Stroke Survivors' Experiences of Physical Rehabilitation: A Systematic Review of Qualitative Studies

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Physiotherapists' decision-making about transition to independent walking in hospital after stroke: a qualitative study

PURPOSE

Physiotherapists working in hospitals have a key role in decisions about when a person with stroke is safe to walk independently. The aim of this study was to explore the factors influencing decision-making of physiotherapists in this situation.

METHODS

A qualitative design with semi-structured interviews and reflexive thematic analysis was used. Fifteen physiotherapists with recent experience working in inpatient stroke rehabilitation participated.

RESULTS

Multiple factors influence decision-making about walking independence after stroke in hospitals. Four themes were identified: (1) Assessment of walking safety involves observation of walking function and consideration of complex individual factors; (2) Perspectives on risk vary, and influence whether a person is considered safe to walk; (3) Institutional culture involves background pressures that may influence decision-making; and (4) Physiotherapists adopt a structured, individualised mobility progression to manage risk. Physiotherapists consistently use observation of walking and understanding of attention and perception in this decision-making. There can sometimes be a conflict between goals of independence and of risk avoidance, and decisions are made by personal judgements.

CONCLUSIONS

Decision-making about independent walking for people in a hospital after a stroke is complex. Improved guidance about clinical assessment of capacity and determining acceptable risk may enable physiotherapists to engage more in shared decision-making.IMPLICATIONS FOR REHABILITATIONRegaining independence in walking after a stroke comes with the potential risk of falls.Assessment of walking safety should be specific to the complexity of the situation and consider perception and cognition.Benefits of activity and autonomy, and the risk of falls need to be considered in decisions about walking independence.Patients with the capacity to understand consequences and accept risk can be active participants in determining what is sufficiently safe.

Co-design of a walking activity intervention for stroke survivors

Introduction

Stroke survivors may not maintain gains made in gait performance after task-oriented circuit training. Behavior change interventions may enhance the long-term adoption of physical activity. This study uses a co-design methodology to develop an intervention and tools to facilitate physical and exercise therapists in supporting an active lifestyle in stroke survivors, which is defined as a lifestyle that integrates daily walking performance with day-to-day activity.

Objectives

(1) To describe the insights generated during the co-design process; and (2) To describe the tools that were developed during the co-design process.

Methods

A multidisciplinary team consisting of staff members of the Royal Dutch Society for Physical Therapy, exercise and physical therapists specializing in neurorehabilitation and conducting task-oriented circuit class training in primary care settings or day therapy centers within residential care facilities, stroke survivors and their carers, experts in measuring movement behavior in stroke survivors, a company specializing in manufacturing sensors and related software, behavior change specialists, and co-designers all collaborated in a three-stage (define, develop, and deliver) co-design process.

Results

In the design process, the team iteratively developed a prototype accelerometer system for measuring walking performance with a feedback function for stroke survivors and their therapists and a prototype toolbox for therapists to support the facilitation of behavior change in their stroke survivors.

Discussion

This study shows how co-design can be applied to develop interventions for stroke survivors. Both the prototype system for measuring walking performance and the toolbox incorporate behavior change techniques to support a more physically active lifestyle in stroke survivors. Further research will investigate the feasibility of the intervention.

"Wasting time": a qualitative study of stroke survivors' experiences of boredom in non-therapy time during inpatient rehabilitation

PURPOSE

Stroke survivors regularly report experiencing boredom during inpatient rehabilitation which may detrimentally affect mood, learning and engagement in activities important for functional recovery. This study explores how stroke survivors meaningfully occupy their non-therapy time and their experiences of boredom, to further our understanding of this complex phenomenon.

METHODS

Secondary analysis of transcripts from semi-structured interviews with stroke survivors exploring activity during non-therapy time. Transcripts were coded and analysed using a hybrid approach of inductive and deductive thematic analysis, guided by a published boredom framework.

RESULTS

Analysis of 58 interviews of 36 males and 22 females, median age 70 years, revealed four main themes: (i) Resting during non-therapy time is valued, (ii) Managing "wasted" time, (iii) Meaningful environments support autonomy and restore a sense of normality, and (iv) Wired to be social. Whilst limited therapy, social opportunities and having "nothing to do" were common experiences, those individuals who felt in control and responsible for driving their own stroke recovery tended to report less boredom during their rehabilitation stay.

CONCLUSION

Creating rehabilitation environments that support autonomy, socialisation and opportunities to participate in activity are clear targets to reduce boredom during non-therapy time, increase meaningful engagement and possibly improve rehabilitation outcomes post-stroke.

The precarity of patient participation - a qualitative interview study of experiences from the acute stroke and rehabilitation journey

INTRODUCTION

Active patient participation is an important factor in optimizing post-stroke recovery, yet it is often low, regardless of stroke severity. The reasons behind this trend are unclear.

PURPOSE

To explore how people who have suffered a stroke, perceive the transition from independence to dependence and whether their role in post-stroke rehabilitation influences active participation.

METHODS

In-depth interviews with 17 people who have had a stroke. Data were analyzed using systematic text condensation informed by the concept of autonomy from enactive theory.

RESULTS

Two categories emerged. The first captures how the stroke and the resultant hospital admission produces a shift from being an autonomous subject to "an object on an assembly line." Protocol-based investigations, inactivity, and a lack of patient involvement predominantly determine the hospital context. The second category illuminates how people who have survived a stroke passively adapt to the hospital system, a behavior that stands in contrast to the participatory enablement facilitated by community. Patients feel more prepared for the transition home after in-patient rehabilitation rather than following direct discharge from hospital.

CONCLUSION

Bodily changes, the traditional patient role, and the hospital context collectively exacerbate a reduction of individual autonomy. Thus, an interactive partnership between people who survived a stroke and multidisciplinary professionals may strengthen autonomy and promote participation after a stroke.

The relationship between levels of physical activity and participation in everyday life in stroke survivors: A systematic review and meta-analysis

BACKGROUND

Stroke survivors demonstrate decreased physical activity (PA) and take time to return to participation in everyday life, but the relationship between the two variables is unknown.

OBJECTIVE

To investigate the correlation and trajectory over time between levels of PA and participation in everyday life in stroke survivors.

METHODS

PubMed, Web of Science, Scopus, SPORTDiscus, Rehabilitation&Sport Medicine Source, and PEDro databases were searched from inception to January 2024. Cross-sectional and prospective studies evaluating both levels of PA and participation in stroke survivors were included. Two reviewers independently conducted the study selection, data extraction, and quality assessment. Meta-analyses of pooled correlation coefficients were calculated when at least two studies reported a correlation coefficient between the same PA and participation outcomes.

RESULTS

Of 4962 studies identified, 49 were included in the systematic review. Studies were rated high (55%%) or fair (45%) quality. A wide range of monitoring methodologies for assessing PA and participation were found in the 23 prospective studies. Seven studies were included in the meta-analyses, showing a positive moderate correlation between PA time and participation in activities of daily living (n = 148; r = 0.52; P < 0.01; I2 = 81%) in participants <6 months post-stroke, and between PA time and the participation in all areas (n = 126; r = 0.44; P < 0.01; I2 = 0%) in participants ≥6 months post-stroke. Overall, while PA showed significant improvements over time, participation only showed a tendency.

CONCLUSIONS

Despite the heterogeneity, consistent positive associations were found between PA time and participation levels in some areas. Establishing consensus is crucial to reduce heterogeneity and facilitate data pooling.

Nature-Based Design in Stroke Rehabilitation Environments: A Scoping Review

OBJECTIVE

To identify, examine, and map the characteristics of knowledge of nature-based design in stroke rehabilitation facilities, examine how research in this field has been conducted and identify gaps in knowledge.

BACKGROUND

Many stroke survivors have wide ranging impacts, resulting in long hospital stays to undertake rehabilitation. The physical environment can influence brain recovery; however, there is limited evidence to support the design of effective rehabilitation environments. Conversely, the health benefits available from connection with nature are well established. A nature-based design approach may have benefits and implications for the physical environment of inpatient stroke rehabilitation facilities; however, it is unclear what evidence exists in this field.

METHOD

This scoping review followed the JBI methodological guidance for the conduct of scoping reviews, with systematic searches of six databases.

