What are the patient-held illness beliefs after a transient ischaemic attack, and do they determine secondary prevention activities: an exploratory study in a North London General Practice

Physical Activity After Transient Ischemic Attack or Mild Stroke Is Business as Usual

BACKGROUND AND PURPOSE

Regular, sustained moderate-to-vigorous physical activity (MVPA) is a recommended strategy to reduce the risk of recurrent stroke for people who have had transient ischemic attack (TIA) or mild stroke. This study aimed to explore attitudes toward, and experience of engaging in physical activity by adults following a TIA or mild stroke.

METHODS

Constructivist grounded theory methodology informed data collection and analysis. Interviews from 33 adults with TIA or mild stroke (mean age 65 [SD 10] years, 48% female, 40% TIA) were collected.

RESULTS

Business as usual characterized physical activity engagement post-TIA or mild stroke. Most participants returned to prestroke habits, as either regular exerciser or nonexerciser, with only a small number making changes. Influencing factors for physical activity participation included information, challenges, strategies, and support. Business as usual was associated with a perceived lack of information to suggest a need to change behaviors. Nonexercisers and those who decreased physical activity emphasized challenges to physical activity, while regular exercisers and those who increased physical activity focused on strategies and support that enabled participation despite challenges.

DISCUSSION AND CONCLUSION

Information about the necessity to engage in recommended physical activity levels requires tailoring to the needs of the people with TIA or mild stroke. Helpful information in combination with support and strategies may guide how to navigate factors preventing engagement and might influence the low level of physical activity prevalent in this population.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A376).

Structured follow-up pathway to support people after transient ischaemic attack and minor stroke (SUPPORT TIA): protocol for a feasibility study and process evaluation

INTRODUCTION

People who experience transient ischaemic attack (TIA) and minor stroke have limited follow-up despite rapid specialist review in hospital. This means they often have unmet needs and feel abandoned following discharge. Care needs after TIA/minor stroke include information provision (diagnosis and stroke risk), stroke prevention (medication and lifestyle change) and holistic care (residual problems and return to work or usual activities). This protocol describes a feasibility study and process evaluation of an intervention to support people after TIA/minor stroke. The study aims to assess the feasibility and acceptability of (1) the intervention and (2) the trial procedures for a future randomised controlled trial of this intervention.

METHODS AND ANALYSIS

This is a multicentre, randomised (1:1) feasibility study with a mixed-methods process evaluation. Sixty participants will be recruited from TIA clinics or stroke wards at three hospital sites (England). Intervention arm participants will be offered a nurse or allied health professional-led follow-up appointment 4 weeks after TIA/minor stroke. The multifaceted intervention includes: a needs checklist, action plan, resources to support management of needs, a general practitioner letter and training to deliver the intervention. Control arm participants will receive usual care. Follow-up will be self-completed questionnaires (12 weeks and 24 weeks) and a clinic appointment (24 weeks). Follow-up questionnaires will measure anxiety, depression, fatigue, health related quality of life, self-efficacy and medication adherence. The clinic appointment will collect body mass index, blood pressure, cholesterol and medication. Assessment of feasibility and acceptability will include quantitative process variables (such as recruitment and questionnaire response rates), structured observations of study processes, and interviews with a subsample of participants and clinical staff.

ETHICS AND DISSEMINATION

Favourable ethical opinion was gained from the Wales Research Ethics Committee (REC) 1 (23 February 2021, REC reference: 21/WA/0036). Study results will be published in peer-reviewed journals and presented at conferences. A lay summary and dissemination strategy will be codesigned with consumers. The lay summary and journal publication will be distributed on social media.

TRIAL REGISTRATION NUMBER

ISRCTN39864003.

TIA and minor stroke: a qualitative study of long-term impact and experiences of follow-up care

Background

Transient ischaemic attack (TIA) and minor stroke are often considered transient events; however, many patients experience residual problems and reduced quality of life. Current follow-up healthcare focuses on stroke prevention and care for other long-term problems is not routinely provided.

We aimed to explore patient and healthcare provider (HCP) experiences of residual problems post-TIA/minor stroke, the impact of TIA/minor stroke on patients’ lives, and current follow-up care and sources of support.

Methods

This qualitative study recruited participants from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Semi-structured interviews were conducted with 12 TIA/minor stroke patients and 24 HCPs from primary, secondary and community care. Data was analysed using framework analysis.

Results

A diverse range of residual problems were reported post-TIA/minor stroke, including psychological, cognitive and physical impairments. Consultants and general practitioners generally lacked awareness of these long-term problems; however, there was better recognition among nurses and allied HCPs. Residual problems significantly affected patients’ lives, including return to work, social activities, and relationships with family and friends. Follow-up care was variable and medically focused. While HCPs prioritised medical investigations and stroke prevention medication, patients emphasised the importance of understanding their diagnosis, individualised support regarding stroke risk, and addressing residual problems.

