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

Psychometric properties of the Swedish version of the General Self-Efficacy Scale in stroke survivors

The aim of this study was to assess the psychometric properties of a Swedish version of the General Self-Efficacy Scale (GSE) in stroke survivors. The GSE was administered by the same assessor on two occasions 3 weeks apart with 34 stroke survivors (21 men, 13 women; mean age=68.1 years) 6-10 months after stroke. Psychometric properties including targeting and scaling assumptions, and several reliability indices, were calculated. The mean score was well above the midpoint of the scale and the total scores spanned almost the entire scale range. Floor and ceiling effects were within the limits of 15-20% for total scores (0 and 8.8%, respectively), but not for each item individually. Total skewness was estimated at -1.02 and skewness for individual items was estimated as -1.55 to -0.33. The corrected item-total correlations were all above 0.3, except for one item. Cronbach's α was high (0.92) and the test-retest reliability was acceptable (intraclass correlation coefficient2,1=0.82). The mean difference (đ) was -0.68 (NS). The SEM was 2.97 (SEM%; 9.40). In conclusion, although targeting in relation to skewness and ceiling effects was observed in some items, the GSE was reliable for use in mobile stroke survivors 6-10 months after stroke.

The Importance of Patient Involvement in Stroke Rehabilitation

OBJECTIVE

To investigate the perceived needs for health services by persons with stroke within the first year after rehabilitation, and associations between perceived impact of stroke, involvement in decisions regarding care/treatment, and having health services needs met.

METHOD

Data was collected, through a mail survey, from patients with stroke who were admitted to a university hospital in 2012 and had received rehabilitation after discharge from the stroke unit. The rehabilitation lasted an average of 2 to 4.6 months. The Stroke Survivor Needs Survey Questionnaire was used to assess the participants' perceptions of involvement in decisions on care or treatment and needs for health services in 11 problem areas: mobility, falls, incontinence, pain, fatigue, emotion, concentration, memory, speaking, reading, and sight. The perceived impact of stroke in eight areas was assessed using the Stroke Impact Scale (SIS) 3.0. Eleven logistic regression models were created to explore associations between having health services needs met in each problem area respectively (dependent variable) and the independent variables. In all models the independent variables were: age, sex, SIS domain corresponding to the dependent variable, or stroke severity in cases when no corresponding SIS domain was identified, and involvement in decisions on care and treatment.

RESULTS

The 63 participants who returned the questionnaires had a mean age of 72 years, 33 were male and 30 were female. Eighty percent had suffered a mild stroke. The number of participants who reported problems varied between 51 (80%, mobility) and 24 (38%, sight). Involvement in decisions on care and treatment was found to be associated with having health services needs met in six problem areas: falls, fatigue, emotion, memory, speaking, and reading.

CONCLUSIONS

The results highlight the importance of involving patients in making decisions on stroke rehabilitation, as it appears to be associated with meeting their health services needs.

ECONOMIC EVALUATION STUDIES OF SELF-MANAGEMENT INTERVENTIONS IN CHRONIC DISEASES: A SYSTEMATIC REVIEW

Background: To our knowledge, there has been no overall systematic review focusing on the methodological quality of full economic evaluation studies of self-management interventions. Our objective was to systematically review the literature of full economic evaluation studies of self-management interventions in adult chronic patients and to investigate their methodological quality and cost-effectiveness.

Methods: A data extraction form was developed to assess general and randomized controlled trial (RCT) -related characteristics, quality, of the RCTs, economic information and quality of the economic evaluation studies by means of a quality assessment (CHEC-list for trial-based studies, adjusted CHEC-list for model-based studies).

Results: Twenty-three reports were found. Sixteen studies (73 percent) lack information on the control intervention(s). Only one study fulfilled all three criteria for quality of RCTs and five studies (23 percent) did not meet any of these criteria. This review included one model-based study; the other studies were trial-based economic evaluation studies based on a RCT. Eight studies (35 percent) used a societal perspective and 12 (60 percent) synthesized costs and effects. Seven studies were categorized into the highest category (<15 score), nine studies into the “moderate” group (9–14 score), six studies received a “low” score (<8) on the CHEC-list. Eighteen studies found the self-management intervention(s) to be cost-effective compared with other interventions

Conclusions: Self-management interventions for adult chronic patients were heterogeneous and there was no clear, well-considered definition of self-management. Overall, the methodological quality of the full economic evaluation studies was moderate and, therefore, cost-effectiveness results must be interpreted with caution. Future research will benefit from further improvements in methodological quality of both economic study design and analysis, as well as a taxonomy for describing self-management interventions and their contents.

Balance Confidence: A Predictor of Perceived Physical Function, Perceived Mobility, and Perceived Recovery 1 Year After Inpatient Stroke Rehabilitation

OBJECTIVE

To estimate the effect of balance confidence measured at 1 month poststroke rehabilitation on perceived physical function, mobility, and stroke recovery 12 months later.

DESIGN

Longitudinal study (secondary analysis).

SETTING

Multisite, community-based.

PARTICIPANTS

Community-dwelling individuals (N=69) with stroke living in a home setting.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Activities-specific Balance Confidence scale; physical function and mobility subscales of the Stroke Impact Scale 3.0; and a single item from the Stroke Impact Scale for perceived recovery.

RESULTS

Balance confidence at 1 month postdischarge from inpatient rehabilitation predicts perceived physical function (model 1), mobility (model 2), and recovery (model 3) 12 months later after adjusting for important covariates. The covariates included in model 1 were age, sex, basic mobility, and depression. The covariates selected for model 2 were age, sex, balance capacity, and anxiety, and the covariates in model 3 were age, sex, walking capacity, and social support. The amount of variance in perceived physical function, perceived mobility, and perceived recovery that balance confidence accounted for was 12%, 9%, and 10%, respectively.

CONCLUSIONS

After discharge from inpatient rehabilitation poststroke, balance confidence predicts individuals' perceived physical function, mobility, and recovery 12 months later. There is a need to address balance confidence at discharge from inpatient stroke rehabilitation.

The Development of the Improving Participation after Stroke Self-Management Program (IPASS): An Exploratory Randomized Clinical Study

INTRODUCTION

There is a heavy emphasis in rehabilitation on restoration of function post-stroke at the expense of addressing how to manage the impact of stroke and the environment long term. Management of chronic health conditions is often and effectively addressed using self-management education; however, self-management is mostly focused on managing symptoms and health behaviors, not additional participation and community reintegration issues experienced following stroke. This study evaluated the Improving Participation after Stroke Self-Management Program (IPASS) to improve self-efficacy and participation in everyday life activities for individuals living with the long-term consequences of stroke.