RESULTS

Twenty-eight studies were included in the review. Aims and research methods varied widely. Investigations in 19 studies related to gardens and other designed outdoor nature-based environments. Other studies explored natural analogues, nature inside, inside/outside connections, and the natural environment. Findings from the studies were spread across the fields of design, use, exposure to, and engagement in nature-based environments.

CONCLUSION

The characteristics of knowledge underpinning nature-based design in stroke rehabilitation environments are highly diverse, and significant gaps exist in the evidence base. A framework developed during this review for mapping knowledge on the intentions and impacts for spaces and services in this field assisted to identify these gaps and may be applied to other areas of healthcare design research.

Effects of trunk exercises using virtual reality technology on trunk performance and impairment post stroke: a systematic review and meta-analysis

OBJECTIVE

To systematically explore the effects of trunk exercises using virtual reality technology compared to conventional exercises for trunk impairment in patients with subacute and chronic strokes.

METHODS

A comprehensive search of literature published from inception until December 2022 was conducted using PubMed, Cochrane Library, Web of Science, Scopus, IEEE, and the Physiotherapy Evidence Database (PEDro). The inclusion criteria encompassed all randomized controlled trials (RCT) published in the English language involving adults who had had strokes and the evaluation of the effectiveness of virtual reality -based trunk exercises in reducing trunk impairment post stroke as measured by the trunk control test (TCT) and/or the trunk impairment scale (TIS) compared to conventional trunk exercises.

RESULT

A total of 397 studies were retrieved, and six studies were included in the current analysis. A random-effects meta-analysis of six studies indicated that video games had a very large, significant effect (SMD = 1.11; 95%, P < 0.0001) on the delivery of trunk exercises to reduce trunk impairment post stroke at both the subacute and chronic stages.

CONCLUSION

The study findings indicate that trunk exercises using virtual reality have a highly significant effect on reducing trunk impairment in patients with subacute and chronic stroke. Large RCTs are needed to study the effects of virtual reality trunk exercises on the acute, subacute, and chronic stages of stroke.

'Physical well-being is our top priority': Healthcare professionals' challenges in supporting psychosocial well-being in stroke services

BACKGROUND

Following stroke, a sense of well-being is critical for quality of life. However, people living with stroke, and health professionals, suggest that well-being is not sufficiently addressed within stroke services, contributing to persistent unmet needs. Knowing that systems and structures shape clinical practice, this study sought to understand how health professionals address well-being, and to examine how the practice context influences care practice.

METHODS

Underpinned by Interpretive Description methodology, we interviewed 28 health professionals across multiple disciplines working in stroke services (acute and rehabilitation) throughout New Zealand. Data were analysed using applied tension analysis.

RESULTS

Health professionals are managing multiple lines of work in stroke care: biomedical work of investigation, intervention and prevention; clinical work of assessment, monitoring and treatment; and moving people through service. While participants reported working to support well-being, this could be deprioritised amidst the time-oriented pressures of the other lines of work that were privileged within services, rendering it unsupported and invisible.

CONCLUSION

Stroke care is shaped by biomedical and organisational imperatives that privilege physical recovery and patient throughput. Health professionals are not provided with the knowledge, skills, time or culture of care that enable them to privilege well-being within their work. This has implications for the well-being of people with stroke, and the well-being of health professionals. In making these discourses and culture visible, and tracing how these impact on clinical practice, we hope to provide insight into why well-being work remains other to the 'core' work of stroke, and what needs to be considered if stroke services are to better support people's well-being.

PATIENT OR PUBLIC CONTRIBUTIONS

People with stroke, family members and people who provide support to people with stroke, and health professionals set priorities for this research. They advised on study conduct and have provided feedback on wider findings from the research.

Environmental Enrichment in Stroke Research: an Update

Environmental enrichment (EE) refers to different forms of stimulation, where the environment is designed to improve the levels of sensory, cognitive, and motor stimuli, inducing stroke recovery in animal models. Stroke is a leading cause of mortality and neurological disability among older adults, hence the importance of developing strategies to improve recovery for such patients. This review provides an update on recent findings, compiling information regarding the parameters affected by EE exposure in both preclinical and clinical studies. During stroke recovery, EE exposure has been shown to improve both the cognitive and locomotor aspects, inducing important neuroplastic alterations, increased angiogenesis and neurogenesis, and modified gene expression, among other effects. There is a need for further research in this field, particularly in those aspects where the evidence is inconclusive. Moreover, it is necessary refine and adapt the EE paradigms for application in human patients.

Older adults' lived experiences of physical rehabilitation for acquired brain injury and their perceptions of well-being: A qualitative phenomenological study

AIM

To explore the experiences of older adults (65+) living with acquired brain injury regarding their sense of well-being during physical rehabilitation within the Greek Healthcare System.

BACKGROUND

With the increasing ageing population and the life-changing effects of acquired brain injury, there is a need to focus on care for older people and their potential to live well. Rehabilitation systems deserve greater attention, especially in improving the well-being of those who are using them.

DESIGN

A qualitative study design with a hermeneutic phenomenological approach was used.

METHODS

Fourteen older adults living with acquired brain injury and undergoing physical rehabilitation in Greece were purposively sampled. Semi-structured interviews were conducted to collect data and were thematically analysed using van Manen's and Clarke and Braun's methods. The COREQ checklist was followed.

RESULTS

Four themes emerged from the analysis: (1) Challenges of new life situation, (2) Seeking emotional and practical support through social interaction, (3) Identifying contextual processes of rehabilitation, (4) Realising the new self.

CONCLUSIONS

The subjective experiences, intersubjective relations and contextual conditions influence the sense of well-being among older adults living with acquired brain injury, thus impacting the realisation of their new self. The study makes the notion of well-being a more tangible concept by relating it to the degree of adaptation to the new situation and the potential for older adults to create a future whilst living with acquired brain injury.

RELEVANCE FOR CLINICAL PRACTICE

Identifying the factors that impact older adults' sense of well-being during rehabilitation can guide healthcare professionals in enhancing the quality of care offered and providing more dignified and humanising care.

PATIENT OR PUBLIC CONTRIBUTION

Older adults living with acquired brain injury were involved in the study as participants providing the research data.

Effort-based decision making and motivational deficits in stroke patients

Motivational deficits in patients recovering from stroke are common and can reduce active participation in rehabilitation and thereby impede functional recovery. We investigated whether stroke patients with clinically reduced drive, initiation, and endurance during functional rehabilitative training (n = 30) display systematic alterations in effort-based decision making compared to age, sex, and severity-matched stroke patients (n = 30) whose drive appeared unaffected. Notably, the two groups did not differ in self-reported ratings of apathy and depression. However, on an effort-based decision-making task, stroke patients with clinically apparent drive impairment showed intact willingness to accept effort for reward, but were more likely to fail to execute the required effort compared to patients without apparent drive impairments. In other words, the decision behavioural assessment revealed that stroke patients that displayed reduced drive, initiation, and endurance during inpatient neurorehabilitation failed to persist in goal-directed effort production, even over very short periods. These findings indicate that reduced drive during rehabilitative therapy in post-stroke patients is not due to a diminished motivation to invest physical effort, but instead is related to a reduced persistence with effortful behaviour.

Implementing ward-based practice books to increase the amount of practice completed during inpatient stroke rehabilitation: a mixed-methods process evaluation

PURPOSE

Stroke survivors must complete large amounts of practice to achieve functional improvements but spend many hours inactive during their rehabilitation. We conducted a mixed methods process evaluation exploring factors affecting the success of a 6-month behaviour change intervention to increase use of ward-based practice books.

METHODS

Audits of the presence, quality and use of ward based-practice books were conducted, alongside focus groups with staff (n = 19), and interviews with stroke survivors (n = 3) and family members (n = 4). Quantitative data were analysed descriptively. Focus group and interview transcripts were analysed using qualitative analysis.

RESULTS

Personal (patient-related) factors (including severe weakness, cognitive and communication deficits of stroke survivors), staff coaching skills, understanding and beliefs about their role, affected practice book use. Staff turnover, nursing shift work and a lack of action planning reduced success of the behaviour change intervention.

CONCLUSIONS

Staff with the necessary skills and understanding of their role in implementing ward practice overcame personal (patient-related) factors and assisted stroke survivors to successfully practice on the ward. To improve success of the intervention, repeated training of new staff is required. In addition to audit and feedback, team action planning is needed around the presence, quality, and use of ward practice books.