Conclusion

HCPs could better communicate information about TIA/minor stroke diagnosis and secondary stroke prevention using lay language, and improve their identification of and response to important residual impairments affecting patients.

Experiences of transient ischaemic attack diagnosis and secondary prevention: a qualitative review

Background:

A transient ischaemic attack (TIA) diagnosis is a serious, early sign that a person is at high risk of stroke. However, little is known about patients' experiences, perceptions and behaviours regarding TIA symptoms, diagnosis and secondary prevention.

Aim:

To explore patients' experiences of TIA symptoms, diagnosis and treatment, and secondary prevention.

Methods:

A qualitative review was conducted using a meta-aggregation approach. Five major databases were searched to identify eligible papers. Findings were extracted and grouped into categories to generate synthesised findings.

Findings:

Four papers (69 participants) were included. Three synthesised findings were developed: The first 24 hours; Impact and effect on quality of life; and Reducing the risk. Following TIA diagnosis, patients may experience persistent anxiety and fatigue, and many patients do not understand the importance of secondary prevention.

Conclusion:

There is a lack of awareness of TIA symptoms and of the importance of seeking immediate help and engaging with secondary prevention.

Real-life experiences of people with transient ischaemic attack or minor stroke: A qualitative literature review

AIMS AND OBJECTIVES

To explore and present findings of qualitative studies exploring real-life experiences of people with transient ischaemic attack or minor stroke.

BACKGROUND

Transient ischaemic attack and minor stroke significantly increase the risk of stroke. Primarily, literature has examined healthcare pathways, patient outcomes and models of care through quantitative methodologies. Several studies have explored patient experiences using qualitative approaches. However, these findings have not been systematically collated or critically appraised to better understand the experiences of this population.

DESIGN

A literature review of the qualitative evidence.

METHOD

A systematic literature search was conducted in CINAHL, MEDLINE, EMBASE and PsycINFO between January 2005-October 2016 to identify qualitative studies that explored real-life experiences of people with transient ischaemic attack or minor stroke. The relevant EQUATOR guidelines were followed. Findings of relevant studies were critically appraised and collated using a thematic approach.

RESULTS

The search retrieved 709 articles. Twelve articles were included after critical review. Three themes emerged including recognition, awareness and action; the vulnerable self; and social and personal life change. Participants experienced ongoing vulnerability and change in their personal and social lives. Specifically, people believed that their condition did not reflect their physical appearance and led to their needs being unmet by health professionals.

CONCLUSIONS

This is the first review of the literature to collate the thoughts, perspectives and experiences of people living with transient ischaemic attack or minor stroke. They reveal a complex, life-altering experience characterised by vulnerability, instability and change. Education that assists clinicians to connect with these experiences may alleviate the patient-reported disconnection with health professionals.

RELEVANCE TO CLINICAL PRACTICE

Physical and psychosocial dysfunctions were consistently reported to be overlooked or undetected by clinicians. Educating clinicians might enable them to better understand patient experiences, improve therapeutic interactions and meet the needs of this population.

Perspectives of older people engaging in nurse-led cardiovascular prevention programmes: a qualitative study in primary care in the Netherlands

Background

Cardiovascular prevention programmes are increasingly being offered to older people. To achieve the proposed benefits, adherence is crucial. Understanding the reasons for adherence and non-adherence can improve preventive care.

Aim

To gain insight into what motivates older people living in the community to partake in a cardiovascular prevention programme, and reasons for subsequent continuation or withdrawal.

Design and setting

Qualitative study of current and former participants of the ongoing ≥6 year PreDIVA (prevention of dementia by intensive vascular care) trial in primary care practices in suburban areas in the Netherlands.

Method

Semi-structured interviews were conducted with a purposive sample of 15 participants (aged 76–82 years). Interviews were audiorecorded and analysed by two independent researchers using a thematic approach. Participants were asked about their motivation for participating in the programme, along with the facilitators and barriers to continue doing so.

Results

Responders reported that regular check-ups offered a feeling of safety, control, or being looked after, and were an important motivator for participation. For successful continuation, a personal relationship with the nurse and a coaching approach were both essential; the lack of these, along with frequent changes of nursing staff, were considered to be barriers. Participants considered general preventive advice unnecessary or patronising, but practical support was appreciated.

Conclusion

To successfully engage older people in long-term, preventive consultations, the approach of the healthcare provider is crucial. Key elements are to offer regular check-ups, use a coaching approach and to build a personal relationship with the patient.

Barriers to medication adherence for the secondary prevention of stroke: a qualitative interview study in primary care

Background

Medications are highly effective at reducing risk of recurrent stroke, but success is influenced by adherence to treatment. Among survivors of stroke and transient ischaemic attack (TIA), adherence to medication is known to be suboptimal.

