dwelling individuals at least 6 months poststroke, 44 with and 32 without aphasia, participated in the cross-sectional study. The Stroke Impact Scale (SIS) ADL/IADL domain was the primary outcome measure with aphasia status, residual neurological impairment, depressive symptoms, and anxiety as predictor variables.

FINDINGS

Aphasia status, residual neurological impairment, and anxiety were independent predictors of self-perceived ADL/IADL function, together accounting for more than half the variance. Depression was not associated with ADL/IADL.

IMPLICATIONS.

Clinician awareness of the influence of anxiety on self-perceived ADL/IADL function, particularly for people with aphasia, may lead to future interventions that improve self-perceived ADL/IADL function.

Tailoring and Evaluating an Intervention to Support Self-management After Stroke: Protocol for a Multi-case, Mixed Methods Comparison Study

Background

Self-management programs are recognized as a valuable approach to supporting people with long-term conditions, such as stroke, in managing their daily lives. Bridges Self-Management (Bridges) focuses on how practitioners interact and support patients’ confidence, skills, and knowledge, and it is an example of a complex intervention. Bridges has been developed and used across multiple health care pathways in the United Kingdom and is theoretically informed by social cognition theory and self-efficacy principles. Evidence shows that self-management programs based on the construct of self-efficacy can be effective. There is still much to learn about how health care services or pathways should implement support for self-management in a sustainable way and whether this implementation process is different depending on the context or culture of the team or service provided.

Objective

The aim of this study is to tailor and evaluate an intervention (Bridges) to support self-management after stroke in a Swedish context.

Methods

We will use a pretest-posttest design with a case study approach to evaluate the feasibility and implementation of self-management support in two stroke settings. This project includes a complex intervention and depends on the actions of individuals, different contexts, and the adaptation of behavior over time. A mixed methods approach was chosen to understand both outcomes and mechanisms of impact. Data collection will comprise outcome measurements and assessment tools as well as qualitative interviews. Data will be collected concurrently and integrated into a mixed methods design.

Results

Recruitment and data collection for the first site of the project ran from September 1, 2021, to January 17, 2022. The intervention at the first site was conducted from November 1, 2021, to March 5, 2022. The evaluation will start after the implementation phase. The second site has been recruited, and the baseline data collection will start in spring 2022. The intervention will start in early autumn 2022. Data collection will be completed by the end of 2022.

Conclusions

This study represents a unique, highly relevant, and innovative opportunity to maximize knowledge and minimize practice gaps in rehabilitation stroke care. The study will produce robust data on the intervention and in-depth data on the contextual factors and mechanisms related to the feasibility of the intervention and for whom it is feasible. Bridges has been used in the United Kingdom for more than 10 years, and this study will explore its contextualization and implementation within a Swedish stroke environment. The evaluation will study results at the patient, staff, and organizational levels and provide recommendations for the adoption and refinement of future efforts to support self-management.

International Registered Report Identifier (IRRID)

DERR1-10.2196/37672

Measures of self-regulation used in adult rehabilitation populations: A systematic review and content screening

Objective

We aimed to identify generic measures of self-regulation and to examine the degree to which these measures fit a recently developed conceptual model of self-regulation in a rehabilitation context.

Data sources

Pubmed, Embase, PsycInfo, and CINAHL were searched.

Review methods

Articles were included if they were published between January 2015 and August 2020 and reported on empirical studies (trials and observational studies) using a measure of self-regulation or a related concept, in an adult rehabilitation population. Main content was analysed by linking all items of the selected measures to one or more of the six sub-themes of self-regulation: (1) insight into physical and cognitive impairments, (2) insight into the consequences of the impairments, (3) insight into abilities, (4) to be able to communicate limitations, (5) trust in body and functioning, and (6) make use of abilities.

Results

Two reviewers independently screened 7808 abstracts, resulting in the inclusion of 236 articles. In these articles, 80 different measures were used to assess self-regulation or related concept. Nineteen of these measures met the inclusion criteria and were included for the content analyses. Nine of these were self-efficacy measures. No measures covered four or more of the six sub-themes of self-regulation. The three sub-themes on gaining insights were covered less compared to the sub-domains ‘trust’ and ‘make use of abilities’.

Conclusions

Many measures on self-regulation exist None of these measures cover all six sub-themes of self-regulation considered important to measure self-regulation as a rehabilitation outcome.

The association of efficacy, optimism, uncertainty and health anxiety with inflammatory bowel disease activity

OBJECTIVE

Positive and negative psychological attributes have been shown to influence disease outcomes in many chronic health conditions. We aimed to evaluate the association between self-efficacy, optimism, health anxiety and intolerance of uncertainty and disease activity in inflammatory bowel disease (IBD).

METHODS

Adults with confirmed and recently active IBD enrolled in a prospective cohort study. Demographics, disease information, validated measures of psychological functioning related to general self-efficacy, optimism, health anxiety and intolerance of uncertainty were collected at baseline, week 26 and week 52. Clinical disease activity was assessed using the Inflammatory Bowel Disease Symptom Inventory (IBDSI), self-reported flares, and intestinal inflammation using fecal calprotectin (FCAL), collected at baseline, weeks 26 and 52. Generalized estimating equations were used to test the association between psychological functioning and disease activity.

RESULTS

Participants' (n = 154) mean age was 43.4 years (SD 12.5), 69.5% were women and 64.1% had Crohn's disease. Adjusting for demographic variables, higher self-efficacy was associated with lower likelihood of flare by self-report (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.71, 0.91) and IBDSI (OR 0.89, 95% CI 0.80, 0.99), while higher health anxiety was associated with greater likelihood of flare by self-report (OR 1.07, 95% CI 1.01, 1.18) and higher symptomatic disease activity (IBDSI; OR 1.14, 95% CI 1.05, 1.24). The psychological attributes were not significantly associated with active disease as measured by inflammation (FCAL).

CONCLUSION

General self-efficacy and health anxiety are relevant in understanding patient experience with disease activity, and may be appropriate targets for psychological intervention in the care of individuals with IBD.

