Using stroke to explore the Life Thread Model: An alternative approach to understanding rehabilitation following an acquired disability

Experiences of acquired brain injury survivors participating in online and hybrid performance arts programmes: an ethnographic study

BACKGROUND

Performance arts can benefit people with acquired brain injury (ABI). This study explored the online delivery during COVID-19 restrictions, of a performance art intervention through the experiences of participants, artists and facilitators.

METHODS

Two community-based programmes were delivered. Online ethnographic observations and semi-structured interviews with participants, artists and facilitators were completed.

RESULTS

The programmes benefited participants by addressing loneliness and isolation; building confidence through peer support; improving physical limitations through movement; improving communication through music and vocal work; and using poetry, visual arts, metaphor and performance to make sense of participants' experiences. Participants had mixed experiences of participation, but it was an acceptable alternative to in-person arts interventions for those who overcame digital challenges.

CONCLUSIONS

ABI survivors can engage in online performance art programmes and find participation valuable for their health, well-being, and recovery. More work is needed to explore the generalisability of these findings, especially given digital poverty.

Music Upper Limb Therapy - Integrated (MULT-I) supports a positive transformation in sense of self post stroke: a thematic analysis

PURPOSE

To understand how the experience of Music Upper Limb Therapy - Integrated (MULT-I) interconnects with the experience of stroke.

METHODS

Thematic analysis of semi-structured interviews and video-recorded MULT-I sessions from a larger mixed-methods study. Thirty adults with post-stroke hemiparesis completed pre-intervention interviews, of whom fifteen participated in MULT-I. Thirteen of the participants in MULT-I completed post-intervention interviews.

RESULTS

The experience of stroke was characterized by five themes: (1) sudden loss of functional abilities, (2) disrupted participation, (3) desire for independence, (4) emotional distress and the need for support, and (5) difficulty negotiating changes in sense of self. The experience of MULT-I was characterized by three themes: (1) MULT-I activated movement and empowered personal choice, (2) MULT-I created a safe place to process emotional distress and take on challenges, and (3) MULT-I fostered a sense of belonging and a positive transformation in sense of self. These themes combined create a framework which illustrates the process by which MULT-I addressed each challenge described by survivors of stroke, facilitating a positive transformation in sense of self.

CONCLUSION

MULT-I promotes physical, emotional, and social wellbeing following a stroke. This integrated approach supports a positive transformation in sense of self. These findings have implications for improving psychosocial well-being post stroke.

(Re)constructing identity following acquired brain injury: The complex journey of recovery after stroke

INTRODUCTION

People with poststroke acquired brain injury (ABI) face a complex and often troubled identity reconstruction journey. The literature is rich with studies related to the psychological and neuropsychological components involved in rehabilitation, but it is lacking with respect to the investigation of the existential dimensions and the challenges associated with finding new senses and meanings for one's identity and future perspectives, body and interpersonal relationships.

METHODS

The aim of this study is to investigate the narrative processes of identity reconstruction after brain damage. Through a qualitative approach, 30 autobiographical narratives about self, body and the relationships with others were collected and analyzed. Semistructured interviews were used for the data collection. Narrative and positioning analysis were applied.

RESULTS

Four main positionings emerged: sanctioning a radical break with one's previous life; assuming a sense of salvation and compulsory as well as irreversible adaptation to the limitations associated with one's condition; feeling different and disabled; and considering new possibilities and active constructions of self-being in relationship with others. These results underline the narrative processes of construction of the injury and the identity and delineate possible resources and instruments to improve the clinical practice for health practitioners. They are also valuable for other professionals who deal with neurological services and rehabilitation, such as psychological counselling and support for persons who have experienced ABI and their families.

PATIENT OR PUBLIC CONTRIBUTION

This work resulted from a close collaboration between two universities and a hospital neurological rehabilitation department in the Veneto Region (Northern Italy). Three associations of people with stroke and their families living in the same area contributed to designing the research on the basis of the needs expressed by their members with the aim to identify strategies and devices to be implemented in the public service to improve the care pathway. They also participated in the interpretation of the data.