Aim

To identify and report barriers to medication adherence for the secondary prevention of stroke/TIA.

Design and setting

A qualitative interview study was conducted within general practice surgeries in the East of England, UK.

Method

Patients were approached by letter and invited to take part in a qualitative research study. Semi-structured interviews were undertaken with survivors of stroke, caregivers, and GPs to explore their perspectives and views around secondary prevention and perceived barriers to medication adherence. Key themes were identified using a grounded theory approach. Verbatim quotes describing the themes are presented here.

Results

In total, 28 survivors of stroke, including 14 accompanying caregivers and five GPs, were interviewed. Two key themes were identified. Patient level barriers included ability to self-care, the importance people attach to a stroke event, and knowledge of stroke and medication. Medication level barriers included beliefs about medication and beliefs about how pills work, medication routines, changing medications, and regimen complexity and burden of treatment.

Conclusion

Patients who have had a stroke are faced with multiple barriers to taking secondary prevention medications in UK general practice. This research suggests that a collaborative approach between caregivers, survivors, and healthcare professionals is needed to address these barriers and facilitate medication-taking behaviour.

Physical activity participation in community dwelling stroke survivors: synergy and dissonance between motivation and capability. A qualitative study

OBJECTIVES

The evidence supporting benefits of physical activity (PA) on fitness, functioning, health and secondary prevention after stroke is compelling. However, many stroke survivors remain insufficiently active. This study explored survivors' perspectives and experiences of PA participation to develop an explanatory framework that physiotherapists and other health professionals can use to develop person-specific strategies for PA promotion.

DESIGN

Qualitative study using semi-structured in-depth interviews. Data was audio-recorded and transcribed. Analysis followed the Framework Approach.

SETTING

Community setting, interviews conducted within participants' homes.

PARTICIPANTS

Community dwelling stroke survivors (n=38) six months or more after the end of their rehabilitation, purposively selected by disability, PA participation and socio-demographic status.

RESULTS

Findings suggest that survivors' beliefs, attitudes, and physical and social context generated synergy or dissonance between motivation (desire to be active) and capability (resources to be active) for PA participation. Dissonance occurred when motivated survivors had limited capability for activity, often leading to frustration. Confidence to achieve goals and determination to overcome barriers, acted as activity catalysts when other influences were synergistic. We illustrate these relationships in a dynamic explanatory model that can be used to support both novel interventions and personal activity plans.

CONCLUSIONS

This study suggests a shift is required from purely pragmatic approaches to PA promotion towards conceptual solutions. Understanding how synergy or dissonance between motivation and capability influence individual survivors' behaviour will support physiotherapists and other health professionals in promoting PA. This study provides a model for developing person-centred, tailored interventions that address barriers encountered by stroke survivors.

Balance and Gait Impairment in Transient Ischemic Attack and Minor Stroke

BACKGROUND

There has been little research into gait and balance impairment in transient ischemic attack (TIA) and minor stroke, despite these conditions affecting large numbers of people and the potential impact on function. The aim of this study was to determine the impact of TIA and minor stroke on gait and balance.

METHODS

Twelve people with TIA or minor stroke without previous gait/balance problems and 12 age- and sex-matched controls were recruited. Participants (mean age 67 years) underwent a comprehensive assessment including physiological, balance, and gait measures (clinical and computerized [NeuroCom/GAITRite]). Matched-pairs analysis was undertaken.

RESULTS

Groups were similar in body mass index, vision, leg proprioception/strength, and reaction time. Cognition was worse in the TIA/minor stroke group: mean Montreal Cognitive Assessment score 22.2 versus 26.6, P = .001. People with TIA/minor stroke were significantly worse on all but one clinical test. Median scores for TIA/minor stroke versus control were as follows: Timed Up and Go (TUG), 9.4 versus 7.6 seconds, P = .019; TUG dual task, 12.3 versus 8.5 seconds, P = .012; Four Square Step Test, 10.9 versus 7.2 seconds, P = .006. Mean Step Test score for TIA/minor stroke versus control was 14.1 versus 17.7, P = .021. The TIA/minor stroke group also had significantly worse performance on computerized tests: increased turn time/sway, increased step length, slower comfortable/fast gait speeds, and greater proportion of gait cycle spent in double support.

CONCLUSIONS

This study found that people with TIA/minor stroke have gait and balance dysfunction despite having no obvious physiological impairments. Intervention studies aimed at improving balance and gait in this population are needed.