Telehealth in long-term neurological conditions: the potential, the challenges and the key recommendations

Long-term neurological conditions (LTNCs) cause physical and psychological symptoms that have a significant impact on activities of daily living and quality of life. Multidisciplinary teams are effective at providing treatment for people with LTNCs; however, access to such services by people with disabilities can be difficult and as a result, good quality care is not universal. One potential solution is telehealth. This review describes the potential of telehealth to support people with LTNCs, the challenges of designing and implementing these systems, and the key recommendations for those involved in telehealth to facilitate connected services that can benefit patients, carers and healthcare professionals. These recommendations include understanding the problems posed by LTNCs and the needs of the end-user through a person-centred approach. We discuss how to work collaboratively and use shared learning, and consider how to effectively evaluate the intervention at every stage of the development process.

Leveraging Factors of Self-Efficacy and Motivation to Optimize Stroke Recovery

The International Classification of Functioning, Disability and Health framework recognizes that an individual's functioning post-stroke reflects an interaction between their health condition and contextual factors encompassing personal and environmental factors. Personal factors significantly impact rehabilitation outcomes as they determine how an individual evaluates their situation and copes with their condition in daily life. A key personal factor is self-efficacy-an individual's belief in their capacity to achieve certain outcomes. Self-efficacy influences an individual's motivational state to execute behaviors necessary for achieving desired rehabilitation outcomes. Stroke rehabilitation practice and research now acknowledge self-efficacy and motivation as critical elements in post-stroke recovery, and increasing evidence highlights their contributions to motor (re)learning. Given the informative value of neuroimaging-based biomarkers in stroke, elucidating the neurological underpinnings of self-efficacy and motivation may optimize post-stroke recovery. In this review, we examine the role of self-efficacy and motivation in stroke rehabilitation and recovery, identify potential neural substrates underlying these factors from current neuroimaging literature, and discuss how leveraging these factors and their associated neural substrates has the potential to advance the field of stroke rehabilitation.

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.

Examining Clinical Practice Guidelines for Exercise and Physical Activity as Part of Rehabilitation for People with Stroke: A Systematic Review

BACKGROUND

Stroke is the leading cause of chronic physical disability in Western industrialised nations. Despite clear guidelines for exercise in individuals with many non-communicable diseases, the guidance for people with stroke (PwS) who frequently present with multiple comorbidities is less clear. A systematic review of exercise guidelines was undertaken to synthesise themes and patterns.

METHODS

The review was completed according to the PRISMA statement. Guideline-specific databases were searched for worldwide clinical practice guidelines (CPGs). All included papers underwent quality assessment using the AGREE II protocol. Content synthesis and analysis of the guidelines was undertaken using CERT.

RESULTS

Searching identified 2184 papers. After duplicate removal and screening by title and abstract, 22 CPGs remained for review. Seven guidelines identified three key roles for exercise interventions: (1) promoting a healthy lifestyle, (2) prevention of further strokes and (3) rehabilitation. Of concern, many CPGs fail to recommend appropriate safety measures and standards, pre-, during and post-exercise or tailor for specific needs.

CONCLUSIONS

Global guidelines for exercise in PwS lack in-depth and technical information on the exercise delivery methods, application and dosage required to progress exercise interventions for PwS.

IMproving Physical ACtivity after stroke via Treadmill training (IMPACT) and self-management: a randomised trial

Aim: To determine if treadmill training embedded in self-management education commencing during stroke inpatient rehabilitation results in more physical activity than usual gait training.

Method: A prospective, parallel-group, randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis involving 119 stroke survivors undergoing rehabilitation who were able to walk independently was undertaken. The experimental group undertook treadmill training (40-60% heart rate reserve) and self-management education for 30 minutes, three times a week for 8 weeks and the control group undertook the same amount of usual gait training. Outcomes were measured at baseline (Week 0), on completion of the intervention (Week 8) and beyond the intervention (Week 26). The primary outcome was physical activity measured as steps/day using an activity monitor. Secondary outcomes were walking ability, cardiorespiratory fitness, cardiovascular risk, depression, self-efficacy, perception of physical activity, participation, and quality of life.

Results: After 8 weeks, the experimental group took 1436 more steps/day (95% CI 229 to 2643) than the control group. By 6 months, they took 871 more steps/day (95% CI -385 to 2129) than the control group. There was no difference between groups in any other outcome.

Conclusions: In individuals undergoing rehabilitation after stroke, 8 weeks of treadmill training embedded in self-management resulted in more physical activity than usual gait training and this was largely maintained at 6 months, despite little effect on walking or cardiorespiratory fitness, suggesting the self-management was responsible.

Trial Registration: ACTRN12613000744752.

Data Access: Data are available from the corresponding author.

Spiritual Self-care in Stroke Survivors: A Qualitative Study

Self-care and quality of life challenges significantly affect post-stroke life. Stroke patients look for strategies to improve their performance and cope with their new situation. The aim of this study was to explore spirituality in self-care from the perspective of stroke survivors in the northwest of Iran. Purposive sampling is done on 15 participants through Semi-structured interviews of obtained data through conventional content analysis approach. Two categories of "spiritual self-care" as the main theme included "supplication" comprising subcategories of "worship and prayer", "resort" and "trust" and "religious beliefs" with subcategories of "divine providence" and "divine blessing". Based on results of this study, Spirituality increases motivation for self-care and adaptation, reduces stress and helps patiently manage diseases as realities.

Supported self-management in community stroke rehabilitation: what is it and how does it work? A protocol for a realist evaluation study

INTRODUCTION

A growing evidence base demonstrates the effectiveness of supported self-management in stroke for stroke survivors and their families. However, there is significant variation in its implementation in community stroke care and little understanding about how supported self-management works and is delivered across different settings, models used and contexts of community stroke rehabilitation.