Exercise preference in stroke survivors: a concept analysis

Background

Exercise preference in stroke survivors is related to their adherence to long-term rehabilitation regimen and functional recovery. Although explored recently, the term exercise preference still lacks a clear definition.

Objective

The aim of this study is to conceptualize exercise preference in stroke survivors.

Methods

The Walker and Avant method was applied as a framework for the conceptual analysis of exercise preference. Data from 34 publications were collected using seven databases (PubMed, Web of Science, Embase, CINAHL, CNKI, Wanfang Data, and CBM) and applied in the analysis. The search period was from the inception of the database to April 30, 2023.

Results

Exercise preference in stroke survivors was defined according to four attributes: priority of choice, behavioral tendency, affective priming, and patience in adherence. The common antecedents of the concept of exercise preference in stroke survivors were classified into patient-related, therapy-related, and environmental-related categories and the consequences were classified into three categories: patient-related, rehabilitation provider-related, and rehabilitation service system-related.

Conclusion

Exercise preference in stroke survivors refers to the patient's choice, tendency, affective response, and attitude toward engagement in the recommended rehabilitation regimen. It is beneficial for understanding the essential attributes of exercise preference in stroke survivors by clarifying the concept. In addition, it will facilitate the development of instruments for assessing exercise preference in stroke survivors and the construction of theory-based intervention programs that can improve adherence to exercise rehabilitation.

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

OBJECTIVE

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

DATA SOURCES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The influence of communal spaces on patient activity in rehabilitation: a mixed methods study

PURPOSE

This study aimed to determine whether patients are more active in communal spaces compared to their bedrooms and explore patient perspectives on communal spaces for activity, rest, and wellbeing.

MATERIALS AND METHODS

A prospective study observed participants via behavioural mapping in a mixed inpatient rehabilitation unit for up to three days. Physical, social, and cognitive activity levels in communal spaces were compared with activity in bedrooms using independent t-tests. Three focus groups explored participants' perspectives on communal spaces for activity, rest and wellbeing using thematic analysis.

RESULTS

Thirty-three participants (age 71.6 ± 13years, 39%male) were observed, and a subset (n = 12) (age 67.3 ± 16.9, 50%male) participated in focus groups. Participants spent a greater proportion of time being physically active (mean difference 22.7%, 95%CI 8.7-36.6, p = 0.002) and socially active (mean difference 23.6%, 95%CI 9.1-38.1, p = 0.002) in communal spaces than bedrooms. No difference in cognitive activity was found. Participants perceived communal spaces to positively influence mood and activity. Reduced independence was a barrier, while visitors, activities, and an inviting design attracted people to communal areas.

CONCLUSION

Communal spaces may positively influence patient activity and mood during inpatient rehabilitation. Future studies should seek strategies to optimise engagement in communal environments.IMPLICATIONS FOR REHABILITATIONOptimising patient activity throughout the day in inpatient rehabilitation is important to support recovery.Communal spaces in inpatient rehabilitation hospitals can positively influence patient activity and mood.Strategies to promote use of communal spaces in the inpatient rehabilitation hospital are needed.

Environmental Enrichment for Stroke and Traumatic Brain Injury: Mechanisms and Translational Implications

Acquired brain injuries, such as ischemic stroke, intracerebral hemorrhage (ICH), and traumatic brain injury (TBI), can cause severe neurologic damage and even death. Unfortunately, currently, there are no effective and safe treatments to reduce the high disability and mortality rates associated with these brain injuries. However, environmental enrichment (EE) is an emerging approach to treating and rehabilitating acquired brain injuries by promoting motor, sensory, and social stimulation. Multiple preclinical studies have shown that EE benefits functional recovery, including improved motor and cognitive function and psychological benefits mediated by complex protective signaling pathways. This article provides an overview of the enriched environment protocols used in animal models of ischemic stroke, ICH, and TBI, as well as relevant clinical studies, with a particular focus on ischemic stroke. Additionally, we explored studies of animals with stroke and TBI exposed to EE alone or in combination with multiple drugs and other rehabilitation modalities. Finally, we discuss the potential clinical applications of EE in future brain rehabilitation therapy and the molecular and cellular changes caused by EE in rodents with stroke or TBI. This article aims to advance preclinical and clinical research on EE rehabilitation therapy for acquired brain injury. © 2024 American Physiological Society. Compr Physiol 14:5291-5323, 2024.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Innovation

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

A Brain Computer Interface Neuromodulatory Device for Stroke Rehabilitation: Iterative User-Centered Design Approach

BACKGROUND

Rehabilitation technologies for people with stroke are rapidly evolving. These technologies have the potential to support higher volumes of rehabilitation to improve outcomes for people with stroke. Despite growing evidence of their efficacy, there is a lack of uptake and sustained use in stroke rehabilitation and a call for user-centered design approaches during technology design and development. This study focuses on a novel rehabilitation technology called exciteBCI, a complex neuromodulatory wearable technology in the prototype stage that augments locomotor rehabilitation for people with stroke. The exciteBCI consists of a brain computer interface, a muscle electrical stimulator, and a mobile app.

OBJECTIVE

This study presents the evaluation phase of an iterative user-centered design approach supported by a qualitative descriptive methodology that sought to (1) explore users' perspectives and experiences of exciteBCI and how well it fits with rehabilitation, and (2) facilitate modifications to exciteBCI design features.

METHODS

The iterative usability evaluation of exciteBCI was conducted in 2 phases. Phase 1 consisted of 3 sprint cycles consisting of single usability sessions with people with stroke (n=4) and physiotherapists (n=4). During their interactions with exciteBCI, participants used a "think-aloud" approach, followed by a semistructured interview. At the end of each sprint cycle, device requirements were gathered and the device was modified in preparation for the next cycle. Phase 2 focused on a "near-live" approach in which 2 people with stroke and 1 physiotherapist participated in a 3-week program of rehabilitation augmented by exciteBCI (n=3). Participants completed a semistructured interview at the end of the program. Data were analyzed from both phases using conventional content analysis.

RESULTS

Overall, participants perceived and experienced exciteBCI positively, while providing guidance for iterative changes. Five interrelated themes were identified from the data: (1) "This is rehab" illustrated that participants viewed exciteBCI as having a good fit with rehabilitation practice; (2) "Getting the most out of rehab" highlighted that exciteBCI was perceived as a means to enhance rehabilitation through increased engagement and challenge; (3) "It is a tool not a therapist," revealed views that the technology could either enhance or disrupt the therapeutic relationship; and (4) "Weighing up the benefits versus the burden" and (5) "Don't make me look different" emphasized important design considerations related to device set-up, use, and social acceptability.

CONCLUSIONS

This study offers several important findings that can inform the design and implementation of rehabilitation technologies. These include (1) the design of rehabilitation technology should support the therapeutic relationship between the patient and therapist, (2) social acceptability is a design priority in rehabilitation technology but its importance varies depending on the use context, and (3) there is value in using design research methods that support understanding usability in the context of sustained use.

Correlation between kinetic and kinematic measures, clinical tests and subjective self-evaluation questionnaires of the affected upper limb in people after stroke

Introduction

Assessment of stroke recovery should include multiple sources of information in order to obtain a complete understanding of the individual's rehabilitation progress. Self-evaluation questionnaires' scores do not always correspond to the scores of commonly used clinical evaluation tools. The purpose of this study was to assess the relationship between self-evaluation questionnaires, clinical tests, and kinematic and kinetic analyses of the affected upper limb after stroke, and to determine the correlation between these measures and self-reported general function 2-4 years after the stroke.

Methods

Twenty-six subjects recovering from stroke were included in the study. Spearman's correlation coefficient was used to measure the correlation between Stroke Impact Scale (SIS), Motor activity Log (MAL), Fugl-Meyer Assessment (FMA) and Action Reach Arm Test (ARAT) scores, and kinematic and kinetic analyses. A logistic regression was used to assess the extent to which these measures may predict the participants' functional self-reported status 2-4 years post stroke.

Results

Sections regarding hand function, hand force and general ADL of the self-evaluation questionnaires correlated with kinematic variables. However, only questionnaires that focus on hand function correlated with clinical tests. Mean and maximal hand velocity had the strongest correlations with self-evaluation questionnaires and with the clinical tests, more than other kinematic variables. Self-evaluation questionnaires and clinical tests were found to be correlated with hand kinetic metrics force-to-time ratio and number of force peaks. SIS hand force domain, mean velocity and maximal velocity predicted self-reported general function 2-4 years after the stroke.