Transient ischaemic attack: a qualitative study of the long term consequences for patients

BACKGROUND

Transient ischaemic attack (TIA) is characterised by its transient nature with symptoms of neurological dysfunction resolving within 24 hours. The occurrence of TIA is a major risk factor for stroke with 10-15% of TIA patients going on to have ischaemic stroke. Internationally, recommendations for the management of TIA focus on the need for early diagnosis and medical management of the acute increased risk of ischaemic stroke. However there is a limited amount of evidence that some patients suffer enduring consequences as a result of this 'transient' event. This paper focusses on patients' long term lived experience following a TIA.

METHODS

Semi structured interviews were carried out with patients who had a TIA between two and 24 months previously. Participants were asked about their TIA, the advice and management received and any changes made as a result of the TIA. Interviews were recorded and transcribed verbatim. Thematic content analysis involved scrutinising transcripts to look for links and associations within and between accounts in a process similar to the grounded theory approach of open coding. The category of transience emerged and was explored in more detail to examine the enduring consequences of TIA.

RESULTS

Thirty nine patients aged between 31 and 89 years were interviewed. Accounts detailed the long term impact of the TIA and the subsequent 'at risk' status, on the physical and psychosocial wellbeing of participants. Some participants sought to proactively manage the consequences of their TIA but found it difficult to obtain the information and support they needed, whereas others felt that no further action was needed to prevent future stroke.

CONCLUSION

Current definitions conceptualise TIA as a transient event however our study suggests that some patients experienced long term consequences as a result of their TIA. These included anxiety and uncertainty in the light of their increased stroke risk. TIA patients need access to detailed, evidence based stroke prevention information from a credible source, and support to help them understand and apply the information over time, if they are to effectively self-manage the long term consequences of TIA and reduce their risk of future stroke.

Delay in seeking medical help following Transient Ischemic Attack (TIA) or "mini-stroke": a qualitative study

Background

Prompt treatment following Transient Ischemic Attack (TIA) can reduce the risk of subsequent stroke and disability. However, many patients delay in making contact with medical services. This study aimed to explore TIA patients' accounts of delay between symptom onset and contacting medical services including how decisions to contact services were made and the factors discussed in relation to delay.

Methods

Twenty interviews were conducted with TIA patients in England. Using a previous systematic review as an initial framework, interview data were organised into categories of symptom recognition, presence of others and type of care sought. A thematic analysis was then conducted to explore descriptions of care-seeking relevant to each category.

Results

Delay in contacting medical services varied from less than an hour to eight days. Awareness of typical stroke symptoms could lead to urgent action when more severe TIA symptoms were present but could lead to delay when experienced symptoms were less severe. The role of friends and family varied widely from deciding on and enacting care-seeking decisions to simply providing transport to the GP practice. When family or friends played a greater role, and both made and enacted care-seeking decisions, delays were often shorter, even when patients themselves failed to identify symptoms. Healthcare professionals also impacted on patients' care-seeking with greater delays in seeking further care for the same episode described when patients perceived a lack of urgency during initial healthcare interactions.

Conclusions

This study provides new information on patients' decisions to contact medical services following TIA and identifies overlapping factors that can lead to delay in receiving appropriate treatment. While recognition of symptoms may contribute to delay in contacting medical services, additional factors, including full responsibility being taken by others and initial healthcare interactions, can over-ride or undermine the importance of patients' own identification of TIA.

Non-focal neurological symptoms associated with classical presentations of transient ischaemic attack: qualitative analysis of interviews with patients

Background

Improving the recognition of transient ischaemic attack (TIA) at initial healthcare contact is essential as urgent specialist assessment and treatment reduces stroke risk. Accurate TIA detection could be achieved with clinical prediction rules but none have been validated in primary care. An alternative approach using qualitative analysis of patients' experiences of TIA may identify novel features of the TIA phenotype that are not detected routinely, as such techniques have revealed novel early features of other important conditions such as meningococcaemia. We sought to determine whether the patient's experience of TIA would reveal additional deficits that can be tested prospectively in cohort studies to determine their additional diagnostic and prognostic utility at the first healthcare contact.

Methodology and Findings

Qualitative semi-structured interviews with 25 patients who had experienced definite TIA as determined by a stroke specialist; framework analysis to map symptoms and key words or descriptive phrases used against each individual, with close attention to the detail of the language used. All interview transcripts were reviewed by a specialist clinician with experience in TIA/minor stroke. Patients described non-focal symptoms consistent with higher function deficits in spatial perception and awareness of deficit, as well as feelings of disconnection with their immediate surroundings. Of the classical features, weakness and speech disturbance were described in ways that did not meet the readily recognisable phenotype.

Conclusion/Significance

Analysis of patients' narrative accounts reveals a set of overlooked features of the experience of TIA which may provide additional diagnostic utility so that providers of first contact healthcare can recognise TIA more easily. Future research is required in a prospective cohort of patients presenting with transient neurological symptoms to determine how frequent these features are, what they add to diagnostic information and whether they can refine measures to predict stroke risk.