Developing and testing the feasibility of a new internet-based intervention-A case study of people with stroke and occupational therapists

INTRODUCTION

Internet-based interventions are called for within rehabilitation to meet the limited access to support for self-management after stroke. Therefore, a new intervention program, "Strategies for Empowering activities in Everyday life" (SEE) was developed. The aim of this study was to explore and describe how clients with stroke and their occupational therapists experienced the SEE intervention process and whether SEE has the potential to promote an active everyday life.

METHODS

A qualitative descriptive case study was designed. Four people with stroke (two of each sex, mean age 66,5 years) and their two occupational therapists (one of each sex) were included. A mix of data collection methods as interviews, assessments, registration forms and fieldnotes was used to uncover the participants' experiences and potential changes. Data were analysed with pattern matching.

FINDINGS

The analysed data formed three categories: "Not being able to take on the internet-based intervention", "Being facilitated in the change process of everyday life through the internet-based intervention", and "Providing a new internet-based intervention is a transition from ordinary practice". These categories included two to four subcategories that reflected aspects of SEE feasibility and acceptability with a focus on content and delivery.

CONCLUSION

The first test of the intervention indicates that the content and delivery of SEE can be feasible and acceptable both for clients and occupational therapists. The findings suggest that SEE has the potential to support clients' self-reflections and their adoption of strategies that influence engagement in daily activities and satisfaction with life in various ways. Further research with large-scale studies is needed.

A manual-based family intervention for families living with acquired brain or spinal cord injury: a qualitative study of families' experiences

PURPOSE

To explore families' experiences of participating in a family intervention, targeting families living with the consequences of acquired brain injury (ABI) or spinal cord injury (SCI).

MATERIALS AND METHODS

Individuals with ABI or SCI and their family members were recruited from a randomised controlled trial investigating the effectiveness of the manual-based family intervention, which consisted of eight weekly sessions. Semi-structured interviews were conducted with 16 families (n = 33). The data were analyzed through reflexive thematic analysis.

RESULTS

One central theme was developed "A sense of belonging together again", describing the value of the reciprocal format of the family intervention, where individuals with ABI or SCI and their family members gained new insights into each other while building up their relationship. The central theme was supported by three additional themes: "Strengthened communication and emotional control", "Acknowledging the changed life situation" and "Being seen as a whole person".

CONCLUSIONS

The family intervention supported the families to strengthen family cohesion and to be capable to manage the changed life situation. The findings emphasize the importance of a family-centered approach in neurorehabilitation, and how healthcare professionals play a significant role in facilitating families to achieve a balanced level of family cohesion.

Stroke survivors' views on their priorities for upper-limb recovery and the availability of therapy services after stroke: a longitudinal, phenomenological study

PURPOSE

Forty percent of stroke survivors have a persistent lack of function in the upper limb, causing significant disability. Most personal-care tasks and meaningful activities require bi-manual function of both upper limbs. However, lower-limb mobility is often viewed as the priority in stroke services. Perspectives of stroke survivors on priorities for upper-limb recovery and therapy have not been investigated in detail. Therefore, this study aimed to explore their views.

MATERIALS AND METHODS

Thirteen stroke survivors each engaged in up to four semi-structured interviews over 18 months. A phenomenological approach guided the research.

RESULTS

Three themes were identified. Priorities change on coming home: recovery of walking is a priority early after stroke but upper-limb recovery becomes equally important over time, particularly once living at home. Limited therapy services: therapy has a short duration, prioritizes lower-limb mobility, and is short-lived in the community; people feel abandoned by services. Active partners in recovery: stroke survivors want intermittent access to review and advice so they can be active partners with therapists to manage their upper-limb recovery.