Conclusion

Self-evaluation questionnaires should be considered for wider use in the clinical evaluation of a patient's stroke recovery, since they add important information on the individual's functional status, which is not reflected in the clinical tests.

Use of Gamification for Adult Physical Rehabilitation in Occupational Therapy; A Novel Concept?

AIM

This commentary discusses the concept of 'gamification' as referred to implicitly or explicitly in the occupational therapy literature. Although occasionally noted to be a new frontier for occupational therapy, our analysis suggests that game mechanics and gamification elements are, in fact, a 'road long traveled' by occupational therapists and that gamification evokes the core aims and vision of occupational therapy. Gamification has been implicitly incorporated into the occupational therapy literature for years, and its benefit of enhancing therapeutic outcomes is evident in many instances. We contend that a more explicit use of the term gamification within the occupational therapy literature will lead to a framework in which both practitioners and researchers can structure and evaluate therapeutic outcomes.

Codesigning implementation strategies to improve evidence-based stroke rehabilitation: A feasibility study

INTRODUCTION

People with lived experience are rarely involved in implementation science research. This study was designed to assess the feasibility of codesigning and delivering implementation strategies with people with lived experience of stroke and health professionals to improve evidence-based stroke rehabilitation.

METHODS

We used Experience-Based CoDesign to design and deliver strategies to implement Stroke Clinical Guideline recommendations at one Australian inpatient stroke rehabilitation unit. Workgroups were formed with health professionals and people with 6-12 months experience of living with stroke (survivors and carers). Feasibility of the codesign approach (focusing on acceptability, implementation fidelity, signal of promise) was evaluated using mixed methods, using data from interviews, observations and inpatient self-reported outcomes.

RESULTS

Of 18 people with stroke invited, eight (44%) agreed to join the lived experience workgroup. All disciplines with ≥1 full-time staff members on the stroke unit were represented on the health professional workgroup. Median workgroup attendance over 6 months was n = 8 health professionals, n = 4 survivors of stroke and n = 1 carers. Workgroup members agreed to focus on two Guideline recommendations: information provision and amount of therapy. Workgroup members indicated that the codesign approach was enjoyable and facilitated effective partnerships between health professionals and lived experience workgroup members. Both cohorts reported contributing valuable input to all stages of the project, with responsibility shifting between groups at different project stages. The codesigned strategies signalled promise for improving aspects of information provision and creating additional opportunities for therapy. We could not compare patient-reported outcomes before and after the implementation period due to high variability between the preimplementation and postimplementation patient cohorts.

CONCLUSION

It is feasible to codesign implementation strategies in inpatient rehabilitation with people with lived experience of stroke and health professionals. More research is required to determine the effect of the codesigned strategies on patient and service outcomes.

PATIENT OR PUBLIC CONTRIBUTION

People with lived experience of stroke codesigned and evaluated implementation strategies. Author F. C. has lived experience of stroke and being an inpatient at the inpatient rehabilitation service, and has provided input into analysis of the findings and preparation of this manuscript.

Acquired brain injury (ABI) survivors' experience of occupation and activity during their inpatient stay: a scoping review

PURPOSE

This review aimed to characterise and map: (1) what type of evidence and what dominant study characteristics are available regarding acquired brain injury (ABI) survivors' experience of occupation and activity in hospital? (2) How are occupation and activity conceptualised in the literature? (3) How are ABI survivors experiencing occupation and activity while in hospital? (4) What factors create barriers or opportunities for engagement in occupations or activity in hospital? (5) Are there any knowledge gaps identified?

MATERIALS AND METHODS

A scoping review was conducted examining literature published between 2017 and 2022. Relevant studies were systematically retrieved from electronic databases.

RESULTS

Thirty-four publications were included. There were more quantitative studies (n = 18). Much of the research has been conducted outside of the UK. The populations studied were principally stroke (n = 22). The concept of activity rather than occupation predominates. Patients spend their time alone and inactive. Structural and contextual barriers for engaging in activity are identified. Qualitative study designs exclude ABI survivors with communication or cognitive impairment.

CONCLUSIONS

There is a paucity of research with ABI survivors in hospitals in the UK. Alternative methodological approaches such as ethnography would ensure those with communication or cognitive impairment are not excluded from research. Implications for rehabilitationRehabilitation professionals, especially occupational therapists, need to lead acquired brain injury (ABI) research in acute hospital settings in the UK.Conceptualisation of meaningful activity and occupation needs a clearer focus in ABI research.Qualitative studies frequently exclude participants with cognitive or communication impairments so methodologies that are more inclusive and representative of brain injury survivors are needed.

Stroke Inpatient Rehabilitation Environments: Aligning Building Construction and Clinical Practice Guidelines Through Care Process Mapping

BACKGROUND

Stroke inpatient rehabilitation is a complex process involving stroke survivors, staff, and family utilizing a common space for a shared purpose: to optimize recovery. This complex pathway is rarely fully described. Stroke care is ideally guided by Clinical Practice Guidelines, and the rehabilitation built environment should serve to optimize care delivery, patient and staff experience. We aimed to articulate the inpatient stroke rehabilitation process of care in a series of process maps, and to understand the degree to which current stroke clinical and building construction (ie, design) guidelines align to support inpatient stroke rehabilitation.

METHODS

We used the Value-Focused Process Engineering methodology to create maps describing the events and activities that typically occur in the current stroke inpatient rehabilitation service model. These maps were completed through individual and group session consultations with stroke survivors, architects, policy makers, and clinical experts. We then determined which sections of the Australian Stroke Rehabilitation Guidelines and the Australasian Health Facility Design Guidelines could be aligned and applied to the process maps.

RESULTS

We present a summary process map for stroke inpatient rehabilitation, alongside detailed process maps for 4 different phases of rehabilitation (admission, a normal weekday, a weekend day, and discharge) using Value-Focused Process Engineering notation. The integration of design and clinical guidelines with care pathway maps revealed where guidelines lack detail to be readily linked to current stroke inpatient care practice, providing an opportunity to design stroke inpatient rehabilitation spaces based on the activities occurring within them.

CONCLUSIONS

Our findings highlight gaps where clinical and design experts should work together to use guidelines to their full potential; and to improve the process of planning for future stroke rehabilitation units.

Users' experiences of intensive robotic-assisted gait training post-stroke - "a push forward or feeling pushed around?"

PURPOSE

Robotic-assisted gait training (RAGT) is suggested to improve walking ability after stroke. The purpose of this study was to describe experiences of robotic-assisted gait training as part of a gait training intervention among persons in the chronic phase after stroke.

MATERIALS AND METHODS

Semi-structured interviews were performed with 13 participants after a 6-week intervention including treadmill gait training with the Hybrid Assistive Limb® (HAL) exoskeleton. Data were analysed using qualitative content analysis.

RESULTS

Four categories emerged: (1) A rare opportunity for potential improvements describes the mindset before the start of the intervention; (2) Being pushed to the limit represents the experience of engaging in intensive gait training; (3) Walking with both resistance and constraints reveals barriers and facilitators during HAL training; (4) Reaching the end and taking the next step alone illustrates feelings of confidence or concern as the intervention ended.

CONCLUSIONS

The gait training intervention including RAGT was considered demanding but appreciated. Support and concrete, individual feedback was crucial for motivation, whilst the lack of variation was a barrier. Results encourage further development of exoskeletons that are comfortable to wear and stimulate active participation by enabling smoothly synchronised movements performed during task-specific activities in different environments. IMPLICATIONS FOR REHABILITATIONWhen provided in a suitable context, the mental and physical challenges of intensive robotic-assisted gait training can be both inspiring and motivating.Support and engagement along with informative feedback from therapists are suggested crucial for motivation.Intensive task-specific gait training may preferably be performed in an enriched environment and combined with other physiotherapy treatments to stimulate engagement.

Important findings of a technology-assisted in-home music-based intervention for individuals with stroke: a small feasibility study

PURPOSE

To examine the feasibility of stroke survivors receiving music-based rehabilitation via a mobile app.

MATERIALS AND METHODS

We recruited ten chronic stroke survivors who were community-dwelling with mild-moderate upper extremity (UE) paresis. Participants were encouraged to exercise their paretic UE with a commercial instrument training app, Yousician, with a piano keyboard at home for three weeks. The feasibility of the training was measured by: (a) the acceptance of using the app to receive in-home piano training (e.g., daily usage time, exit interview) and (b) the effects of the app functionality as a rehabilitation tool (e.g., participants' motor improvements after training).