METHODS

A multisite, single-blind, exploratory randomized clinical study was conducted with participants with mild-to-moderate chronic stroke (n = 185). Participants were randomized either to receive the IPASS intervention immediately or to a wait list control group. The assessment was completed pre- and post-intervention and at 6-9 months post-intervention follow-up. The primary outcome assessments included measures of self-efficacy to manage chronic health conditions and to participate in everyday life activities.

RESULTS

The results show that there was significant short-term increase in health-related self-efficacy both within-group and between-groups in managing chronic conditions which were retained at follow-up; the average effect size was 0.46, indicating moderate effect overall. Further, a significant short-term increase was found in participation self-efficacy, with an overall moderate effect size of 0.55.

CONCLUSIONS

These results provide early support for the use of IPASS to help improve self-efficacy to manage health behaviors and to improve participation post-stroke. Further investigation is warranted to confirm these findings with an active control group and a more sensitive outcome measure to capture participation changes.

Feasibility study of an integrated stroke self-management programme: a cluster-randomised controlled trial

OBJECTIVES

To test the feasibility of conducting a controlled trial into the effectiveness of a self-management programme integrated into stroke rehabilitation.

DESIGN

A feasibility cluster-randomised design was utilised with stroke rehabilitation teams as units of randomisation.

SETTING

Community-based stroke rehabilitation teams in London.

PARTICIPANTS

78 patients with a diagnosis of stroke requiring community based rehabilitation.

INTERVENTION

The intervention consisted of an individualised approach to self-management based on self-efficacy. Clinicians were trained to integrate defined self-management principles into scheduled rehabilitation sessions, supported by a patient-held workbook.

MAIN OUTCOMES MEASURES

Patient measures of quality of life, mood, self-efficacy and functional capacity, and health and social care utilisation, were carried out by blinded assessors at baseline, 6 weeks and 12 weeks. Fidelity and acceptability of the delivery were evaluated by observation and interviews.

RESULTS

4 community stroke rehabilitation teams were recruited, and received a total of 317 stroke referrals over 14 months. Of these, 138 met trial eligibility criteria and 78 participants were finally recruited (56.5%). Demographic and baseline outcome measures were similar between intervention and control arms, with the exception of age. All outcome measures were feasible to use and clinical data at 12 weeks were completed for 66/78 participants (85%; 95% CI 75% to 92%). There was no significant difference in any of the outcomes between the arms of the trial, but measures of functional capacity and self-efficacy showed responsiveness to the intervention. Observation and interview data confirmed acceptability and fidelity of delivery according to predetermined criteria. Costs varied by site.

CONCLUSIONS

It was feasible to integrate a stroke self-management programme into community rehabilitation, using key principles. Some data were lost to follow-up, but overall results support the need for conducting further research in this area and provide data to support the design of a definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN42534180.

Self-care Concept Analysis in Cancer Patients: An Evolutionary Concept Analysis

Background:

Self-care is a frequently used concept in both the theory and the clinical practice of nursing and is considered an element of nursing theory by Orem. The aim of this paper is to identify the core attributes of the self-care concept in cancer patients.

Materials and Methods:

We used Rodgers’ evolutionary method of concept analysis. The articles published in English language from 1980 to 2015 on nursing and non-nursing disciplines were analyzed. Finally, 85 articles, an MSc thesis, and a PhD thesis were selected, examined, and analyzed in-depth. Two experts checked the process of analysis and monitored and reviewed the articles.

Results:

The analysis showed that self-care concept is determined by four attributes of education, interaction, self-control, and self-reliance. Three types of antecedents in the present study were client-related (self-efficacy, self-esteem), system-related (adequate sources, social networks, and cultural factors), and healthcare professionals-related (participation).

Conclusion:

The self-care concept has considerably evolved among patients with chronic diseases, particularly cancer, over the past 35 years, and nurses have managed to enhance their knowledge about self-care remarkably for the clients so that the nurses in healthcare teams have become highly efficient and able to assume the responsibility for self-care teams.

Experiences of Self-Management Support Following a Stroke: A Meta-Review of Qualitative Systematic Reviews

BACKGROUND

Supporting self-management in stroke patients improves psychological and functional outcomes but evidence on how to achieve this is sparse. We aimed to synthesise evidence from systematic reviews of qualitative studies in an overarching meta-review to inform the delivery and development of self-management support interventions.

METHODS

We systematically searched eight electronic databases including MEDLINE, EMBASE and CINAHL for qualitative systematic reviews (published January 1993 to June 2012). We included studies exploring patients', carers' or health care professionals' experiences relevant to self-management support following a stroke, including studies describing the lived experience of surviving a stroke. We meta-synthesised the included review findings using a meta-ethnographic framework.

RESULTS

Seven reviews, reporting 130 unique studies, were included. Themes emerging from the reviews were pertinent, consistent and showed data saturation; though explicit mention of self-management support was rare. Our meta-review highlighted the devastating impact of stroke on patients' self-image; the varying needs for self-management support across the trajectory of recovery; the need for psychological and emotional support throughout recovery particularly when physical recovery plateaus; the considerable information needs of patients and carers which also vary across the trajectory of recovery; the importance of good patient-professional communication; the potential benefits of goal-setting and action-planning; and the need for social support which might be met by groups for stroke survivors.

CONCLUSIONS

The observed data saturation suggests that, currently, no further qualitative research simply describing the lived experience of stroke is needed; we propose that it would be more useful to focus on qualitative research informing self-management support interventions and their implementation. Our findings demonstrate both the on-going importance of self-management support and the evolving priorities throughout the stages of recovery following a stroke. The challenge now is to ensure these findings inform routine practice and the development of interventions to support self-management amongst stroke survivors.

Exploring the Role of Accelerometers in the Measurement of Real World Upper-Limb Use After Stroke

The ultimate goal of upper-limb rehabilitation after stroke is to promote real-world use, that is, use of the paretic upper-limb in everyday activities outside the clinic or laboratory. Although real-world use can be collected through self-report questionnaires, an objective indicator is preferred. Accelerometers are a promising tool. The current paper aims to explore the feasibility of accelerometers to measure upper-limb use after stroke and discuss the translation of this measurement tool into clinical practice. Accelerometers are non-invasive, wearable sensors that measure movement in arbitrary units called activity counts. Research to date indicates that activity counts are a reliable and valid index of upper-limb use. While most accelerometers are unable to distinguish between the type and quality of movements performed, recent advancements have used accelerometry data to produce clinically meaningful information for clinicians, patients, family and care givers. Despite this, widespread uptake in research and clinical environments remains limited. If uptake was enhanced, we could build a deeper understanding of how people with stroke use their arm in real-world environments. In order to facilitate greater uptake, however, there is a need for greater consistency in protocol development, accelerometer application and data interpretation.