CONCLUSION

Therapy services should recognize stroke survivors' changing priorities and work with them as active partners in upper-limb recovery. Intermittent access to review and advice should be included in service design.Implications for rehabilitationStroke survivors' priorities may change over time from recovery of walking toward upper-limb recovery.Post-stroke services can be perceived as insufficient to meet the needs of stroke survivors who want to participate actively in rehabilitation of their upper limb.Stroke survivors may prefer services that are more flexible to provide regular review of their progress, access to guidance and support to self-manage their recovery.

Early Opportunities to Explore Occupational Identity Change: Qualitative Study of Return-To-Work Experiences After Stroke

BACKGROUND

Rates of return-to-work after stroke are low, yet work is known to positively impact people's wellbeing and overall health outcomes.

OBJECTIVE

To understand return-to-work trajectories, barriers encountered, and resources that may be used to better support participants during early recovery and rehabilitation.

PARTICIPANTS

The experiences of 31 participants (aged 25-76 years) who had or had not returned to work after stroke were explored.

METHODS

Interview data were analysed using reflexive thematic analysis methods within a broader realist research approach.

RESULTS

Participants identified an early need to explore a changed and changing occupational identity within a range of affirming environments, thereby ascertaining their return-to-work options early after stroke. The results articulate resources participants identified as most important for their occupational explorations. Theme 1 provides an overview of opportunities participants found helpful when exploring work options, while theme 2 explores fundamental principles for ensuring the provided opportunities were perceived as beneficial. Finally, theme 3 provides an overview of prioritized return-to-work service characteristics.

CONCLUSION

The range and severity of impairments experienced by people following stroke are broad, and therefore their return-to-work needs are diverse. However, all participants, irrespective of impairment, highlighted the need for early opportunities to explore their changed and changing occupational identity.

A qualitative exploration of fatherhood after acquired brain injury (ABI)

Acquired Brain Injury (ABI) significantly affects individuals across multiple areas of intimate, familial, and parental domains. Gender and identity are pivotal research areas in navigating life after ABI. To date, scant research has explored gendered experiences, particularly those related to the masculine lifeworld. This study aimed to explore how men who were fathers before their injuries experience fatherhood after ABI. An Interpretative phenomenological analysis (IPA) methodology was used, and seven fathers participated in the semi-structured interviews (time since injury 1-18 years, age range 27-66 years) which explored their meaning-making. Four superordinate themes were drawn from all interviews through engaging with the qualitative research process: (1) what being a father means, (2) altered relationships with others, (3) becoming lost and finding their way through, and (4) renewed fatherhood. The findings show intersectionality between pre-and post-injury comparisons of self and social identities, alongside the contextual and societal identities in the subjective fathering experiences. Through increased understanding, we may enable fathers to find new ways to resolve, reformulate, and connect to move into their future possible fatherhood. The importance of this research is in giving voice to these less represented men so that we may shape our understanding to aid future fathers post-ABI.

A qualitative study exploring how stroke survivors' expectations and understanding of stroke Early Supported Discharge shaped their experience and engagement with the service

PURPOSE

To explore how stroke survivors' expectations and understanding of Early Supported Discharge (ESD) helped them make sense of their experiences, and shaped their engagement with the service.

METHODS

Data were collected as part of a study of large-scale implementation of stroke ESD: the WISE realist mixed-methods study. Semi-structured interviews were conducted with five purposefully selected stroke survivors from six sites in England implementing stroke ESD (n = 30). Participants were aged 32-88 years (20 males). Interviews were audio recorded, transcribed verbatim and transcripts were analysed using reflexive thematic analysis.

RESULTS

Three overarching themes were identified: (1) ESD as a post-stroke recovery tool, (2) desire to recover quickly, (3) psychosocial impact and support. Stroke survivors were uncertain about what to expect when they first entered the service, however, their experience of ESD exceeded their expectations and increased their engagement with the service. Stroke survivors especially valued the goal-oriented approach the team adopted. Rehabilitation at home was perceived as positive and practical, encouraging independence within real-life contexts. Psycho-social support played an important role in the stroke survivors' rehabilitation.