RESULTS

Our small sample size of participants demonstrated general positive feedback and self-motivation (e.g., interest in extended training time) about using a mobile app to receive in-home, music-based UE training. Participants showed no trend of declined usage and practiced on average ∼33 min per day for 4-5 days per week during the 3-week participation. We also observed positive results in the Fugl-Meyer Assessment, Action Research Arm Test, and Nine Hole Peg Test after training.

CONCLUSIONS

This study provided insight into the feasibility of delivering music-based interventions through mobile health (mHealth) technology for stroke populations. Although this was a small sample size, participants' positive and negative comments and feedback provided useful information for future rehab app development. We suggest four ways to further improve and design a patient-oriented app to facilitate the use of a mHealth app to deliver in-home music-based interventions for stroke survivors.

In defence of falling: the onomastics and ethics of "therapeutic" falls in rehabilitation

Aim: Despite efforts towards a more just culture, rehabilitation providers still experience shame and trauma when their patients fall. This paper proposes a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls in rehab are not seen as something to be avoided at all costs, but rather as part of the recovery journey for some patients.Methods: Patients who understand and are willing to take on the risks of falling are more likely to collaborate with their care team to practice higher-risk activities, such as walking to the bathroom independently at night, as part of their recovery. If a fall takes place in this context, we argue that it should be considered a "therapeutic" fall.Results: This paper details some of the clinical and ethical approaches to supporting a care environment where values-and potential conflicts-about the benefits and challenges of risk-taking are recognized. An expanded concept of a therapeutic fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Conclusion: The goal of this work is to offer rehabilitation patients greater opportunities to make autonomous decisions about their mobility, and lay the groundwork for a more successful transition home.IMPLICATIONS FOR REHABILITATIONDespite best efforts, patients are often less active than they or their rehabilitation team might wish them to be.An expanded concept of a "therapeutic" fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Rehabilitation is the right environment to support shared decision-making about risk that better prepares patients and families for the often challenging transition back to community living.This works represents a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls are not something to be avoided at all costs, but can instead be part of the journey to recovery.

Perspectives of health professionals on physical activity and sedentary behaviour in hospitalised adults: A systematic review and thematic synthesis

OBJECTIVE

To explore health professionals' perspectives on physical activity and sedentary behaviour of hospitalised adults to understand factors that contribute to these behaviours in this environment.

DATA SOURCES

Five databases (PubMed, MEDLINE, Embase, PsycINFO and CINAHL) were searched in March 2023.

REVIEW METHODS

Thematic synthesis. Included studies explored perspectives of health professionals on the physical activity and/or sedentary behaviour of hospitalised adults using qualitative methods. Study eligibility was assessed independently by two reviewers and results thematically analysed. Quality was assessed using the McMaster Critical Review Form and confidence in findings assessed using GRADE-CERQual.

RESULTS

Findings from 40 studies explored perspectives of over 1408 health professionals from 12 health disciplines. The central theme identified was that physical activity is not a priority in this setting due to the complex interplay of multilevel influences present in the interdisciplinary inpatient landscape. Subthemes, the hospital is a place for rest, there are not enough resources to make movement a priority, everyone's job is no one's job and policy and leadership drives priorities, supported the central theme. Quality of included studies was variable; critical appraisal scores ranged from 36% to 95% on a modified scoring system. Confidence in findings was moderate to high.

CONCLUSION

Physical activity in the inpatient setting is not a priority, even in rehabilitation units where optimising function is the key. A shift in focus towards functional recovery and returning home may promote a positive movement culture that is supported by appropriate resources, leadership, policy, and the interdisciplinary team.

Stroke survivors' perspectives on decision-making about rehabilitation and the prospect of taking recovery-promoting drugs: A qualitative study

Objectives

To investigate factors which influence stroke survivors' decision-making about their rehabilitation and the prospect of taking recovery-promoting drugs, to enhance their recovery.

Methods

Seventeen stroke survivors who had undertaken stroke rehabilitation, and three spouses, participated in focus groups and individual interviews in northern Queensland, Australia. Inductive thematic analysis of the interview data was conducted in accordance with Braun and Clarke's six-phase process.

Results

Two specific, pivotal decision points during participants' stroke recovery process were identified: 1) overall, when deciding what rehabilitation they would undertake and hypothetically what recovery-promoting drugs they would take, and 2) on a daily basis, when deciding whether to participate in rehabilitation and take recovery-promoting drugs on any given day. Six themes which described factors influencing their decision-making were: 'My options for rehabilitation and recovery-promoting drugs'; 'The costs of rehabilitation and recovery-promoting drugs'; 'My recovery goals'; 'What I can deal with today'; 'The people my rehabilitation and recovery-promoting drugs affect'; and 'Fitting rehabilitation and recovery-promoting drugs into my life.' These themes were applicable at either one or both of the identified decision points.

Conclusion

Factors that influence stroke survivors' decision-making, overall and on a day-to-day basis, need to be considered to ensure they can make the best decisions for themselves to achieve their full recovery potential. Understanding the conditions under which a stroke survivor would take a recovery-promoting drug will contribute to the development of dosing protocols to which stroke survivors could adhere.

Stroke Survivor's Satisfaction and Experience with Rehabilitation Services: A Qualitative Systematic Review

Research in healthcare is increasingly focused on quality assurance and continuous quality improvement aiming to promote service quality. Satisfaction is a key endpoint in outcomes research and service benchmarking, along with "traditional" clinical outcomes. What controls stroke survivors' satisfaction differs among qualitative studies' conclusions, but there is general consensus on the importance of communication, improvement in activity, and engagement in goal setting. This review aims to collect and synthesise studies of the satisfaction of stroke survivors with rehabilitation services. A systematic search was conducted in seven electronic databases, including CINAHL, OVID, Pedro, Scopus Midline, Web of Science, and PubMed. The database search yielded 1339 studies, while one additional work was identified through hand searching. After removing duplicates, 74 studies were read in full, and after resultant exclusions, 12 qualitative studies were systematically reviewed, extracted, and appraised by two reviewers independently (HAS and RT) and the third reviewer (CS) was available for any disagreement. Five analytical themes were identified: Healthcare Professional-Patient Relationship (HCP), Delivery Service, Perceived Patient Autonomy (PPA), Expectations Shape Satisfaction, and Culture Influences Satisfaction. The studies of survivors' satisfaction, experiences, and their rehabilitative needs with the services they receive have provided different factors that influence their satisfaction during rehabilitation in different countries worldwide. However, the context in which the studies were conducted is quite limited, and more detailed studies are required for many underexplored contexts.

The role of the physical environment in stroke recovery: Evidence-based design principles from a mixed-methods multiple case study

Hospital design can impact patient outcomes, but there is very little healthcare design evidence specific to stroke rehabilitation facilities. Our aim was to explore, from the patient perspective, the role of the physical environment in factors crucial to stroke recovery, namely, stroke survivor activity (physical, cognitive, social), sleep, emotional well-being, and safety. We conducted a mixed-methods multiple-case study at two inpatient rehabilitation facilities in Victoria, Australia, (n = 20 at Case 1, n = 16 at Case 2) using "walk-through" semi-structured interviews, behavioural mapping, questionnaires, and retrospective audit. Four interrelated themes emerged: 1) entrapment and escape; 2) power, dependency, and identity in an institutional environment; 3) the rehabilitation facility is a shared space; and 4) the environment should be legible and patient-centred. Quantitative data revealed patterns in patient activity; stroke survivors spent over 75% of their time in bedrooms and were often inactive. Convergent mixed methods analysis was used to generate a new conceptual model of the role of the physical environment in stroke survivors' behaviour and well-being, highlighting the importance of variety and interest, privacy without isolation, and patient-centred design. This model can be used by designers, healthcare providers, and policy makers to inform the design of rehabilitation environments.

A multicenter explanatory survey of patients' and clinicians' perceptions of motivational factors in rehabilitation

BACKGROUND

Patient motivation is an important determinant of rehabilitation outcomes. Differences in patients' and clinicians' perceptions of motivational factors can potentially hinder patient-centered care. Therefore, we aimed to compare patients' and clinicians' perceptions of the most important factors in motivating patients for rehabilitation.