Development and initial evaluation of the psychometric properties of self-efficacy and adherence scales for patients with a left ventricular assist device

CONTEXT

No tools exist to measure patients' self-efficacy for and adherence to the complex home-care regimen after having a left ventricular device (LVAD) implanted.

OBJECTIVE

To develop 2 new instruments, the LVAD Patient Self-Efficacy Scale (LPSES) and the LVAD Patient Home Management Adherence Scale (LPHMAS), and evaluate their psychometric properties.

METHODS

This multistage instrumentation study recruited 102 patients (77.5% men and 22.5% women) aged 20 to 82 years, predominantly from the Midwest (34.3%) and the Northeast (26.5%) regions of the United States. Main indications for LVAD were bridge-to-transplant (69.6%) and destination therapy (21.6%), with mean implant duration of 19.9 (SD, 15.5) months. Study participants completed the following instruments: LPSES, LPHMAS, General Self-Efficacy Scale (GSES), Medical Outcomes Study General Adherence (MOSGA), and Self-Care Heart Failure Index (SCHFI) confidence and maintenance subscales. Item analyses, psychometric properties including factorial and convergent validities, and internal consistency reliability were tested.

RESULTS

Factor analyses showed that the variances for the 20-item LPSES and 9-item LPHMAS were 60.2% and 53.6%, respectively. Convergent validity of the newly developed instruments was supported by the following correlations: LPSES and GSES (r = 0.34); LPSES and SCHFI-confidence (r = 0.60); LPHMAS and MOSGA (r = 0.33); LPHMAS and SCHFI-maintenance (r = 0.40). Internal consistency reliability coefficients were 0.94 (LPSES) and 0.84 (LPHMAS). Based on these data, the LPSES and LPHMAS are valid and reliable measures of self-efficacy and adherence specific for LVAD patients. Confirmatory testing is needed to further support the validity of these instruments for use in research and clinical practice.

[Effectiveness of a self-management program using goal setting based on a G-AP for patients after a stroke]

PURPOSE

This study was conducted to develop a self-management program using goal setting for patients after a stroke. The program was based on a theory-based Goal setting and Action Planning framework (G-AP), and the effectiveness of the program was examined.

METHODS

A non-equivalent control group pretest-posttest design was used. The experimental group (n=30) received the self-management program using goal setting based on the G-AP over 7 weeks. The education was delivered individually with a specifically designed stroke workbook. The control group (n=30) received only patient information leaflets about stroke.

RESULTS

There were significant differences between the two groups. Stroke knowledge, self-efficacy, and health behavior compliance were significantly higher (all p<.001), and hospital anxiety (p<.001) and depression (p<.001) were significantly lower in the experimental group compared to the control group.

CONCLUSION

This self-management program using goal setting based on a G-AP was found to be useful and beneficial for patients in stroke rehabilitation settings.

Development and psychometric evaluation of a new patient -reported outcome measure for stroke self -management: The Southampton Stroke Self - Management Questionnaire (SSSMQ)

BACKGROUND

Self-management is important to the recovery and quality of life of people following stroke. Many interventions to support self-management following stroke have been developed, however to date no reliable and valid outcome measure exists to support their evaluation. This study outlines the development and preliminary investigation of the psychometric performance of a newly developed patient-reported outcome measure (PROM) of self-management competency following stroke; the Southampton Stroke Self-Management Questionnaire (SSSMQ).

METHODS

A convenience sample of 87 people who had had a stroke completed responses to the SSSMQ, the Stroke Self-Efficacy Questionnaire and the Stroke Impact Scale. Scaling properties were assessed using Mokken Scale Analysis. Reliability and construct validity were assessed using intra-class correlation coefficient (ICC), Mokken and Cronbach's reliability coefficients and Spearman rank order correlations with relevant measures.

RESULTS

Mokken scaling refined the SSSMQ to 28 scalable items. Internal consistency reliability (Mokken r = 0.89) and test-retest reliability (ICC = 0.928) were excellent. Hypotheses of expected correlations with additional measures held, demonstrating good evidence for construct validity.

CONCLUSIONS

Early findings suggest the Southampton Stroke Self-Management Questionnaire is a reliable and valid scale of self-management competency. The SSSMQ represents a potentially valid PROM for the evaluation of self-management following stroke.

Investigation of psychometric properties of the Falls Efficacy Scale using Rasch analysis in patients with hemiplegic stroke

[Purpose] The purpose of this study was to investigate the psychometric properties of the Falls Efficacy Scale using Rasch analysis in patients with hemiplegic stroke. [Subjects] Fifty-five community-dwelling hemiplegic stroke patients were selected as participants. [Methods] Data were analyzed using the Winsteps program (version 3.62) with the Rasch model to confirm the unidimensionality through item fit, reliability, and appropriateness of the rating scale. [Results] There were no misfit persons or items. Furthermore, infit and outfit statistics appeared adjacent. The person separation value was 3.07, and the reliability coefficient was 0.90. The reliability of all items was at an acceptable level for patients with hemiplegic stroke. [Conclusion] This was the first study to investigate the psychometric properties of the Falls Efficacy Scale using Rasch analysis. The results of this study suggest that the 6-point Falls Efficacy Scale is an appropriate tool for measuring the self-perceived fear of falling in patients with hemiplegic stroke.

Mediating effect of self-control in relation to depression, stress, and activities of daily living in community residents with stroke

[Purpose] This study aimed to determine whether self-control mediates the relation between depression, stress, and activities of daily living in community residents with stroke. [Subjects and Methods] This study is a secondary analysis of data from 108 community-dwelling stroke patients in Korea. Data were collected through self-reporting questionnaires, including the Korean version of the Center for Epidemiological Studies Depression Scale, Korean version of the Brief Encounter Psychosocial Instrument, and the modified Barthel index. The path model was tested to investigate causal relations between variables, obtain maximum-likelihood estimates of model parameters, and provide goodness-of-fit indices. [Results] The proposed path model showed good fit to the data. Depression and stress have a significant direct effect on self-control and a significant indirect effect on activities of daily living through self-control. Depression and stress accounted for 28.0% of the variance in self-control. Depression, stress, and self-control accounted for 8.4% of the variance in explaining activities of daily living. [Conclusion] The level of self-control is an important indicator of activities of daily living in stroke patients. We suggest that interventions such as enhancement of confidence in one’s self-control ability could be effective in improving the physical activity of stroke patients with depressive mood and stress.

Choral singing therapy following stroke or Parkinson's disease: an exploration of participants' experiences

PURPOSE

People with stroke or Parkinson's disease (PD) live with reduced mood, social participation and quality of life (QOL). Communication difficulties affect 90% of people with PD (dysarthria) and over 33% of people with stroke (aphasia). These consequences are disabling in many ways. However, as singing is typically still possible, its therapeutic use is of increasing interest. This article explores the experiences of and factors influencing participation in choral singing therapy (CST) by people with stroke or PD and their significant others.