CONCLUSIONS

Ensuring stroke survivors are fully informed about ESD and what to expect, optimises engagement with the services, improves experience and could enhance outcomes.IMPLICATIONS FOR REHABILITATIONInforming stroke survivors about what to expect from ESD services could optimise engagement and improve their experience.The provision of personalised and target focussed therapy at home improves stroke survivors' experience and could potentially accelerate recovery.Preparing stroke survivors early for discharge from ESD can reduce anxiety and enhance engagement with the service.

A new model to guide identity-focused multidisciplinary rehabilitation for children and young people following acquired brain injury: I-FoRM

A complexity of biological, psychological, environmental and systemic factors influences a child's adaption after acquired brain injury (ABI), all of which transform as the child matures. Multidisciplinary rehabilitation teams are challenged by balancing family system needs and the child's needs, whilst promoting the child's functional skills in difficult or unappealing tasks. This paper presents the conceptual basis for a model for use in childhood ABI neurorehabilitation to address these challenges. A non-systematic narrative review of literature pertinent to integrated neurorehabilitation of pediatric ABI was conducted. Contemporary models of adult and pediatric psychosocial adaptation involving identity following ABI were reviewed. Key findings were then synthesized with models of pediatric resilience and self-concept development. The resulting model describes a cyclical adaptation process whereby the child learns experientially about their self and their world after ABI. Processes of identity development play a central role - particularly emotive processes of self-evaluation - by influencing the child's motivation for participation, tolerance for challenge, self-regulation and emerging self-awareness. The model directs clinicians to use the psychosocial processes of identity development to enhance the child's willingness and capacity to engage in the daily challenges of rehabilitation. Further systematic development and evaluation of the model is needed.

The process of identity change following ABI from the perspectives of adolescents and their mothers: A relational grounded theory approach

This study explored the process of identity adjustment following adolescent brain injury, within the systemic context of the parent-adolescent dyad. Six young people with an ABI (mean age 16.5 years, range 15-18 years; TBI: n = 3) were individually interviewed, and six respective mothers (mean age 45 years, range 37-50 years). A novel relational qualitative grounded theory approach was used, with analyses of dyads linked in an attempt to capture the shared process of adaptation post-injury for young people and their parents. Shared themes emerged for adolescents and mothers regarding "continuity and change" and "acknowledging or rejecting" experiences of change post injury. Adolescents experienced change as an, at times, distressing sense of being "not normal". While mothers turned towards their child, working hard to try to "fix everything", adolescents sought continuity of identity in the context of peer relationships, withdrawing socially to avoid feeling abnormal, reframing or finding new relationships. Some mothers sought to fill social losses through family or disability-specific activity. This study provides a relational understanding of the process of identity adjustment post adolescent BI. Future research and clinical practice should recognize the significant work of mothers, and significance of social relationships to adolescents' emerging post-injury identity.

Developing connections for engagement in stroke rehabilitation

Background and Aims:

Engagement is increasingly recognised as important for maximising rehabilitation outcome following stroke. However, engagement can be challenging when neurological impairment impacts a persons’ ability to activate the regulatory processes necessary for engagement and in the context of a changed self. We explored engagement in stroke rehabilitation from the perspective of people with stroke with a primary focus on identifying key processes that appeared important to engagement in stroke rehabilitation.

Design and Methods:

This study drew on Interpretive Description methodology. Maximum variation and theoretical sampling were used to capture diversity in the sample and access a depth and breadth of perspectives. Data collection included semi-structured interviews with people with stroke (n = 19). Data were analysed through a collaborative and iterative process drawing on range of analytical tools including coding, memoing, diagramming and group discussions.

Findings:

Our findings highlight that engagement is a complex, nuanced, responsive, flexible and inherently two-way process. Developing connections appeared central to engagement with connections taking various forms. The most fundamental was the therapeutic connection between the person with stroke and their practitioner as it provided the foundation on which to build other connections. Connection was made possible through five collaborative processes: Knowing, Entrusting, Adapting, Investing and Reciprocating.