METHODS AND ANALYSIS

Using a mixed method, realist approach across two phases, this protocol describes a study on community-based supported self-management. The aim is to identify the mechanisms and outcomes of supported self-management in stroke and to understand how supported self-management is implemented in different contexts of community stroke rehabilitation. Phase 1 involves (1) a realist synthesis, (2) a scoping and mapping of current community rehabilitation settings and (3) a Q-methodology study to develop initial programme theories about how community-based supported self-management works, for whom and in what contexts. Phase 2 involves realist informed interviews/focus groups with stroke survivors, community rehabilitation practitioners and team managers from across Scotland to test and refine programme theories and an explanatory model for how supported self-management works across different contexts of community-based stroke rehabilitation.

ETHICS AND DISSEMINATION

Ethical approval and R&D approvals have been granted from East of Scotland Research Ethics Committee (REC reference number: 19/ES/0055) and participating NHS boards. An understanding of how, for whom and in what contexts community-based supported self-management works will help to strengthen its delivery in practice. Such an understanding will enable the design of context-specific recommendations for policy and practice that genuinely reflect the challenges in implementing supported self-management in community stroke care. Results will be disseminated to clinical partners working in community stroke rehabilitation, stroke survivors and families and to policymakers and third sector partners involved in the provision of long-term support for people affected by stroke.

PROSPERO REGISTRATION NUMBER

CRD42020166208.

The effect of game-based in comparison to conventional circuit exercise on functions, motivation level, self-efficacy and quality of life among stroke survivors

INTRODUCTION

Stroke survivors are commonly at risk of functional decline, which increase their dependency in activities of daily living and eventually affects their motivation level, self-efficacy, and quality of life. Circuit exercise has been shown to be useful in enhancing functional performance and quality of life of chronic stroke survivors. There is a need to review the existing "usual circuit exercise" and develop a better approach, such as game-based circuit exercise. Training in enriched and fun environment may possibly further promote neuroplasticity. However, evidence on inducing fun element in the existing circuit exercise among stroke survivors is limited. Also, no studies are available to date which report the benefit of circuit exercise on stroke survivors' self-efficacy and motivation level. Therefore, this study aims to assess the effectiveness of game-based circuit exercise in comparison to conventional circuit exercise on functional outcome (lower limb strength, postural stability and aerobic endurance), motivation level, self-efficacy and quality of life among stroke survivors. This study also aims to assess whether the outcomes gained from the 2 interventions could be sustained at week 12 and 24 post-trial.

METHODS

This is an assessor-blinded randomized control trial comparing 2 types of intervention which are game-based circuit exercise (experimental group) and conventional circuit exercise (control group). Based on sample size calculation using GPower, a total number of 82 participants will be recruited and allocated into either the experimental or the control group. Participants in the experimental group will receive a set of structured game-based exercise therapy which has the components of resistance, dynamic balance and aerobic exercises. While participants in the control group will receive a conventional circuit exercise as usually conducted by physiotherapists consisting of 6 exercise stations; cycling, repeated sit to stand, upper limb exercise, lower limb exercise, stepping up/down and walking over obstacles. Both groups will perform the given interventions for 2 times per week for 12 weeks under the supervision of 2 physiotherapists. Outcomes of the interventions will be measured using 30-second chair rise test (for lower limb strength), Dynamic Gait Index (for postural stability), 6-minute walk test (aerobic capacity), Intrinsic Motivation Inventory questionnaire (for motivation level), stroke self-efficacy questionnaire (for self-efficacy) and Short Form-36 quality of life questionnaire (for quality of life). All data will be analyzed using descriptive and inferential statistics.

DISCUSSION

This study will provide the information regarding the effectiveness of including game elements into circuit exercise training. Findings from this study will enable physiotherapists to design more innovative exercise therapy sessions to promote neuroplasticity and enhance functionality and quality of life among stroke survivors under their care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN 12621001489886 (last updated 1/11/2021).

Acceptability and deliverability of an auditory rhythmical cueing (ARC) training programme for use at home and outdoors to improve gait and physical activity post-stroke

BACKGROUND

Although laboratory studies demonstrate that training programmes using auditory rhythmical cueing (ARC) may improve gait post-stroke, few studies have evaluated this intervention in the home and outdoors where deployment may be more appropriate. This manuscript reports stakeholder refinement of an ARC gait and balance training programme for use at home and outdoors, and a study which assessed acceptability and deliverability of this programme.

METHODS

Programme design and content were refined during stakeholder workshops involving physiotherapists and stroke survivors. A two-group acceptability and deliverability study was then undertaken. Twelve patients post-stroke with a gait related mobility impairment received either the ARC gait and balance training programme or the gait and balance training programme without ARC. Programme provider written notes, participant exercise and fall diaries, adverse event monitoring and feedback questionnaires captured data about deliverability, safety and acceptability of the programmes.

RESULTS

The training programme consisted of 18 sessions (six supervised, 12 self-managed) of exercises and ARC delivered by a low-cost commercially available metronome. All 12 participants completed the six supervised sessions and 10/12 completed the 12 self-managed sessions. Provider and participant session written records and feedback questionnaires confirmed programme deliverability and acceptability.

CONCLUSION

An ARC gait and balance training programme refined by key stakeholders was feasible to deliver and acceptable to participants and providers.

TRIAL REGISTRATION

ISCTRN 12/03/2018.

High-intensity treadmill training and self-management for stroke patients undergoing rehabilitation: a feasibility study

BACKGROUND

Physical activity undertaken by stroke survivors is generally low. This trial investigated the feasibility of delivering a high-intensity treadmill and self-management program to people with stroke undergoing inpatient rehabilitation and determine whether physical activity, walking ability and cardiorespiratory fitness could be increased.

METHOD

A phase I, single-group, pre-post intervention study was conducted with stroke survivors undergoing inpatient rehabilitation who could walk. Participants undertook a high-intensity treadmill and self-management program for up to 30 min, three times a week for 8 weeks under the supervision of their usual physiotherapist. Feasibility was determined by examining compliance, satisfaction and adverse events. Clinical outcomes were amount of physical activity, walking ability, and cardiorespiratory fitness collected pre-training (week 0), post-training (week 8), and at follow-up (week 26).