METHOD

Participants (eight people with stroke, six with PD) were recruited from a community music therapy choir running CST. Significant others (seven for stroke, two for PD) were also recruited. Supported communication methods were used as needed to undertake semi-structured interviews (total N = 23).

RESULTS

Thematic analysis indicated participants had many unmet needs associated with their condition, which motivated them to explore self-management options. CST participation was described as an enjoyable social activity, and participation was perceived as improving mood, language, breathing and voice.

CONCLUSIONS

Choral singing was perceived by people with stroke and PD to help them self-manage some of the consequences of their condition, including social isolation, low mood and communication difficulties.

IMPLICATIONS FOR REHABILITATION

Choral singing therapy (CST) is sought out by people with stroke and PD to help self-manage symptoms of their condition. Participation is perceived as an enjoyable activity which improves mood, voice and language symptoms. CST may enable access to specialist music therapy and speech language therapy protocols within community frameworks.

Towards an Understanding of Racial Differences in Post-stroke Disability

Due to the aging of the baby boomer generation, the number of stroke survivors is expected to increase from 7 million to over 10 million in 2030. Stroke survivorship will be particularly important for African Americans who have a higher incidence of strokes compared to non-Hispanics whites and greater post stroke disability. Current evidence suggests that the most prominent racial differences in post-stroke disability emerge in the post-stroke period. Further work, with a focus on modifiable factors, is needed to understand which factors in the post-stroke period lead to racial differences in post-stroke disability.

Development and Evaluation of Self-Management and Task-Oriented Approach to Rehabilitation Training (START) in the Home: Case Report

BACKGROUND

The incidence of stroke and subsequent level of disability will increase, as age is the greatest risk factor for stroke and the world's population is aging. Hospital admissions are too brief for patients to regain necessary function. Research to examine therapy delivered within the home environment has the potential to expedite relearning of function and reduce health care expenditures.

PURPOSE

This case report describes the use of the knowledge-to-action cycle (KTA) to develop and evaluate an evidence-based approach for rehabilitation in the home that incorporates self-management and task-oriented functional training (TOFT) for people with stroke.

CASE DESCRIPTION

The KTA cycle was used to guide adaptation of evidence from self-management and TOFT into an approach titled START (Self-Management and Task-Oriented Approach to Rehabilitation Training). Three stakeholder symposiums identified barriers and supports to implementation. Clinical practice leaders were engaged as partners in the development of the intervention. An online learning management system housed the resources to support therapist training. Therapist focus groups were conducted and stroke outcomes were used to assess patient response.

OUTCOMES

Eight therapists completed 4 workshops and applied the home intervention in 12 people with stroke. A mentoring process for therapists included feedback from peers and experts after viewing treatment videos. Therapist response was determined from the focus groups; patient response was measured by standardized assessments. The therapists noted that the intervention was easier to implement with patients who were motivated and had minimal cognitive impairment.

DISCUSSION

The KTA cycle provided a structure for the development of this evidence-based rehabilitation intervention, which was feasible to implement in the home. Further evaluation needs to be undertaken to assess the effectiveness of START.

Self-Care Self-Efficacy Correlates with Independence in Basic Activities of Daily Living in Individuals with Chronic Stroke

BACKGROUND

(1) To characterize the self-care self-efficacy (SCSE) of community dwelling individuals with chronic stroke and (2) to determine the contribution of SCSE to the independence in basic and instrumental activities of daily living (BADL and IADL) and the participation of individuals with chronic stroke. SCSE is the confidence in one's own ability to perform self-care activities.

METHODS

This cross-sectional study included fifty community-dwelling individuals mean (SD) age 59.8 (9.3) years, mean (SD) 3.1 (1.7) years post-stroke who were able to walk at least 10 meters. SCSE was assessed using the Stroke Self-Efficacy Questionnaire (SSEQ), BADL was assessed by the Functional Independence Measure (FIM) (interview), the IADL questionnaire assessed IADL and the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) assessed participation. Correlation and regression analyses were performed after controlling for grip strength, executive functions and gait speed, factors known to influence independence in daily living.

RESULTS

The mean SCSE level was moderate-high (70%). Significant moderate correlations were found between SCSE to independence in BADL (r = .596, P < .001), IADL (r = .567, P < .001) and participation (r = .340, P < .005). SCSE of our cohort explained 7.4% of the variance of the individual's independence in BADL after controlling for executive functions and gait speed, but did not contribute to their independence in IADL and participation.

CONCLUSIONS

Higher SCSE of individuals with chronic stroke contributes to more independence in BADL. Additional questionnaires regarding self efficacy for IADL should be developed and investigated.

Who is in control? Clinicians' view on their role in self-management approaches: a qualitative metasynthesis

OBJECTIVE

To explore clinician perceptions of involvement in delivery of self-management approaches.

SETTING

All healthcare settings.

DESIGN

EBSCO, Scopus and AMED databases were searched, in July 2013, for peer-reviewed studies in English reporting original qualitative data concerning perceptions of clinicians regarding their involvement in or integration of a self-management approach. Of 1930 studies identified, 1889 did not meet the inclusion criteria. Full text of 41 studies were reviewed by two independent reviewers; 14 papers were included for metasynthesis. Findings and discussion sections were imported into Nvivo-10 and coded line-by-line. Codes were organised into descriptive themes and cross-checked against original sources to check interpretation, and refined iteratively until findings represented an agreed understanding. Studies were appraised for quality.

RESULTS

Delivering self-management in practice appeared to be a complex process for many clinicians. The issue of 'control' arose in all studies, both in the qualitative data and authors' interpretations. The first theme: Who is in control?--represented ways clinicians talked of exercising control over patients and the control they expected patients to have over their condition. The second theme: Changing clinician views--reflected what appeared to be an essential transformation of practice experienced by some clinicians in the process of integrating self-management approaches into the practice. A range of challenges associated with shifting towards a self-management approach were reflected in the third theme, Overcoming challenges to change. Tensions appeared to exist around forming partnerships with patients. Strategies found helpful in the process of change included: dedicating time to practice reciprocity in communication style, peer support and self-reflection.

CONCLUSIONS

A consistent finding across studies is that 'control' is a key feature of how self-management is viewed by clinicians. They described challenges associated with the paradigm shift required to share or let go of control. Future research should identify whether strategies described by clinicians are key to successful self-management.