Conclusions:

Engagement is a social and relational process enabled through an inherently person-centred approach and active and ongoing reflexivity – highlighting the importance of a humanising approach to care where aspects of self, care and emotion are evident, for both the person with stroke and their practitioner.

It takes two to tango: The therapeutic alliance in community brain injury rehabilitation

Objective:

A positive therapeutic (or working) alliance has been associated with better outcomes for clients in the psychotherapeutic and traumatic brain injury (TBI) rehabilitation literature. The aim of this pilot study was to gain an understanding of the therapeutic alliance in community rehabilitation from the perspectives of adults with TBI and their close others who have completed a community rehabilitation programme.

Method:

This study used a constructivist, qualitative methodology which applied grounded theory analysis techniques. Using purposeful sampling, three pairs of participants (adults with TBI and close others) who had finished a community rehabilitation programme completed separate in-depth interviews which were transcribed verbatim and progressively analysed using a process of constant comparison.

Results:

A preliminary framework illustrating participants’ experience of a therapeutic alliance was generated, comprising three interconnected themes: being recognised as an individual, working together and feeling personally connected. All participants viewed being able to work together as important in their experience of community rehabilitation and described features that helped and hindered the alliance.

Conclusion:

These pilot study results demonstrate the importance of the therapeutic alliance to the rehabilitation experience of individuals with TBI and those close to them.

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

Background

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

Methods

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

Discussion

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

Trial registration

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

How does a narrative understanding of change in families post brain injury help us to humanise our professional practice?

In this paper, we critically explore the discourse of change post brain injury and challenge the dominant discourse of negative change, which alone leaves little room for other perspectives to exist. These negative changes pose a considerable risk to the well-being of families who may benefit from engaging in richer accounts making room for a more coherent and connected sense of self and family post-injury. We explore how narrative approaches provide opportunities for all practitioners to expand their professional scripts and support families to move towards a future which is not dominated by a discourse of loss. While loss and negative change is an important and very real consequence, of brain injury, focusing purely on stories of loss is life limiting for family members and can cause psychological distress. The life thread model is offered as a visible tool for all practitioners to engage with and use while working with families, providing a concrete focus for reflection and discussion of narratives relating to change which otherwise can feel quite abstract in everyday practice. We argue that one way we can humanise our professional practice is to support all practitioners to engage in a narrative understanding of family change following ABI.

The experience of families following traumatic brain injury in adult populations: A meta-synthesis of narrative structures

BACKGROUND

Traumatic brain injury has a significant effect on uninjured family members. Typically, this has been examined with a focus on psychopathological outcomes including stress, depression and anxiety. However, in recent years there has been increasing interest in the subjective experiences of families post-injury leading to a plethora of qualitative studies. Therefore, an in-depth examination and synthesis of this literature is now relevant and timely.

OBJECTIVE

To examine the subjective experiences of families following traumatic brain injury in adult populations in the sub/post-acute period through the synthesis of original qualitative research.

DESIGN

This paper presents a meta-synthesis using Thomas and Harden's framework of 'thematic synthesis' rooted in a critical realist philosophy.

DATA SOURCES

In July 2019 five electronic databases, were searched for the terms 'traumatic brain injury', 'family' and 'qualitative'. Studies were included if the primary research reported qualitative data about the subjective experiences of family members of adults with traumatic brain injury and had been published in a peer reviewed journal. Studies with mixed brain injury samples, child or adolescent traumatic brain injury or disorders of consciousness were excluded. Hand searching and citation searches were also completed.

REVIEW METHODS

Two reviewers screened titles, abstracts and full text and reached consensus through critical discussion. Thirty papers were finally agreed for inclusion in this review. Each study was then assessed for relevance, resonance and rigour using the Critical Appraisal Skills Programme (CASP) tool. Line by line coding of the findings in each paper was conducted as the basis for a thematic analysis and synthesis.