RESULTS

Forty stroke survivors participated, completing 10 (SD 6) sessions, 94% at the specified training intensity, with high satisfaction and no adverse events related to the intervention. At week 8, participants completed 2749 steps/day (95% CI 933 to 4564) more physical activity than at week 0. Walking distance increased by 110 m (95% CI 23 to 196), walking speed by 0.24 m/s (95% CI 0.05 to 0.42), and VO2 peak by 0.29 ml/kg/min (95% CI 0.03 to 0.56). At week 26, increases in physical activity, walking distance and speed, and cardiorespiratory fitness were maintained.

CONCLUSIONS

A high-intensity treadmill training program embedded within a self-management approach during inpatient rehabilitation appears feasible and potentially may offer sustained improvements in physical activity, walking ability, fitness, and quality of life. A randomised trial is warranted.

TRIAL REGISTRATION

This feasibility study was registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000764730 ).

Dance-based exergaming on postural stability and kinematics in people with chronic stroke - A preliminary study

INTRODUCTION

The study evaluated the feasibility, and compliance of a dance-based exergaming (DBExG) on postural stability (PS) and lower extremity (LE) kinematics, along with post-intervention changes in gait function and falls self-efficacy in people with chronic stroke (PwCS).

METHODS

Fifteen PwCS underwent DBExG for six weeks using Kinect "Just Dance 3." Pre- to post- changes were recorded during DBExG assessment on a fast-paced song (130 bpm) using an 8-camera motion capture system to assess PS (center of mass [CoM] excursions [EXs] in the anterior-posterior [AP] and mediolateral [ML] directions) and LE kinematics (hip, knee, and ankle joint angle EXs). Gait function was also assessed with gait parameters, such as gait speed, cadence, and gait symmetry on an electronic walkway. Falls self-efficacy was recorded with Falls Efficacy Scale (FES).

RESULTS

The AP and ML CoM EXs and paretic joint angle EXs significantly increased pre- to post- DBExG assessment (p < .05). Gait parameters, and falls self-efficacy measures significantly changed pre- to post- DBExG (p < .05).

CONCLUSIONS

Results exhibited the feasibility of the proposed DBExG for positively impacting postural stability, and kinematics, along with increasing gait function and falls self-efficacy among PwCS.

Development of a self-management intervention for stroke survivors with aphasia using co-production and behaviour change theory: An outline of methods and processes

Background

Self-management is a promising approach to improve quality of life after stroke. However, evidence for the appropriateness and effectiveness of self-management for stroke survivors with aphasia is limited. This article reports on the process used to develop a supported self-management intervention for stroke survivors with aphasia (SSWA) using co-production and behaviour change theory. Preparatory research included systematic reviews, and qualitative interviews and focus groups with SSWA, family members and speech and language therapists (SLTs).

Materials and methods

We conducted six, 2 hour long intervention development workshops with key stakeholders. The workshops were informed by principles of co-production and the intervention development process outlined by the Behaviour Change Wheel (BCW). We also incorporated the findings of our preparatory research within workshops. Each workshop included an introduction, 1–2 co-production tasks and time for feedback at the end of the session. Data were analysed on an ongoing basis so that findings could be used to feed in to subsequent workshops and intervention development.

Results

Workshop participants (n = 12) included; SSWA (n = 5), family members (n = 3) and SLTs (n = 4). Together, participants engaged with accessible and participatory co-production tasks which aligned with the BCW framework. Participants engaged in discussion to define self-management in behavioural terms (behavioural diagnosis) and to identify what needed to change to support self-management. Participant’s co-produced solutions for supporting self-management and discussed options to implement these in practice. Prototype materials were generated by the research team and evaluated by participants. Intervention functions and behaviour change techniques (BCTs) were mapped to the solutions generated by participants by the research team, after the final workshop. A supported self-management intervention for SSWA was developed which will be delivered by SLTs through community stroke services.

Conclusions

This paper reports the process we used to integrate co-production work with behaviour change theory to develop a complex self-management intervention. This is of relevance for researchers looking to harness the strengths of co-production methods and theory in intervention design. Future research will feasibility test the supported self-management intervention developed. This paper provides transparency to our intervention development process which will help others to better interpret the findings of our feasibility work.

The effect of music therapy on language recovery in patients with aphasia after stroke: a systematic review and meta-analysis

OBJECTIVE

The aim of this meta-analysis was to evaluate the evidence on the effectiveness of music therapy in the recovery of language function in post-stroke aphasia, compared with conventional therapy or no therapy.

METHODS

We searched studies that explored the effect of music therapy on language function in post-stroke aphasia and published in PubMed, Embase, the Cochrane Library, Web of Science, CINAHL, ProQuest Digital Dissertations, and ClinicalTrials.gov from inception to March 2021. Six reviewers independently screened out eligible studies, extracted data, and evaluated the methodological quality. Results were pooled using mean difference (MD) with 95% confidence interval (CI). Heterogeneity was assessed by the chi-square test and I² statistic.

RESULTS

Six studies were included in this meta-analysis involving 115 patients. The methodological quality of these studies ranged from poor to excellent. There was significant mean difference in functional communication for post-stroke aphasia by 1.45 (95% CI: 0.24, 2.65; P = 0.02, from poor to excellent evidence), in repetition by 6.49 (95% CI: 0.97, 12.00; P = 0.02, from acceptable to excellent evidence), and in naming by 11.44 (95% CI: 1.63, 21.26; P = 0.02, from acceptable to excellent evidence). But there was no significant difference in comprehension for post-stroke aphasia by 7.21 (95% CI: - 10.88, 25.29; P = 0.43, from acceptable to excellent evidence).

CONCLUSIONS

Music therapy can improve functional communication, repetition, and naming in patients with post-stroke aphasia, but did not significantly improve comprehension.

TRIAL REGISTRATION

CRD42021251526.