A systematic review of the efficacy of self-management programs for increasing physical activity in community-dwelling adults with acquired brain injury (ABI)

BACKGROUND

Individuals living with acquired brain injury, typically caused by stroke or trauma, are far less likely to achieve recommended levels of physical activity for optimal health and well-being. With a growing number of people living with chronic disease and disability globally, self-management programs are seen as integral to the management of these conditions and the prevention of secondary health conditions. However, to date, there has been no systematic review of the literature examining the efficacy of self-management programs specifically on physical activity in individuals with acquired brain injury, whether delivered face-to-face or remotely. Therefore, the purpose of this review is to evaluate the efficacy of self-management programs in increasing physical activity levels in adults living in the community following acquired brain injury. The efficacy of remote versus face-to-face delivery was also examined.

METHODS

A systematic review of the literature was conducted. Electronic databases were searched. Two independent reviewers screened all studies for eligibility, assessed risk of bias, and extracted relevant data.

RESULTS

Five studies met the inclusion criteria for this review. Studies were widely heterogeneous with respect to program content and delivery characteristics and outcomes, although all programs utilized behavioral change principles. Four of the five studies examined interventions in which physical activity was a component of a multifaceted intervention, where the depth to which physical activity specific content was covered, and the extent to which skills were taught and practiced, could not be clearly established. Three studies showed favorable physical activity outcomes following self-management interventions for stroke; however, risk of bias was high, and overall efficacy remains unclear. Although not used in isolation from face-to-face delivery, remote delivery via telephone was the predominant form of delivery in two studies with support for its inclusion in self-management programs for individuals following stroke.

CONCLUSIONS

The efficacy of self-management programs in increasing physical activity levels in community-dwelling adults following acquired brain injury (ABI) is still unknown. Research into the efficacy of self-management programs specifically aimed at improving physical activity in adults living in the community following acquired brain injury is needed. The efficacy of remote delivery methods also warrants further investigation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013006748.

Factors associated with community ambulation in chronic stroke

PURPOSE

Loss of independent community ambulation is one of the most disabling consequences of stroke. The aim of this study was to investigate the association of multiple personal and post-stroke factors with community ambulation in persons between 1- and 3-year post-stroke.

METHODS

This was a cross-sectional study of 40 community-dwelling stroke patients, >18 years, between 1- and 3-year post-stroke. The main outcome measures used were self-report community ambulation questionnaire, demographic information, 10-M Walk Test, Timed Up and Go test, Activities-Specific Balance Confidence Scale, Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Trail-Making Test-Part B, Single Letter Cancellation Test.

RESULTS

Age, number of medications and use of a walking aid were found to be significantly associated with community ambulation (p ≤ 0.05). Gait speed, walking balance and balance self-efficacy were also found to be significantly associated with community ambulation (p ≤ 0.05). Balance self-efficacy was the only factor independently associated with community ambulation post-stroke (p ≤ 0.05).

CONCLUSION

Balance self-efficacy may be a significant determinant in the attainment of independent community ambulation post-stroke. This suggests that physical aspects such as gait speed and walking balance should not be considered in isolation when addressing community ambulation post-stroke.

IMPLICATIONS FOR REHABILITATION

Balance self-efficacy may play a significant role in the attainment of independent community ambulation in a chronic stroke population. Physiotherapy interventions addressing community ambulation post-stroke should consider methods for improving balance self-efficacy in chronic stroke, such as self management programmes.

Translating the science into practice: shaping rehabilitation practice to enhance recovery after brain damage

The revolution in neuroscience provided strong evidence for learning-dependent neuroplasticity and presaged the role of motor learning as essential for restorative therapies after stroke and other disabling neurological conditions. The scientific basis of motor learning has continued to evolve from a dominance of cognitive or information processing perspectives to a blend with neural science and contemporary social-cognitive-psychological science, which includes the neural and psychological underpinnings of motivation. This transformation and integration across traditionally separate domains is timely now that clinician scientists are developing novel, evidence-based therapies to maximize motor recovery in the place of suboptimal solutions. We will review recent evidence pertaining to therapeutic approaches that spring from an integrated framework of learning-dependent neuroplasticity along with the growing awareness of protocols that directly address the patient's fundamental psychological needs. Of importance, there is mounting evidence that when the individual's needs are considered in the context of instructions or expectations, the learning/rehabilitation process is accelerated.

A systematic review of the effectiveness of stroke self-management programs for improving function and participation outcomes: self-management programs for stroke survivors

PURPOSE

A systematic review of stroke self-management programs was conducted to: (i) identify how many and what self-management support strategies were included in stroke self-management interventions and (ii) describe whether self-management programs effectively improved outcomes, focusing specifically on function and participation outcomes.

METHODS

Twelve databases were searched for the years 1986-2012 to identify self-management programs for stroke survivors. Pre-post, quasi-experimental and randomized controlled trial study designs were included. Descriptive information about the intervention was scrutinized to identify what self-management support strategies were present in the intervention and comparisons were made between programs using a group versus a one-to-one format. All outcomes were included and categorized.

RESULTS

The most prominent strategies identified in our review were goal setting and follow-up, and an individualized approach using structured information and professional support. There are indications that self-management programs can significantly increase participation and functional ability. However, the high level of clinical heterogeneity in program delivery, outcomes and level of stroke severity made it impossible to conduct a meta-analysis. Further examination of individual self-management support strategies, such as linking rehabilitation goal setting to post-acute self-management programs, the inclusion of family members and the contribution of peer-support is warranted.

IMPLICATIONS FOR REHABILITATION

Self-management programs for stroke survivors. Linking post-acute self-management programs to rehabilitation goal setting could improve outcomes. Involving family members in self-management programs may benefit stroke survivors.

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

Background

Despite robust evidence concerning self-management for some long-term conditions (LTCs), others lack research explicitly on self-management and, consequently, some patient groups may be overlooked.

Aim

To undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts.

Methods

Self-management is ‘the tasks . . . individuals must undertake to live with one or more chronic conditions . . . [including] . . . having the confidence to deal with medical management, role management and emotional management of their conditions’. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus). For each LTC we conducted systematic overviews of systematic reviews of randomised controlled trials (RCTs) of self-management support interventions (‘quantitative meta-reviews’); and systematic overviews of systematic reviews of qualitative studies of patients’ experiences relating to self-management (‘qualitative meta-reviews’). We also conducted an original systematic review of implementation studies of self-management support in the LTCs. We synthesised all our data considering the different characteristics of LTCs. In parallel, we developed a taxonomy of the potential components of self-management support.