RESULTS

Descriptive themes were identified followed later by analytical themes. This final stage was informed by a narrative lens and from these, eight narrative functions belonging to four dimensions were identified from the subjective experiences of families post-traumatic brain injury. Specifically, these were: (1) Displacing and Anchoring; (2) Rupturing and Stabilising; (3) Isolating and Connecting; (4) Harming and Healing.

CONCLUSIONS

The interpretation of the narrative functions revealed the substantial existential work involved in negotiating lives, maintaining family system equilibrium and moving forward. As such, family members have their own unique narrative needs. Despite contemporary service models built around the injured person, service providers are well placed to support families in this everyday narrative work through actively attending to narrative structures and understanding the implications of these for family experience. The study protocol was registered with PROSPERO (International prospective register of systematic reviews) in July 2018 (Registration number: CRD42018085824). Tweetable abstract: This synthesis showed the immense and invisible work required for family members to maintain family system equilibrium and negotiate their lives post-TBI.

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

BACKGROUND

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

AIM

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

METHOD AND MATERIALS

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

RESULTS

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

CONCLUSION

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

SIGNIFICANCE

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

Participation in social and leisure activities while re-constructing the self: understanding strategies used by stroke survivors from a long-term perspective

PURPOSE

To further understand social and leisure (SL) participation after stroke and how it can be supported in a long-term perspective, this study aims to deepen the understanding of strategies used by long-term stroke survivors in relation to SL activities.

MATERIALS AND METHODS

The study has a qualitative design, using a grounded theory approach, and is based on in-depth interviews with 10 persons who had a stroke 15 years ago and four of their family members.

RESULTS

The findings comprise nine different strategies used by the participants. These had two overarching purposes; to protect and re-construct the post-stroke self and to enable participation in valued SL activities despite challenges. The findings are summarized in one overarching theme: "Employing different strategies to balance costs and rewards of engagement in social and leisure activities".

CONCLUSIONS

Strategies for SL participation involves balancing different priorities in life and can change over time as they are continuously influenced by various personal and environmental conditions. These findings contribute to an improved understanding of why and how people hold on to activities, give up activities and find new activities after a stroke. It also highlights the need for a long-term perspective on stroke rehabilitation and support.IMPLICATIONS FOR REHABILITATIONRe-engagement in social and leisure activities after stroke is a long-term process and various types of support may be needed during different stages of recovery and adaptation.Successful rehabilitation interventions build on an understanding of each individual's priorities, goals and strategies and how these may change or manifest over time.Special attention should be given to the individual's perception of costs and benefits in relation to engagement in activities, and the role that it has for the person's identity.By providing knowledge and supporting the use of adequate coping strategies, rehabilitation professionals can help patients find a new and accepted post-stroke identity.

Holding space and transitional space: stroke survivors' lived experience of being on an acute stroke unit. A hermeneutic phenomenological study

Despite substantial reorganisation of stroke unit provision in the United Kingdom, limited qualitative research has explored how stroke survivors experience the acute stroke unit. This hermeneutic phenomenological study used accounts from four stroke survivors who experienced one of two acute stroke units. Through detailed analysis, the acute stroke unit emerged as a meaningful space, in two distinct but interconnected forms. As holding space, the unit was understood to offer protection and safe haven, as the stroke survivors looked to cope and respond to the temporal, bodily, biographical disruption and significant vulnerability brought about by stroke and by being in hospital. Holding was fulfilled by different people (including their fellow stroke survivors) and reflected a human response to human need and existential vulnerability. This space, and the practices within it, functioned to hold them intimately but also at a distance from their prestroke lifeworld. As such, the acute stroke unit holding space was intertwined with how it supported, encouraged or provoked transition. In the transitional space of the acute stroke unit, stroke survivors described how they survived the hospital-healthcare space, stroke unit and poststroke space. This paper articulates how transition was meaningfully signified through its absence or presence, as they transformed, relinquished or re-asserted their 'self', and in one case, recovered whilst 'in there'. The findings of this study provide phenomenological insight into stroke survivors' lived experience, the meaningful holding and transitional contribution of the unit, and how these spatial forms were intertwined. These insights are discussed in relation to the existing evidence base and stroke unit provision.