METHODS

This multicenter explanatory survey research was conducted from January to March 2022. In 13 hospitals with an intensive inpatient rehabilitation ward, 479 patients with neurological or orthopedic disorders undergoing inpatient rehabilitation and 401 clinicians, including physicians, physical therapists, occupational therapists, and speech-language-hearing therapists, were purposively selected using inclusion criteria. The participants were asked to choose the most important factor motivating patients for rehabilitation from a list of potential motivational factors.

RESULTS

Here we show that realization of recovery, goal setting, and practice related to the patient's experience and lifestyle are the three factors most frequently selected as most important by patients and clinicians. Only five factors are rated as most important by 5% of clinicians, whereas nine factors are selected by 5% of patients. Of these nine motivational factors, medical information (p < 0.001; phi = -0.14; 95% confidence interval = -0.20 to -0.07) and control of task difficulty (p = 0.011; phi = -0.09; 95% confidence interval = -0.16 to -0.02) are selected by a significantly higher proportion of patients than clinicians.

CONCLUSIONS

These results suggest that when determining motivational strategies, rehabilitation clinicians should consider individual patient preferences in addition to using the core motivational factors supported by both parties.

Overcoming the monster! Perceptions of physiotherapy students regarding the use of stroke master plots for building therapeutic relationships; a vignette study

BACKGROUND

Narrative master plots identify illness stories which are recognisable within clinical settings. Responses to different master plots by physiotherapy students can lack empathy and need to be understood further. One narrative master plot for people with stroke that has not been well studied is called 'overcoming the monster'. Research is needed to understand physiotherapy students' reactions to this master plot.

OBJECTIVE

To examine the responses of physiotherapy students to three variations of the master plot called 'overcoming the monster' generated from patients who have had a stroke.

METHODS

A qualitative narrative vignette study was undertaken. A university in the West Midlands (England) was used to access physiotherapy students on the pre-registration programs. A purposive sample of students volunteered to complete a single vignette questionnaire at one time point. The vignette provided three unique examples of the master plot overcoming the monster as told by people with stroke. Students responded to each by asking specific questions that captured demographic information and questions that captured reactions to the different versions of the master plot. Categorical-content narrative analysis was undertaken.

RESULTS

Thirty-two first year (BSc) students, thirty-nine first year (pre-registration) MSc students and nineteen third year (BSc) students participated in this study. Neither first year groups had undertaken any clinical placement hours. All third-year students had finished the required clinical placement hours for the physiotherapy course. Students consistently demonstrated empathy towards this master plot. Students often valued the variant of the story which illustrated how difficulties following stroke could be experienced as an 'adventure'. Students also valued and were motivated by the story variant that considered a family member as a source of motivation and encouragement. The story variant which focused on the shortcomings of the health care system was more often related to by the final year BSc students and MSc students. However, first year students, particularly BSc students, reported being more emotionally affected by the vignette.

CONCLUSION

All variants of the master plot overcoming the monster appeared to generate empathetic responses. This is important because it highlights the value of students' understanding the patients' story and challenges or 'monsters' faced. Therapeutic relationships will benefit from training physiotherapy students on the importance of listening and exploring challenges people with stroke face.

Patients' experiences with rehabilitation care: a qualitative study to inform patient-centred outcomes

PURPOSE

To explore patients' experiences with rehabilitation, with a particular focus on outcomes that are perceived to be of value.

MATERIALS AND METHODS

Semi structured interviews were conducted with adults who recently had rehabilitation for a chronic health condition in a hospital or community setting. Banja's definition of rehabilitation (personally fulfilling, socially meaningful and functionally effective) informed the enquiry and interpretation of the findings. Thematic analysis was used to categorise the data into codes and themes.

RESULTS

16 people (40-84 years, 69% male, n = 11) participated in individual telephone-interviews, describing their perspectives on what mattered to them about rehabilitation. The themes generated from the data suggested that participants focused on important social, functional and personal outcomes, but also required two fundamental features in their rehabilitation, namely a personalised and relational experience and a clear understanding of their own progress delivered in a way that is meaningful to them.

CONCLUSIONS

People who undertake rehabilitation express diverse expectations when assessing their outcomes and progress, although common elements could be identified. Participants valued a number of key features about the delivery and evaluation of their rehabilitation. These features revolved around the personalisation of the process and having clarity about progress.Implications for rehabilitationRehabilitation therapists should encourage ongoing personalised discussions about progress to promote clear and shared understanding of what clients and therapists expect, alongside the use of current available measures.Rehabilitation therapists should consider providing opportunities for participants to self-reflect about their experiences and modify their goals based on personal progress and deeper understanding of their circumstances.Rehabilitation therapists should consider assessing the extent to which the individual feels satisfied with and capable of achieving these outcomes before departing from the rehabilitation service.Overall, rehabilitation teams should think about spending more time with the patient to prioritise and understand their individual goals and values.

Recovery beyond functional restoration: a systematic review of qualitative studies of the embodied experiences of people who have survived a stroke

OBJECTIVE

To synthesise the qualitative evidence of embodied experiences of people who have survived a stroke, the experiences of making sense of oneself, others and the world in the poststroke bodies.DesignQualitative systematic review.

DATA SOURCES

Five electronic databases, PsycINFO, PubMed, MEDLINE, CINAHL Plus and Cochrane Library, were employed to search for qualitative studies published up to February 2022.

INCLUSION CRITERIA

Literature in English that employed qualitative methods to investigate the embodied experiences of people who have survived a stroke.

QUALITY APPRAISAL

Two reviewers independently appraised the quality of the included studies based on the tool developed by Salter et al in 2008. It consists of seven questions assessing the credibility and relevance of the studies. Discrepancies were resolved until a consensus was reached.

DATA EXTRACTION AND SYNTHESIS

Thematic synthesis was applied to synthesise the related findings from all the included studies. Two reviewers were involved in the process.

RESULTS

1482 records were identified. After the screening process, 34 studies were included in this review. Three analytical themes and their related descriptive themes emerged. Analytical themes included 'disconnection between oneself, others and the world,' 'the transitional period: exploring and negotiating,' and 'reconnecting with oneself, others and the world'.

CONCLUSION

The findings demonstrated that the embodied experiences of people who have survived a stroke progressed from feeling disconnected to reconnecting with themselves, others and the world. Stroke recovery should not only be limited to functional restoration. Approaching 're-embodiment', the realignment between oneself and one's body, is crucial in reintegrating with others and the world on the trajectory toward recovery.

PROSPERO REGISTRATION NUMBER

CRD42020183125.

Motor imagery as an intervention to improve activities of daily living post-stroke: A systematic review of randomized controlled trials

Introduction:

Motor imagery (MI) may be an effective tool for improving activities of daily living (ADL) post-stroke. However, no review to date has examined ADL independence when investigating training effectiveness. This review aimed to evaluate the quality of evidence and the effectiveness of MI training for improving ADL independence post-stroke.

Method:

Randomized controlled trial (RCT) studies comparing MI to conventional therapies were reviewed. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.

Results:

Thirteen articles met inclusion criteria. The overall quality was considered moderate to good, with a PEDro score ranging from 3 to 8. Most studies (9 out of 13) were considered good quality, with one rating of poor quality and three of fair quality. The primary findings suggest that MI training is a low-risk tool that may facilitate ADL independence. Audio-based MI training seems to improve ADL independence when paired with other rehabilitation methods, but the results should be interpreted with caution.

Conclusion:

To our knowledge, this is the first systematic review to examine RCTs investigating MI effectiveness in improving ADL post-stroke. Results support the use of MI to facilitate ADL independence. However, more research is needed to establish practice guidelines for implementing MI training post-stroke.

Uncovering the experiences of engaging in an inpatient occupation-based group program: The LifeSkills group

BACKGROUND

Consumer engagement is an important element for developing and maintaining value-based healthcare standards. Occupation-based practice in the context of a group has been adopted by inpatient rehabilitation clinicians, but little research has explored if these groups are valuable and useful to patients.

AIMS/OBJECTIVES

To explore the experiences of patients participating in an occupation-based group intervention for instrumental activities of daily living to understand its value and usefulness in an inpatient rehabilitation setting.

MATERIAL AND METHODS

Interpretive description guided the development of the study. Semi-structured interviews were completed with 15 participants of an occupation-based group, the LifeSkills group. Comparative analysis was used to analyse the data and develop themes.