Results

We included 30 qualitative systematic reviews (including 515 unique studies), 102 quantitative systematic reviews (including 969 RCTs), and 61 studies in the implementation systematic review. Effective self-management support interventions are multifaceted, should be tailored to the individual, their culture and beliefs, a specific LTC and position on the disease trajectory, and underpinned by a collaborative/communicative relationship between the patient and health-care professional (HCP) within the context of a health-care organisation that actively promotes self-management. Self-management support is a complex intervention and although many components were described and trialled in the studies no single component stood out as more important than any other. Core components include (1) provision of education about the LTC, recognising the importance of understanding patients’ pre-existing knowledge and beliefs about their LTC; (2) psychological strategies to support adjustment to life with a LTC; (3) strategies specifically to support adherence to treatments; (4) practical support tailored to the specific LTC, including support around activities of daily living for disabling conditions, action plans in conditions subject to marked exacerbations, intensive disease-specific training to enable self-management of specific clinical tasks; and (5) social support as appropriate. Implementation requires a whole-systems approach which intervenes at the level of the patient, the HCP and the organisation. The health-care organisation is responsible for providing the means (both training and time/material resources) to enable HCPs to implement, and patients to benefit from, self-management support, regularly evaluating self-management processes and clinical outcomes. More widely there is a societal need to address public understanding of LTCs. The lack of public story for many conditions impacted on patient help-seeking behaviour and public perceptions of need.

Conclusions

Supporting self-management is inseparable from the high-quality care for LTCs. Commissioners and health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded aspect of care. Further research is needed to understand how health service managers and staff can achieve this culture change in their health-care organisations.

Study registration

This study is registered as PROSPERO CRD42012002898.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Starting early: integration of self-management support into an acute stroke service

Self-management support following stroke is rare, despite emerging evidence for impact on patient outcomes. The promotion of a common approach to self-management support across a stroke pathway requires collaboration between professionals. To date, the feasibility of self-management support in acute stroke settings has not been evaluated.

The Bridges stroke self-management package (SMP) is based on self-efficacy principles. It is delivered by professionals and supported by a patient-held workbook. The aim of this project was to introduce the Bridges stroke SMP to the multidisciplinary staff of a London hyperacute and acute stroke unit.

The ‘Plan Do Study Act’ (PDSA) cycle guided iterative stages of project development, with normalisation process theory helping to embed the intervention into existing ways of working. Questionnaires explored attitudes, beliefs and experiences of the staff who were integrating self-management support into ways of working in the acute stroke setting.

Self-management support training was delivered to a total of 46 multidisciplinary stroke staff. Of the staff who attended the follow-up training, 66% had implemented Bridges self-management support with patients since initial training, and 100% felt their practice had changed. Questionnaire findings demonstrated that staff attitudes and beliefs had changed following training, particularly regarding ownership and type of rehabilitation goals set, and prioritisation of self-management support within acute stroke care.

Staff initiated an audit of washing and dressing practices pre- and post-training. This was designed to evaluate the number of occasions when techniques were used by staff to facilitate patients’ independence and self-management. They found that the number of occasions featuring optimum practice went from 54% at baseline to 63% at three months post-training.

This project demonstrated the feasibility of integrating self-management support into an acute stroke setting. Further work is required to evaluate sustainability of the Bridges stroke SMP, to understand the barriers and opportunities involved in engaging all professional groups in integrated self-management support in acute stroke settings, and to assess patient reported outcomes.

Innovative technologies applied to sensorimotor rehabilitation after stroke

Innovative technologies for sensorimotor rehabilitation after stroke have dramatically increased these past 20 years. Based on a review of the literature on "Medline" and "Web of Science" between 1990 and 2013, we offer an overview of available tools and their current level of validation. Neuromuscular electric stimulation and/or functional electric stimulation are widely used and highly suspected of being effective in upper or lower limb stroke rehabilitation. Robotic rehabilitation has yielded various results in the literature. It seems to have some effect on functional capacities when used for the upper limb. Its effectiveness in gait training is more controversial. Virtual reality is widely used in the rehabilitation of cognitive and motor impairments, as well as posture, with admitted benefits. Non-invasive brain stimulation (rTMS and TDCS) are promising in this indication but clinical evidence of their effectiveness is still lacking. In the same manner, these past five years, neurofeedback techniques based on brain signal recordings have emerged with a special focus on their therapeutic relevance in rehabilitation. Technological devices applied to rehabilitation are revolutionizing our clinical practices. Most of them are based on advances in neurosciences allowing us to better understand the phenomenon of brain plasticity, which underlies the effectiveness of rehabilitation. The acceptation and "real use" of those devices is still an issue since most of them are not easily available in current practice.

Depression in older adults: screening and referral

Depression is related to disability and affects rehabilitation participation, outcomes, and compliance with treatment. Improving older adult depression detection and referral requires knowledge, skills, supportive organizational policies, and access to mental health experts. This review provides a selected overview of evidence-based approaches for screening of suspected cases of depression in older adults by physical therapists and other non-mental health professionals and discusses procedures to refer suspected cases to primary care providers and/or mental health specialists for evaluation, including resources and a tool to assist in communicating depression-related information to the primary care provider or mental health specialist. We hope that this review will promote the incorporation of evidence-based screening and referral of suspected cases of depression in older adults into routine practice.

Developing the Bridges self-management programme for New Zealand stroke survivors: A case study

Background/aim

This case study describes the adaptation of the UK-developed Bridges stroke self-management programme (Bridges SMP) into a version relevant and acceptable to the New Zealand (NZ) context.

Methods

Stakeholder consultation and qualitative methodology explored the acceptability and relevance of the Bridges SMP in NZ. Focus group discussions were held with stroke survivors (n=60) and neurorehabilitation therapists (n= 17). Semi-structured interviews were conducted with 22 stroke survivors. Based on data gathered the authors culturally and contextually adapted the accompanying Bridges SMP workbook. This study piloted the adapted programme with six stroke survivors and used semi-structured interviews to explore their perceptions of it.

Findings

The Bridges SMP was considered acceptable and beneficial for developing skills to self-manage recovery following stroke. The main recommended adaptation was the inclusion of NZ stories into the accompanying workbook. Four themes reflected the six pilot study participants' perceptions of the programme: you are not alone, reflection and taking action, life continues after stroke, and taking responsibility.

Conclusions

The Bridges SMP was considered relevant and only required moderate adaptation for use in NZ. The process the authors undertook to contextualise Bridges SMP for NZ will provide guidance to the programme's introduction into other international regions.

Motivators for uptake and maintenance of exercise: perceptions of long-term stroke survivors and implications for design of exercise programmes

PURPOSE

Exercise-after-stroke programmes are increasingly being provided to encourage more physical exercise among stroke survivors, but little is known about what motivates people with stroke to participate in them. This research aimed to identify factors that motivate long-term stroke survivors to exercise, and the implications for programme design.

METHODS

In two separate studies, focus groups and individual interviews were used to investigate the views of long-term stroke survivors on exercise and participating in exercise programmes. Their data were analysed thematically, and the findings of the studies were synthesised.

RESULTS

Eleven stroke survivors and two partners took part in two focus groups; six other stroke survivors (one with a partner) were interviewed individually. Factors reported to influence motivation were the psychological benefits of exercise, a desire to move away from a medicalised approach to exercise, beliefs about stroke recovery, and on-going support to sustain commitment. A number of potential implications of these themes for exercise programme design were identified.