Strategies for Empowering activities in Everyday life (SEE 1.0): study protocol for a feasibility study of an Internet-based occupational therapy intervention for people with stroke

Background

Rehabilitation after stroke seldom focuses on needs related to an active everyday life and the process of change that people must undergo to adapt to an altered capacity and life situation. In particular, occupational therapy in the late phase needs to support clients in adopting sustainable self-initiated management strategies to regain daily activities and an active everyday life. To improve access to rehabilitation, the use of digital solutions has been suggested. This study aims to evaluate the feasibility of the Internet-based occupational therapy intervention “Strategies for Empowering activities in Everyday life” (SEE, version 1.0). We will investigate the feasibility of the intervention process in terms of acceptability and adherence as well as the most suitable outcome measures to evaluate SEE and improve the knowledge about the potential changes and outcomes of SEE for clients with stroke.

Methods

This feasibility study is based on a pretest posttest design without a control group. Quantitative and qualitative data will be collected from clients and staff concurrently embedded in a mixed-method design during the entire study.

Discussion

The project is a first test of a novel Internet-based occupational therapy intervention, and the research will contribute to the continued development and evaluation of the SEE programme. SEE can provide people with strategies in daily activities that can support them to live an active everyday life despite changed capacity and to improve access to rehabilitation interventions.

Trial registration

NCT04588116. Name of the registry: Strategies Empowering Activities in Everyday Life (SEE 1.0). A Web-based Occupational Therapy Intervention. URL of trial registry record. Date of registry: Trial first posted: October 19, 2020; first submitted: October 2, 2020

Self-Efficacy Is a Modifiable Factor Associated with Frailty in Those with Minor Stroke: Secondary Analysis of 200 Cohort Respondents

BACKGROUND

Owing to the improvement in acute care, there has been an increase in the number of people surviving stroke and living with its impairments. Frailty is common in people with stroke and has a significant impact on the prognosis after stroke. To reduce frailty progression, potentially modifiable factors should be identified. Increasing levels of self-efficacy influence both behaviour and physical functioning, and therefore it could be a potential target to prevent frailty.

METHODS

This is a prospective cohort study that involved the secondary analysis of the RISE data to examine the relationship between self-efficacy and frailty. The RISE study is a longitudinal study that consists of 200 adults aged 18+ years after their first stroke event. Data were collected from the respondents at 3 weeks, 6 months, 12 months, and 24 months after their discharge from the hospital. Frailty was assessed using the multidimensional frailty index with scores ranging from 0 to 1, and self-efficacy was assessed using the SESx scale, which was dichotomized as low/moderate or high. Frailty trajectories were examined using the repeated linear model. The generalized estimating equation was used to examine the relationship between self-efficacy and frailty at baseline and in the future (6-24 months). The B coefficients were reported at 95% CI before and after adjusting for potential confounders (age, gender, stroke severity, education, and social support).

RESULTS

A total of 200 responses were analysed, and the mean age of the respondents was 67.78 ± 11.53. Females made up 64% of the sample, and the mean frailty score at baseline was 0.17 ± 0.09. After adjusting for confounders, respondents with low self-efficacy had an approximately 5% increase in their frailty scores at baseline and in the 24-month follow-up period compared to those with high self-efficacy.

CONCLUSION

The result from this study showed that self-efficacy was significantly associated with frailty after stroke. Our findings suggest that self-efficacy may play a role in frailty progression among stroke survivors.

A Prediction Model of Rehabilitation Motivation in Middle-Aged Survivors of Stroke in Rehabilitation Facilities in Korea

BACKGROUND

To improve the health outcomes of survivors of stroke, it is critical that they are highly motivated to engage in rehabilitation activities. Despite the increasing prevalence of strokes among middle-aged adults, there is limited knowledge regarding factors that may affect survivors' motivation to engage in rehabilitation.

OBJECTIVE

The aim of this study was to examine the relationship among factors that predict the rehabilitation motivation of middle-aged survivors after a stroke through structural equation modeling.

METHODS

A total of 200 middle-aged (40-64 years) survivors of stroke from 9 rehabilitation hospitals in Korea completed questionnaires on depressive symptoms, self-efficacy, social support, and rehabilitation motivation. Information on clinical characteristics, including physical function (activities performed during daily life), was collected through the review of medical records. Structural equation modeling was used to construct a prediction model of rehabilitation motivation.

RESULTS

The average subject's age was 56.2 ± 6.6 years, and the mean time since the event of their stroke was 15.02 ± 8.95 months. Subjects' self-efficacy (being able to live everyday life) after their stroke (β = .500, P < .001) and the social support provided by family and medical personnel (β = .284, P < .010) directly affected their rehabilitation motivation. The bootstrapping method showed that depressive symptoms indirectly affected rehabilitation motivation through self-efficacy, as did physical function.

CONCLUSIONS

In middle-aged survivors of stroke, self-efficacy and social support play a critical role in maintaining intrinsic motivation to engage in rehabilitation activities. Self-efficacy should be evaluated periodically and improved by encouraging individuals to achieve goals, emphasizing their self-regulation, especially among those who reported depressive symptoms and low physical function.

Depressive Symptoms Moderate the Relationship Among Physical Capacity, Balance Self-Efficacy, and Participation in People After Stroke

OBJECTIVE

It was previously found that balance self-efficacy mediated the relationship between physical capacity and participation after stroke. The effect of other factors that influence participation, such as depression, on this relationship has not been explored. This study examined the effect of symptoms of depression on the mediated relationship between physical capacity and participation by balance self-efficacy in individuals after stroke.

METHODS

In this cross-sectional study, 282 persons with chronic stroke (>6 months) were classified as having either low or high Geriatric Depression Scale scores. This study used a multiple group structural equation model to test moderated mediation by comparing a constrained model (indicating no effect of depression on the mediation) and an unconstrained model (indicating an effect of depression on the mediation). The models were compared using a chi-squared difference test.

RESULTS

The chi-squared difference test suggested that the unconstrained model was a better fit, indicating that depressive symptoms moderated the mediated relationship between physical capacity and participation (χ2(3, N = 282) = 9.0). In the Low Depression group, a significant indirect effect indicated that balance self-efficacy did mediate the relationship between physical capacity and participation. There was no significant indirect effect in the High Depression group.