RESULTS

Five themes were reported by participants: choice and control, confidence through doing, a real-world connection, the power of the therapeutic relationship and the impact of the shared experience.

CONCLUSIONS AND SIGNIFICANCE

In line with current rehabilitation literature, patient experiences around client-centredness, occupational engagement in a 'real-world' environment, and valued relationships can be facilitated through an occupation-based group. This study supports the implementation of valued-based healthcare in understanding patient perceptions of occupation-based interventions into rehabilitation; ensuring that the right intervention is being used at the right time for the right patient.

Socialize, Eat More, and Feel Better: Communal Eating in Acute Neurological Care

OBJECTIVE

Stroke commonly leads to feelings of isolation and loneliness, especially during the hospital period. The aim of the Communal Eating program was to support patient well-being through introducing opportunities for patients to eat lunch together.

DESIGN

Patients admitted to the Brain Rescue Unit who were identified as appropriate by their attending physicians, nurses, or other clinicians were recruited to attend communal lunch. Their mood, quality of life, loneliness, communication, swallowing safety, and eating behavior were examined.

RESULTS

Those who attended two or more sessions tended to have been lonelier and more psychosocially impaired at baseline. Patients who had one or fewer lunch showed no significant differences from baseline to posthospitalization on any measure. However, for those who ate two or more lunches, changes in loneliness and quality of life trended toward improvement. There was scant evidence of changes to communication or eating habits.

CONCLUSION

Implementing a communal eating program in the acute hospital setting was very feasible and widely supported by patients, families, and staff. The results thus far show modest trends toward fulfilling the goal of supporting emotional well-being, while potentially supporting increased intake and, importantly, do not evidence any measurable harm.

Self-management interventions to improve mobility after stroke: an integrative review

PURPOSE

To review the evidence around self-management interventions used to improve mobility post-stroke.

MATERIALS AND METHODS

An integrative review was carried out. Eight databases were searched from 1992 to July 2021 using keywords based on the PICOS strategy. Two reviewers independently screened and extracted the relevant data. Quality of studies was assessed and a quantitatively led narrative synthesis of data, supported by qualitative evidence, was then conducted.

RESULTS

Twenty-four studies with 823 participants were reviewed. Self-management strategies such as patient education, providing information, goal setting, problem-solving, action planning, self-monitoring, and social support were integrated with rehabilitation therapy to improve mobility post-stroke. The reviewed studies showed improvements in functional mobility and walking ability, self-efficacy, participation in physical activity, and quality of life to various extents. Participants in qualitative studies considered the self-management interventions as a valuable addition to their therapy and perceived the improvement in their mobility following them.

CONCLUSION

There is some evidence that self-management interventions help to improve mobility outcomes post-stroke. Heterogeneity of data in the studies made meta-analysis impossible. Most of the identified studies examined the feasibility and fidelity of the interventions and further research is warranted to examine the efficacy of these interventions to improve functional mobility post-stroke.Implications for rehabilitationSelf-management interventions can improve mobility-related outcomes, which are considered a priority goal for many stroke survivors.Survivors valued their participation in self-management integrated care programmes and linked that to the perceived improvement in their rehabilitation outcomes.Self-management interventions such as patient education, goal-setting, self-monitoring, and professionals/carers support have been found to improve mobility outcomes for stroke survivors.The outcomes that benefited to a slight extent using self-management were; functional mobility, walking ability (speed, distance, and endurance), and a number of steps per day.

Biopsychosocial effects and experience of use of robotic and virtual reality devices in neuromotor rehabilitation: A study protocol

BACKGROUND

Robot-assisted therapy (RAT) and virtual reality (VR)-based neuromotor rehabilitation have shown promising evidence in terms of patient's neuromotor recovery, so far. However, still little is known on the perceived experience of use of robotic and VR devices and the related psychosocial impact. The present study outlines a study protocol aiming to investigate the biopsychosocial effects and the experience of use of robotic and non-immersive VR devices in patients undergoing neuromotor rehabilitation.

METHODS

Adopting a prospective, two-arm, non-randomized study design, patients with different neuromotor diseases (i.e., acquired brain injury, Parkinson's Disease, and total knee/hip arthroplasty) undergoing rehabilitation will be included. In a real-world clinical setting, short- (4 weeks) and long-term (6 months) changes in multiple patient's health domains will be investigated, including the functional status (i.e., motor functioning, ADLs, risk of falls), cognitive functioning (i.e., attention and executive functions), physical and mental health-related quality of life (HRQoL), and the psychological status (i.e., anxiety and depression, quality of life satisfaction). At post-intervention, the overall rehabilitation experience, the psychosocial impact of the robotic and VR devices will be assessed, and technology perceived usability and experience of use will be evaluated through a mixed-methods approach, including both patients' and physiotherapists' perspectives. Repeated measures within-between interaction effects will be estimated, and association analyses will be performed to explore the inter-relationships among the variables investigated. Data collection is currently ongoing.

IMPLICATIONS

The biopsychosocial framework adopted will contribute to expanding the perspective on patient's recovery within the technology-based rehabilitation field beyond motor improvement. Moreover, the investigation of devices experience of use and usability will provide further insight into technology deployment in neuromotor rehabilitation programs, thereby maximising therapy engagement and effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05399043.

Person-centred care in individuals with stroke: a qualitative study using in-depth interviews

BACKGROUND

Person-centred care (PCC) has considerable effects on the clinical practice of health professionals. The purpose of this study was to describe the perspectives and perceived barriers and enablers of individuals with stroke regarding the PCC model in stroke rehabilitation.

METHODS

A qualitative exploratory study was conducted based on an interpretive framework. Participants were recruited using non-probabilistic purposeful sampling and a snowball-technique strategy. The inclusion criteria consisted of: (a) individuals > 18 years, (b) diagnosed with moderate or severe stroke according to the National Institutes of Health Stroke Scale and (c) in the post-acute or chronic stage of the disease. In total, 31 individuals with stroke were included. In-depth interviews and researchers' field notes were used to collect the data. A thematic analysis was performed. Also, credibility, transferability, dependability and confirmability techniques were followed to establish trustworthiness of the data.

RESULTS

Thirty-one individuals with stroke (11 women) were included. Three main themes were identified: (a) The person behind the "patient" label, recognizing the person beyond their illness and valuing their identity and individual characteristics, (b) The person at the centre of care, considering themselves as an active agent in their own care and respecting their preferences and expectations for their care process and (c) Training for PCC, providing health professionals with tools to achieve professional skills for the implementation and development of the PCC model.

CONCLUSIONS AND SIGNIFICANCE

This paper describes relevant aspects that health professionals should consider when providing PCC in the context of the rehabilitation of individuals with stroke. Key messagesThe individuals' perspective regarding person-centred care (PCC) has considerable effects on the clinical practice of health professionals.Individuals with stroke describe how there is a person behind the "patient" label, with identity, needs and desire to participate in decision making.Training in the PCC model helps healthcare professionals identify the needs of individuals with stroke during rehabilitation.

Impairments, and physical design and culture of a rehabilitation unit influence stroke survivor activity: qualitative analysis of rehabilitation staff perceptions

PURPOSE

This study aimed to investigate rehabilitation staff perceptions of factors influencing stroke survivor activity outside of dedicated therapy time for the purpose of supporting successful translation of activity promoting interventions in a rehabilitation unit.

MATERIALS AND METHODS

Purposive sampling of multi-disciplinary teams from four rehabilitation units was performed, and semi-structured interviews were conducted by telephone, digitally audio-recorded and then transcribed verbatim. A stepped iterative process of thematic analysis was employed until data saturation was reached.

RESULTS

All but one of the 22 participants were female, the majority were either physiotherapists or occupational therapists, with a median of 4 years (interquartile range, 2-10) working at their respective rehabilitation units. Analysis of the data revealed three themes: (i) stroke survivor characteristics influence their activity outside therapy, (ii) the rehabilitation environment influences physical, cognitive, and social activity, and (iii) institutional priorities, staff culture, and attitude can be barriers to activity. Rehabilitation units were perceived to be unstimulating, and visitors considered enablers of activity when resources were perceived to be scarce.