CONCLUSIONS

A range of personal beliefs and attitudes and external factors may affect the motivation to exercise, and these vary between individuals. Addressing these factors in the design of exercise programmes for long-term stroke survivors may enhance their appeal and so encourage greater engagement in exercise.

IMPLICATIONS FOR REHABILITATION

Exercise programmes may be more attractive to long-term stroke survivors if the psychological well-being benefits of participation are emphasised in their promotion. Some participants will be more attracted by programmes that are de-medicalised, for example, by being located away from clinical settings, and led by or involving suitably-trained non-clinicians. Programmes offered in different formats may attract stroke survivors with different beliefs about the value of exercise in stroke recovery. Programmes should provide explicit support strategies for on-going engagement in exercise.

The multiple sclerosis self-management scale: clinicometric testing

BACKGROUND

The Multiple Sclerosis Self-Management Scale (MSSM) is currently the only measure that was developed specifically to address self-management among individuals with multiple sclerosis (MS). While good internal consistency (α = 0.85) and construct validity have been demonstrated, other psychometric properties have not been established. This study was undertaken to evaluate the criterion validity, test-retest reliability, and face validity of the MSSM.

METHODS

Thirty-one individuals with MS who met the inclusion criteria were recruited to complete a series of questionnaires at two time points. At Time 1, participants completed the MSSM and two generic self-management tools-the Partners in Health (PIH-12) and the Health Education Impact Questionnaire (heiQ)-as well as a short questionnaire to capture participants' opinions about the MSSM. At Time 2, approximately 2 weeks after Time 1, participants completed the MSSM again.

RESULTS

The available MSSM factors showed moderate to high correlations with both PIH-12 and heiQ and were deemed to have satisfactory test-retest reliability. Face validity pointed to areas of the MSSM that need to be revised in future work. As indicated by the participants, some dimensions of MS self-management are missing in the MSSM and some items such as medication are redundant.

CONCLUSIONS

This study provides evidence for the reliability and validity of the MSSM; however, further changes are required for both researchers and clinicians to use the tool meaningfully in practice.

Community reintegration of stroke survivors: the effect of a community navigation intervention

AIM

The overall aim of the proposed study is to examine a newly implemented navigation intervention intended to support stroke survivors' community integration during the first year following hospital discharge in four regions of Ontario, Canada.

BACKGROUND

Stroke is a leading cause of disability worldwide. Stroke survivors living in the community require regular, ongoing follow-up to assess recovery, prevent deterioration and maximize health outcomes. Internationally published evidence, often conducted in large urban centres, suggests that community reintegration services are an important component of the continuum of care for stroke survivors. This evidence, however, often does not address the particular challenges inherent in smaller urban and rural contexts.

DESIGN

The design of this 2-year mixed-method study will use cohort and focused ethnography.

METHODS

The three stages of this study include: (1) collection of quantitative data to profile the health status, support and extent of community reintegration of stroke survivors; (2) collection of qualitative data from stroke survivors and their care partners about community reintegration and navigation; and following triangulation of findings (3) knowledge translation activities. This study was ethically approved by the academic Research Ethics Board and clinical Research Ethics Board (Sudbury, Ontario) and funded by the Ontario Stroke Network (Canada).

DISCUSSION

Results will describe experiences and outcomes of a community navigation intervention. Engagement of multiple stakeholders has the potential to develop a shared understanding of community reintegration and generate evidence informed recommendations for service enhancement at critical points in stroke recovery to support survivor and community well-being.

Self-management interventions for chronic disease: a systematic scoping review

Objective:

To investigate the contributions of physiotherapy and occupational therapy to self-management interventions and the theoretical models used to support these interventions in chronic disease.

Data sources:

We conducted two literature searches to identify studies that evaluated self-management interventions involving physiotherapists and occupational therapists in MEDLINE, the Cochrane Library, CINAHL, EMBASE, AMED (Allied and Complementary Medicine), SPORTdiscus, and REHABDATA databases.

Study selection:

Four investigator pairs screened article title and abstract, then full text with inclusion criteria. Selected articles ( n = 57) included adults who received a chronic disease self-management intervention, developed or delivered by a physiotherapist and/or an occupational therapist compared with a control group.

Data extraction:

Four pairs of investigators performed independent reviews of each article and data extraction included: (a) participant characteristics, (b) the self-management intervention, (c) the comparison intervention, (d) outcome measures, construct measured and results.

Data synthesis:

A total of 47 articles reported the involvement of physiotherapy in self-management compared with 10 occupational therapy articles. The type of chronic condition produced different yields: arthritis n = 21 articles; chronic obstructive pulmonary disease and chronic pain n = 9 articles each. The theoretical frameworks most frequently cited were social cognitive theory and self-efficacy theory. Physical activity was the predominant focus of the self-management interventions. Physiotherapy programmes included disease-specific education, fatigue, posture, and pain management, while occupational therapists concentrated on joint protection, fatigue, and stress management.

Conclusions:

Physiotherapists and occupational therapists make moderate contributions to self-management interventions. Most of these interventions are disease-specific and are most frequently based on the principles of behaviour change theories.

Religious faith and psychosocial adaptation among stroke patients in Kuwait: a mixed method study

Religious faith is central to life for Muslim patients in Kuwait, so it may influence adaptation and rehabilitation. This study explored quantitative associations among religious faith, self-efficacy, and life satisfaction in 40 female stroke patients and explored the influence of religion within stroke rehabilitation through qualitative interviews with 12 health professionals. The quantitative measure of religious faith did not relate to life satisfaction or self-efficacy in stroke patients. However, the health professionals described religious coping as influencing adaptation post-stroke. Fatalistic beliefs were thought to have mixed influences on rehabilitation. Measuring religious faith among Muslims through a standardized scale is debated. The qualitative accounts suggest that religious beliefs need to be acknowledged in stroke rehabilitation in Kuwait.

Factors Affecting the Ability of the Stroke Survivor to Drive Their Own Recovery outside of Therapy during Inpatient Stroke Rehabilitation

Aim. To explore factors affecting the ability of the stroke survivor to drive their own recovery outside of therapy during inpatient rehabilitation. Method. One-on-one, in-depth interviews with stroke survivors (n = 7) and their main carer (n = 6), along with two focus groups with clinical staff (n = 20). Data was thematically analysed according to group. Results. Stroke survivors perceived "dealing with loss," whilst concurrently "building motivation and hope" for recovery affected their ability to drive their own recovery outside of therapy. In addition, they reported a "lack of opportunities" outside of therapy, with subsequent time described as "dead and wasted." Main carers perceived stroke survivors felt "out of control … at everyone's mercy" and lacked knowledge of "what to do and why" outside of therapy. Clinical staff perceived the stroke survivor's ability to drive their own recovery was limited by the lack of "another place to go" and the "passive rehab culture and environment." Discussion. To enable the stroke survivor to drive their own recovery outside of therapy, there is a need to increase opportunities for practice and promote active engagement. Suggested strategies include building the stroke survivor's motivation and knowledge, creating an enriched environment, and developing daily routines to provide structure outside of therapy time.