CONCLUSION

The results suggest the relationship between physical capacity and participation appears to be mediated by balance self-efficacy in individuals after stroke with low reports of depressive symptoms, but in those with high reports of depressive symptoms, physical capacity and balance self-efficacy are unrelated to participation.

IMPACT

Targeting balance self-efficacy to improve post-stroke participation may be beneficial only for individuals with low reports of depression. In individuals after stroke with high reports of depression, treatment should include and emphasize the treatment of those depressive symptoms. Additional work further examining these complex relationships is warranted.

The Role of Surface Electromyography in Data Fusion with Inertial Sensors to Enhance Locomotion Recognition and Prediction

Locomotion recognition and prediction is essential for real-time human–machine interactive control. The integration of electromyography (EMG) with mechanical sensors could improve the performance of locomotion recognition. However, the potential of EMG in motion prediction is rarely discussed. This paper firstly investigated the effect of surface EMG on the prediction of locomotion while integrated with inertial data. We collected EMG signals of lower limb muscle groups and linear acceleration data of lower limb segments from ten healthy participants in seven locomotion activities. Classification models were built based on four machine learning methods—support vector machine (SVM), k-nearest neighbor (KNN), artificial neural network (ANN), and linear discriminant analysis (LDA)—where a major vote strategy and a content constraint rule were utilized for improving the online performance of the classification decision. We compared four classifiers and further investigated the effect of data fusion on the online locomotion classification. The results showed that the SVM model with a sliding window size of 80 ms achieved the best recognition performance. The fusion of EMG signals does not only improve the recognition accuracy of steady-state locomotion activity from 90% (using acceleration data only) to 98% (using data fusion) but also enables the prediction of the next steady locomotion (∼370 ms). The study demonstrates that the employment of EMG in locomotion recognition could enhance online prediction performance.

Factors Associated with Post-Stroke Depression in Chinese Stroke Survivors

OBJECTIVES

To explore the relationship between participation self-efficacy, sociodemographic and clinical characteristics, and post-stroke depression in stroke survivors and provide insights into the development of rehabilitation programmes.

MATERIALS AND METHODS

A cross-sectional descriptive study was conducted with 336 participants recruited from five hospitals in Kunming, China. Measures included the Chinese version of the Participation Strategies Self-Efficacy Scale (PS-SES-C), Geriatric Depression Scale (GDS), modified Barthel Index, Rivermead Mobility Index (RMI), Reintegration to Normal Living Index (RNLI), and the Social Support Questionnaire (SSQ6). Logistic regression analyses were performed using SPSS 25.0.

RESULTS

Nearly half (44.6%) of the sample was found to have depression. The mean participation self-efficacy score of stroke survivors with depression was significantly lower than that of those without depression. Logistic regression analyses suggested that participation self-efficacy is a constant and major factor negatively associated with depression, with every 10-pt increase in the PS-SES-C score associated with decreased odds of depression (p<0.001). Other features associated with depression prevalence to varying degrees included education level, marital status, pre-morbid financial role in family, stroke symptom severity, history of heart disease, frequency of stroke, lesion side, stroke type, and use of assistive aids.

CONCLUSIONS

Participation self-efficacy is negatively associated with depression in stroke survivors. Rehabilitation programmes might consider incorporating interventions aimed at boosting participation self-efficacy in order to promote positive recovery outcomes among survivors.

Daily Life Upper Limb Activity for Patients with Match and Mismatch between Observed Function and Perceived Activity in the Chronic Phase Post Stroke

We investigated actual daily life upper limb (UL) activity in relation to observed UL motor function and perceived UL activity in chronic stroke in order to better understand and improve UL activity in daily life. In 60 patients, we collected (1) observed UL motor function (Fugl-Meyer Assessment (FMA-UE)), (2) perceived UL activity (hand subscale of the Stroke Impact Scale (SIS-Hand)), and (3) daily life UL activity (bilateral wrist-worn accelerometers for 72 h) data. Data were compared between two groups of interest, namely (1) good observed (FMA-UE >50) function and good perceived (SIS-Hand >75) activity (good match, n = 16) and (2) good observed function but low perceived (SIS-Hand ≤75) activity (mismatch, n = 15) with Mann-Whitney U analysis. The mismatch group only differed from the good match group in perceived UL activity (median (Q1-Q3) = 50 (30-70) versus 93 (85-100); p < 0.001). Despite similar observed UL motor function and other clinical characteristics, the affected UL in the mismatch group was less active in daily life compared to the good match group (p = 0.013), and the contribution of the affected UL compared to the unaffected UL for each second of activity (magnitude ratio) was lower (p = 0.022). We conclude that people with chronic stroke with low perceived UL activity indeed tend to use their affected UL less in daily life despite good observed UL motor function.

An ecological approach to understanding stroke experience and access to rehabilitation services in Ghana: A cross-sectional study

Despite a growing burden of stroke in low-middle-income countries, research on patient's experiences and access to rehabilitation services remains limited. This study explores the experiences of stroke patients in relation to access and use of stroke rehabilitation services, coping strategies and strategies to improve care in Ghana. A cross-sectional study was conducted. A total of 136 adult stroke patients hospitalised and subsequently discharged in three major referral hospitals in Ghana participated in the study. A paper-based questionnaire was used to collect data. Data were inputted into STATA version 12, cleaned and analysed using descriptive statistics and Chi-Square tests. Findings showed that stroke patients experience stroke differently. Early detection (awareness) of stroke symptoms at onset was low (29.4%). Hypertension was the major (58.1%) predisposing risk factor for stroke, followed by diabetes (14.7%). Multiple barriers impede access to outpatient rehabilitation services: high cost of medications (43.4%), transportation constraints (10.3%), long waiting time (6.6%), forgetfulness about appointment (4.4%), limited education on rehabilitation (20.6%), lack of community support (12.5%) and ineffective communication with healthcare providers (5.2%). Recommended strategies to improve access to rehabilitation care included public education on stroke and its associated risk, reduction in the cost of drugs and increased stroke rehabilitation funding by the NHIS, especially for physiotherapy consultation and training support to caregivers on patient care. Given the difference in stroke experience and barriers in accessing rehabilitation care, multi-level health policy and service delivery reforms are needed to improve access to rehabilitation care, including national public awareness campaigns on early signs of stroke and subsidised cost of stroke rehabilitation.