CONCLUSIONS

Our results suggest careful consideration of the involvement of visitors, an individual's needs and preferences, and the institution's priorities and staff attitude may result in greater stroke survivor activity during rehabilitation.Implications for rehabilitationStaff should consider stroke survivor impairments and a rehabilitation unit's institutional priorities and staff attitudes when aiming to enhance stroke survivor engagement in activity.The physical and social environment of a rehabilitation unit can be optimised by rehabilitation staff to promote activity.Utilisation of visitors of stroke survivors on a rehabilitation unit may be one way to enhance engagement in activity.Discussion within the rehabilitation team concerning "ownership" of the role of supporting stroke survivor activity outside of structured therapy time may support better engagement in same.

Reversing the Ruin: Rehabilitation, Recovery, and Restoration After Stroke

PURPOSE OF REVIEW

Stroke is a common cause of disability in aging adults. A given individual's needs after stroke vary as a function of the stroke extent and location. The purpose of this review was to discuss recent clinical investigations addressing rehabilitation of an array of overlapping functional domains.

RECENT FINDINGS

Research is ongoing in the domains of movement, cognition, attention, speech, language, swallowing, and mental health. To best assist patients' recovery, innovative research has sought to develop and evaluate behavioral approaches, identify and refine synergistic approaches that augment the response to behavioral therapy, and integrate technology where appropriate, particularly to introduce and titrate real-world complexity and improve the overall experience of therapy. Recent and ongoing trials have increasingly adopted a multidisciplinary nature - augmenting refined behavioral therapy approaches with methods for increasing their potency, such as pharmaceutical or electrical interventions. The integration of virtual reality, robotics, and other technological advancements has generated immense excitement, but has not resulted in consistent improvements over more universally accessible, lower technology therapy.

Understanding the facilitators and barriers of stroke survivors' adherence to recovery-oriented self-practice: a thematic synthesis

PURPOSE

Stroke survivors receive considerable rehabilitation efforts as inpatients, but one-on-one therapy decreases after discharge. The gap between the amount of required therapy and the lack of its availability in this phase of care may be partly overcome by self-practice. However, patient's adherence to prescribed programs is often low. While single studies have examined factors affecting adherence in this specific case, they have not been reviewed and synthesised previously.

METHODS

A thematic synthesis of qualitative studies explored factors affecting stroke survivors' adherence to prescribed, recovery-oriented self-practice. Five databases were systematically searched for references: Medline, Psycinfo, CINAHL, Embase, and ASSIA. Quality assessment was undertaken using the CASP tool.

RESULTS

From 1308 references, 68 potential papers were read in full, and 12 were included in the review. An overarching theme was identified as: "Tailoring and personalization rather than standardization." It was informed by the following three analytical themes: "The meaning of 'self' in self-practice," "Identifying self-practice as a team effort," and "Self-practice that is grounded in one's reality."

CONCLUSION

To have a positive effect on adherence to self-practice, clinicians are advised to spend time learning about each individual's life circumstances, so they can tailor proposed exercise programs to patients' personal situations, preferences, and needs.IMPLICATIONS FOR REHABILITATIONThe topic of patient's adherence to self-practice of prescribed exercise is a common concern, often voiced by frustrated rehabilitation health professionals. Bridging the gap between the patient's needs for post-discharge intensive therapy and the inability of healthcare systems to provide it could be filled partly by self-practice.Adherence to self-practice has become even more essential since the COVID 19 pandemic and the decrease in face-to-face delivery of rehabilitation due to social distancing requirements.Adherence to exercise is a broad topic. Reasons for poor adherence differ between patient populations and the exercises they are prescribed. This study focuses on post-discharge stroke survivors' adherence to recovery targeted exercise that could be described as repetitive and less physically demanding movements and functions.Reviewed studies were qualitative and usually included a relatively small number of participants within a specific context. Using thematic synthesis, we combined these small pieces of the puzzle into a larger picture, to produce recommendations that could be drawn on by clinicians to improve self-practice adherence.

Walk the Talk: Current Evidence for Walking Recovery After Stroke, Future Pathways and a Mission for Research and Clinical Practice

Achieving safe, independent, and efficient walking is a top priority for stroke survivors to enable quality of life and future health. This narrative review explores the state of the science in walking recovery after stroke and potential for development. The importance of targeting walking capacity and performance is explored in relation to individual stroke survivor gait recovery, applying a common language, measurement, classification, prediction, current and future intervention development, and health care delivery. Findings are summarized in a model of current and future stroke walking recovery research and a mission statement is set for researchers and clinicians to drive the field forward to improve the lives of stroke survivors and their carers.

Effects of a multidisciplinary intervention to promote physical activity in patients with stroke undergoing rehabilitation: study protocol for the ActivePAS pilot randomised controlled trial

Introduction

Physical activity after stroke is related to functional recovery and outcomes. To optimise physical activity adapted to a patient's walking ability and characteristics, multidisciplinary support and interventions are required. The Activate Physical Activity for Stroke pilot randomised controlled trial aims to assess the safety and feasibility of a multidisciplinary intervention that promotes physical activity in patients who had a stroke undergoing rehabilitation.

Methods and analysis

This single-centre, randomised controlled trial will enrol 32 patients who had a stroke undergoing rehabilitation. Patients who had a stroke with the ability to walk 50 m with at least hand assistance, regardless of the use of braces or walking aids, and aged≥20 years will be randomly allocated to a multidisciplinary intervention group or control group. Patients in the intervention group will receive instructions for the self-monitoring of hospitalised physical activity and support to promote physical activity by multidisciplinary staff. The primary outcome of the present study is the safety (adverse events) and feasibility (retention and completion rates) of the multidisciplinary intervention. We assess physical activity using a triaxial accelerometer (UW-204NFC, A&D Company) as one of the secondary outcomes.

Ethics and dissemination

The present study has been approved by the Research Ethics Committee of Konan Women's University and the Ethics Committee of Nishi-Kinen Port Island Rehabilitation Hospital. We will disseminate the results of the present study through a peer-reviewed manuscript and presentations at international conferences.

Trial registration number

UMIN000046731.

Understanding the Professional Care Experience of Patients with Stroke: A Qualitative Study Using In-Depth Interviews

Background:

Professional support and communication stimulates the professional-patient relationship and supports the recovery of stroke patients.

Objectives:

To describe the perspectives of patients with stroke regarding communication, professional support, and their ability to participate in processes and integrated care with health providers.

Methods:

A qualitative study was conducted. A purposeful sampling and snowball-technique were used. Patients diagnosed with moderate or severe stroke in the post-acute or chronic stage of the disease were included. Data collection consisted of in-depth interviews and researcher field notes. A thematic analysis was performed.

Results:

Thirty-one patients were included. Three themes were identified: 1) Providing support, with four categories, professional behavior, personalized attention, the heart of the professional and building a bond with the patient; 2) Facilitating communication, with three categories, the patient as the recipient, the content of the message and the channel, and the professional as the person that conveys the message; and 3) Promoting participation, with two categories, barriers, and incentives to participate.

Conclusions:

When providing support, professionals should consider communicating information and encouraging the participation of stroke patients for integrated care.

Music Upper Limb Therapy-Integrated Provides a Feasible Enriched Environment and Reduces Post-stroke Depression: A Pilot Randomized Controlled Trial

OBJECTIVE

This study's aims were to refine Music Upper Limb Therapy-Integrated (MULT-I) to create a feasible enriched environment for stroke rehabilitation and compare its biologic and behavioral effects with that of a home exercise program (HEP).

DESIGN

This was a randomized mixed-methods study of 30 adults with post-stroke hemiparesis. Serum brain-derived neurotrophic factor and oxytocin levels measured biologic effects, and upper limb function, disability, quality of life, and emotional well-being were assessed as behavioral outcomes. Participant experiences were explored using semistructured interviews.

RESULTS

MULT-I participants showed reduced depression from preintervention to postintervention as compared with HEP participants. Brain-derived neurotrophic factor levels significantly increased for MULT-I participants but decreased for HEP participants, with a significant difference between groups after excluding those with post-stroke depression. MULT-I participants additionally improved quality of life and self-perceived physical strength, mobility, activity, participation, and recovery from preintervention to postintervention. HEP participants improved upper limb function. Qualitatively, MULT-I provided psychosocial support and enjoyment, whereas HEP supported self-management of rehabilitation.

CONCLUSIONS

Implementation of a music-enriched environment is feasible, reduces post-stroke depression, and may enhance the neural environment for recovery via increases in brain-derived neurotrophic factor levels. Self-management of rehabilitation through an HEP may further improve upper limb function.