Self-care management education models in primary care

Self-care management for people living with long-term conditions aims to assist the individual in taking responsibility for their own health. This literature review explores the value and content of the large range of educational models currently in use. Although no single model was found that addressed all the issues, several themes arose. These included the observation that educational models should be based on self-efficacy principles and patient-centred. Method of delivery favoured small groups, using a variety of approaches supported with written information. Duration of the programmes was mainly 6-8 weeks with a follow-up. Programmes should be offered when the patient is ready and not determined by the condition or at diagnosis. Debate remains over whether group leaders should be laypeople and professionals; however, a mixture of both offered the best outcomes. Programmes should not be problem-focused, offering space for support and experience sharing.

The patient's experience of the psychosocial process that influences identity following stroke rehabilitation: a metaethnography

BACKGROUND AND PURPOSE

Patient experience is increasingly being recognised as a key health outcome due to its positive correlation with quality of life and treatment compliance. The aim of this study was to create a model of how patient's experiences of rehabilitation after stroke influence their outcome.

METHODS

A metaethnography of qualitative articles published since 2000 was undertaken. A systematic search of four databases using the keywords was competed. Original studies were included if at least 50% of their data from results was focused on stroke survivors experiences and if they reflected an overarching experience of stroke rehabilitation. Relevant papers were appraised for quality using the COREQ tool. Pata analysis as undertaken using traditional processes of extracting, interpreting, translating, and synthesizing the included studies.

RESULTS

Thirteen studies were included. Two themes (1) evolution of identity and (2) psychosocial constructs that influence experience were identified. A model of recovery was generated.

CONCLUSION

The synthesis model conceptualizes how the recovery of stroke survivors' sense of identity changes during rehabilitation illustrating changes and evolution over time. Positive experiences are shaped by key psychosocial concepts such as hope, social support, and rely on good self-efficacy which is influenced by both clinical staff and external support.

Combining self-help and professional help to minimize barriers to physical activity in persons with multiple sclerosis: a trial of the "Blue Prescription" approach in New Zealand

BACKGROUND AND PURPOSE

Increasing participation in physical activity is a goal for many health care providers working with persons with disability. In order to reduce the physical and social barriers to participation, there is a need to develop approaches that integrate self-help with professional help for autonomous yet supported health promotion. This study reports on an innovative program, entitled the "Blue Prescription approach", in which physical therapists work collaboratively with persons with a disability to promote community-based physical activity participation.

METHODS

We trialed this collaborative approach with two physical therapists and 27 participants with multiple sclerosis (MS) over a three month period. We gathered qualitative data from four sources: (i) individual interviews with our participants, (ii) individual interviews with the physical therapists, (iii) clinical notes, and (iv) Advisory Group meeting notes. We then analyzed these data for categories to inform the content and resources required for delivery of the approach.

RESULTS

For most participants, the Blue Prescription approach facilitated regular engagement in the physical activity of their choice. The Advisory Group provided advice to help solve individual contexts that presented as challenges to participants. Based on review of interview transcripts, we identified four strategies or issues to inform the further development of Blue Prescription.

DISCUSSION AND CONCLUSIONS

Evidence indicated that the Blue Prescription approach can provide a collaborative and flexible way for physical therapists to work with individuals with MS, to increase participation in community-based physical activity. To further develop the approach, there is a need to address issues related to the use of standardized measures and develop strategies to train physical therapists in collaborative approaches for promotion of physical activity.The integration of self-help and professional help provided by the Blue Prescription approach appeared to result in successful promotion of physical activity in persons with MS. Additional testing is required to examine its efficacy in other health care systems, in conditions beyond MS, and in terms of its economic impact.Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A46) for more insights from the authors.

The provision of feedback through computer-based technology to promote self-managed post-stroke rehabilitation in the home

PURPOSE

Building on previous research findings, this article describes the development of the feedback interfaces for a Personalised Self-Managed Rehabilitation System (PSMrS) for home-based post-stroke rehabilitation using computer-based technology.

METHOD

Embedded within a realistic evaluative methodological approach, the development of the feedback interfaces for the PSMrS involved the incorporation of existing and emerging theories and a hybrid of health and social sciences research and user-centred design methods.

RESULTS

User testing confirmed that extrinsic feedback for home-based post-stroke rehabilitation through computer-based technology needs to be personalisable, accurate, rewarding and measurable. In addition, user testing also confirmed the feasibility of using specific components of the PSMrS.

CONCLUSIONS

A number of key elements are crucial for the development and potential utilisation of technology in what is an inevitable shift towards the use of innovative methods of delivering post-stroke rehabilitation. This includes the specific elements that are essential for the promotion of self-managed rehabilitation and rehabilitative behaviour change; the impact of the context on the mechanisms; and, importantly, the need for reliability and accuracy of the technology.

The daily living self-efficacy scale: a new measure for assessing self-efficacy in stroke survivors

PURPOSE

To develop and examine the psychometric properties of the Daily Living Self-Efficacy Scale (DLSES) designed to assess stroke survivors' self-efficacy in daily functioning.

METHOD

Two groups of participants (N = 424) were recruited, a stroke survivor group (n = 259) who were recruited through two stroke associations in Australia and a non-stroke group (n = 165) who were the partners/carers of the stroke survivors (n = 93) and members of the community in Queensland, Australia (n = 72). Principal Component Analyses (PCA) were used to assess the factor structure of the scale and investigations of internal consistency, test-retest reliability, convergent and discriminant validity were conducted.

RESULTS

The final measure is a 12-item scale comprising two subscales: self-efficacy for psychosocial functioning and self-efficacy for activities of daily living. The scale demonstrated high internal consistency, temporal stability and convergent validity, and it discriminated well between the stroke and non-stroke groups.

CONCLUSION

The DLSES is a psychometrically sound measure of self-efficacy in psychosocial functioning and self-efficacy in activities of daily living appropriate for stroke survivors, regardless of level of physical impairment. Implications for Rehabilitation A key factor that may influence outcome following a stroke is the level of self-efficacy that stroke survivors have in their ability to function in their daily life. The DLSES provides a measure of this ability that may be useful in enhancing preparation for the return to the community. The DLSES assesses self-efficacy in two important areas of daily functioning--activities of daily living and psychosocial functioning. This new measure can be administered to stroke individuals regardless of the nature or degree of physical impairment.