Psychological changes after coronary angiographic intervention: pre-post comparison and follow-up

Epidemiological studies demonstrate the relevance of cardiovascular diseases for health policies and medical care, especially coronary heart diseases and myocardial infarction. Research has shown that a significant proportion of patients undergoing coronary angiography suffer from clinically relevant mental stress. The aim of this study is to investigate to what extent the psychological state of cardiology patients changes in short- and mid-term periods after coronary angiography has been performed. The study design is naturalistic, longitudinal and comparative about consecutively admitted patients undergoing coronary angiography (N = 419; consenting patients fulfilling inclusion criteria n = 68) at four measurement points: before and after angiography and 6 weeks and 6 months after discharge. The statistical analysis includes paired t-tests, chi-square tests, effect sizes and random effects regression models. The sample was representative of the target population. The prevalence of risk factors were: 84% heart attack, 31% diabetes and 84% hypertension. There were no angiographic pathological findings in 12% of the sample. The neuroticism levels of the sample was higher than in the general population. There were almost no pre-post differences for depression, anxiety, psychological well-being, self-efficacy, resilience or locus of control. At the mid-term, well-being and anxiety decreased and internal locus of control increased. Neuroticism was negatively and extraversion and openness were positively associated with mental state and resources. The sample showed persistent adverse subsyndromal depressivity. At the mid-term, patients realised that their prognosis also depends on their own behaviour (internal attribution). Special psychosomatic attention should be given to people with subsyndromal depression, higher emotional instability and those with angina pectoris symptoms displaying normal coronary angiography.

Stroke survivors' perceptions of participating in a high repetition arm training trial early after stroke

PURPOSE

The study explored the acceptability of high repetition arm training as part of a randomised controlled trial, early after stroke, when fatigue levels and emotional strain are often high.

MATERIALS AND METHODS

36 sub-acute stroke survivors (61 years+/-15) attended for assessment sessions at 3, 6, and 12 weeks after stroke. Individuals were randomised to receive 6 high repetition arm training sessions between 3 and 6 weeks (intervention) or the control group. Semi-structured interviews were conducted at trial completion. Interview transcripts were analysed through framework analysis conducted independently by 2 researchers.

RESULTS

Stroke survivors participated despite high levels of fatigue because they hoped for personal benefit or to potentially benefit future patients. Benefits reported from participation included physical improvements, psychological benefit, improved understanding of their condition as well as a feeling of hope and distraction. The arm training at three weeks after stroke, aiming for 420 movement repetitions was not considered to be too intensive or too early, and most individuals felt lucky to have been, or would have preferred to be in the early training group.

CONCLUSION

High repetition arm training early after stroke was acceptable to participants. Study participation was generally viewed as a positive experience, suggesting that early intervention may not only be physically beneficial but also psychologically.Implications for rehabilitationStroke survivors report that high repetition arm training early after stroke is acceptable.Participation in rehabilitation research early after stroke provides stroke survivors with hope and meaning despite the high prevalence of fatigue.Complex information needs to be repeated and provided in a number of formats early after stroke.

Participation self-efficacy plays a mediation role in the association between mobility and social participation among stroke survivors

BACKGROUND

Mobility is a major determinant of social participation after stroke and the relationship between the two may be mediated by participation self-efficacy.

OBJECTIVE

To investigate the hypothesis that participation self-efficacy mediates the association between mobility and social participation among stroke survivors.

METHODS

A secondary data analysis of a cross-sectional study aiming to validate the Chinese version of the Participation Strategies Self-Efficacy Scale was conducted. Three hundred and thirty-six stroke survivors were recruited. With mobility as the predictor variable and social participation as the outcome, path analysis was utilized to assess the mediating effect of participation self-efficacy on the association between the two factors.

RESULTS

Mobility was significantly associated with social participation (B=2.773, p<0.001) and participation self-efficacy (B=6.060, p<0.001). After adjusting for mobility, participation self-efficacy was significantly associated with social participation. The association between mobility and social participation was mediated by participation self-efficacy.

CONCLUSIONS

When aiming to improve stroke survivor community reintegration, interventions targeted at boosting participation self-efficacy must be considered given its beneficial mediatory effect on mobility and social participation.

Developing a Framework for Designing and Deploying Technology-Assisted Rehabilitation After Stroke: A Qualitative Study

OBJECTIVE

Many unmet rehabilitation needs of patients with stroke can be addressed effectively using technology. However, technological solutions have not yet been seamlessly incorporated into clinical care. The purpose of this pilot study was to examine how to bridge the gaps between the recovery process, technology, and clinical practice to impact stroke rehabilitation meaningfully.

DESIGN

Semistructured interviews were performed using a grounded theory approach with purposive sampling of 17 diverse expert providers in acute care, inpatient, and outpatient stroke rehabilitation settings. Common themes were identified from qualitative analyses of the transcribed conversations to develop a guiding framework from the emerging concepts.

RESULTS

Four core themes emerged that addressed major barriers in stroke rehabilitation and technology-assisted solutions to overcome these barriers: (1) accessibility to quality rehabilitation, (2) adaptability to patient differences, (3) accountability or compliance with rehabilitation, and (4) engagement with rehabilitation.

CONCLUSIONS

The results suggest a four-pronged framework, the A3E framework that stands for Accessibility, Adaptability, Accountability, and Engagement, to comprehensively address existing barriers in providing rehabilitation services. This framework can guide technology developers and clinicians in designing and deploying technology-assisted rehabilitation solutions for poststroke rehabilitation, particularly using telerehabilitation.

Peer Support to Enhance Social and Emotional Self-Management Following Acquired Brain Injury Rehabilitation: Design of a Pre-post Study With Process Evaluation

Background: Specialized rehabilitation following acquired brain injury provides intensive multidisciplinary treatment to individuals with complex disabilities for optimizing recovery and supporting a safe transition to the community. Post-specialist rehabilitation, patients and caregivers have reported a need for support. We present the design of an implementation study to evaluate a new self-management support service for individuals with acquired brain injury and their caregivers.

Methods: This is a pre–post intervention study with a mixed-method design. The study population comprises individuals aged ≥18 years with acquired brain injury living independently following specialized rehabilitation in the Southern part of the Netherlands. All participants receive a post-rehabilitation support service. The support service consists of several house visits by a peer support volunteer in the first weeks after specialized rehabilitation treatment. The peer support volunteers are trained according to an adapted version of the previously developed Self-Management Support (SMS) program. The SMS program is directed at improving social and emotional self-management. Patient outcomes are assessed by questionnaire pre-, directly post-, and 6 months post-intervention. The primary patient outcome measure is self-efficacy. Secondary outcomes are perceived autonomy, quality of life, and psychological well-being. A process evaluation will be performed to gain insight into barriers and facilitators for the implementation of peer-led SMS by combining both quantitative, questionnaire data and qualitative data derived from focus groups with peer supporters and patients. In a workshop with relevant stakeholders, possibilities for dissemination and sustainability will be explored.

Discussion: This paper describes the design of a practice-based study on feasibility, barriers, and facilitators to the implementation of a home-based, peer-led self-management support intervention for patients with acquired brain injury. We will quantitatively and qualitatively evaluate the change in relevant patient outcomes pre- and post-intervention and the barriers and facilitators related to the implementation of the intervention. Following a positive evaluation, the final stage of the study aims to facilitate deployment and utilization of the intervention.

Effectiveness of the Functional and Cognitive Occupational Therapy (FaCoT) Intervention for Improving Daily Functioning and Participation of Individuals with Mild Stroke: A Randomized Controlled Trial

BACKGROUND

Mild stroke can cause subtle cognitive-behavioral symptoms, which although might be hidden, can restrict community reintegration and participation. Cognitive rehabilitation programs exist for stroke but not specifically for mild stroke and the research evidence varies. The Functional and Cognitive Occupational Therapy (FaCoT) intervention was developed specifically for this population.

OBJECTIVE

To examine the effectiveness of FaCoT intervention for improving daily functioning and participation compared with standard care.

METHOD

A single blind randomized controlled trial with assessments pre (T1), post (T2) and 3-month follow-up (T3). Individuals in the FaCoT group received 10 weekly sessions practicing cognitive and behavioral strategies. The Canadian Occupational Performance Measure (COPM) was the primary outcome measure, IADL-questionnaire, Reintegration to Normal Living questionnaire (RNL) were secondary measures.

RESULTS

In total, 66 community-dwelling individuals with mild stroke were randomly allocated to FaCoT (n = 33, mean (SD) age 64.6 (8.2), 33% women), or control group (n = 33, mean (SD) age 64.4 (10.8), 45% women). Time X Group interaction effects were found for the COPM performance (F(1.4,90.3) = 11.75, p < 0.000) and satisfaction (F(1.5,96.8) = 15.70, p < 0.000), with large effect size values. Significant between-group effects were found for RNL (F = 10.02, p < 0.002, ɳP2 = 0.13). Most participants in FaCoT achieved a clinically important difference in COPM between T1-T2, T1-T3, and in RNL between T1 to T3 compared with the control group.

CONCLUSIONS

FaCoT intervention is effective to improve daily functioning, participation and satisfaction of individuals with mild stroke compared with standard care, therefore FaCoT should be implemented in community rehabilitation settings.

Effects of a Goal-Oriented Intervention on Self-Management Behaviors and Self-Perceived Burden After Acute Stroke: A Randomized Controlled Trial

Background: Stroke generates significant health and social burdens. Self-management has potential importance for supporting individuals in coping and continuing to progress after stroke. However, there is a lack of targeted programs to enhance self-management and reduce self-perceived burden (SPB) following stroke.

Purpose: To evaluate the effects of a goal-oriented intervention on self-management behaviors and SPB among patients after acute stroke.

Methods: This was a randomized controlled trial with a 4-weeks intervention. Participants were randomly allocated to the intervention (n = 48) or control group (n = 48). The intervention and control groups received eight sessions of goal-oriented self-management intervention based on Pender's health promotion model and control care, respectively. Self-management behaviors and SPB were evaluated and compared between the two groups.

Results: After the 1-month follow-up, there were significant differences in the total self-management behaviors score and the scores of six of the self-management dimensions, excluding diet management, between the intervention group and the control group (t = −7.891– −2.815; p ≤ 0.006). Compared to the control group, the intervention group showed a significant decrease in the physical burden, emotional burden, and total SPB scores (t = 2.102–2.071; p = 0.015–0.041). The economic burden score was not significantly different between the two groups (t = 1.707; p = 0.091).

Conclusion: The goal-oriented intervention based on Pender's health promotion model can effectively improve self-management behaviors and reduce physical and emotional SPB among stroke survivors.

Optimising the development of sustainable internet-based occupational therapy interventions: Important key actions and perspectives to consider

BACKGROUND

By examining the health needs of the general population and utilising the potential of digitalisation as a driving force, new internet-based services need to be developed in occupational therapy. However, existing guidelines for the development of complex interventions provide scant information on how to develop internet-based interventions.

AIM

The aim of this paper is to share experiences and illustrate important key actions and new perspectives to consider during the innovation process of developing and designing an internet-based occupational therapy intervention.

METHOD AND MATERIALS

International guidelines for intervention development was reviewed to add important perspectives in the innovation process.

RESULTS

The illustration focuses on five key actions in the development phase to highlight new perspectives and questions important to consider when designing new internet-based occupational therapy interventions.

CONCLUSION

The new perspectives can complement existing guidelines to enhance the development of more effective and sustainable internet-based interventions.

SIGNIFICANCE

The illustration provided has potential to improve the sustainability in innovation processes of new internet-based occupational therapy interventions.