End-of-life conversation from both sides of the bed: voices of family and staff

PURPOSE

Prolonged living with chronic illness and disability expands the discussion of end-of-life conversation because of the complex role of intercommunication among patient, family, and healthcare staff. Little is known about such interaction from participants' different perspectives. This qualitative case study examined end-of-life conversation among patient, family, and staff during long-term hospitalization in a neurological rehabilitation department.

METHODS

After the patient's death, 18 participants responded to in-depth semi-structured interviews: 16 healthcare staff and two family members (the patient's wife and brother). In addition, we used the wife's autoethnographic documentation of her experiences during end-of-life conversation.

RESULTS

Thematic analysis produced three themes: (1) The Rehabilitation Department's Mission - Toward Life or Death? (2) The Staff's Perception of the Patient; (3) Containing Death: End-of-life Conversation from Both Sides of the Bed. These themes represented participants' different perspectives in the intercommunication in overt and covert dialogues, which changed over time. Death's presence-absence was expressed by movement between clinging to life and anticipating death.

CONCLUSION

The study findings emphasize the importance of practitioners' training to accept and openly discuss death as an inseparable part of life-long disability, and the implementation of this stance during end-of-life care via sensitive conversations with patients and their families.IMPLICATIONS FOR REHABILITATIONIt is vital for rehabilitation professionals to be trained to process and accept end-of-life issues as a natural and inseparable part of the life discourse among people with disabilities and their families.Rehabilitation professionals need to acquire tools to grasp the spoken and unspoken issues related to life and death, and to communicate their impressions and understandings with people with disabilities and their families.Rehabilitation professionals need to encourage an open dialogue when communicating with people with disabilities and their families on processes related to parting and death.

From recovery to regaining control of life - the perspectives of people with stroke, their carers and health professionals

Aim: To understand how people with stroke and carers adapt over time, and how health professionals support transition to home.Method: A multi-perspective, prospective, qualitative, longitudinal study was conducted using in-depth semi-structured interviews one and six months after inpatient discharge. Twenty-four participants (eight triads, including people with stroke, carers and health professionals) were included. Thematic and narrative analysis facilitated identification of cross-cutting themes according to individual trajectories post-stroke.Findings: A major theme: "regaining control of life" suggested a shift in perspective after six months at home. Four sub-themes help to understand the triads' perspectives over time: i) importance of team involvement; ii) differences in perceived roles within the triad; iii) differences in expectations and collaboration within the triad and iv) planning a different future. People who were involved in supporting adaptation and rehabilitation processes were reported differently between triads and over time, showing the complexity of interrelations. A reduction in professional involvement was matched by changes in participants' goals and expectations.Conclusion: Findings suggest the importance of a dyadic perspective and a gradual increase in people with stroke and carers' active engagement. Professionals' approach throughout rehabilitation should be modified according to people with stroke and carers' changing needs and expectations.IMPLICATIONS FOR REHABILITATIONDivergence in perspectives about priorities and goals between the person with stroke their carers and healthcare professionals can lead to the creation of different agendas within rehabilitation.An open dialogue and decision-making process that involves both the person with stroke and carers is highly recommended for the identification of shared rehabilitation goals and to support ongoing recovery post discharge.A tailored approach to rehabilitation is required which focusses on shared priorities and includes individual or collective support for the person with stroke and their carers.Ongoing consultation about the desires of the person with stroke about rehabilitation, priorities and goals is important in order to tailor the professional approach to the stage individuals are at with their coping and adjustment post stroke.

Sharing stories of lived experience: A qualitative analysis of the intersection of experiences between storytellers with acquired brain injury and storytelling facilitators

Introduction

Narrative storytelling is a relational process. While interest in storytelling in brain injury rehabilitation is increasing, little attention has been directed to the interpersonal relationships experienced through storytelling. As part of a larger study exploring narrative storytelling, this paper reports on the intersection of experiences between those sharing their story and those listening to the story.

Method

A qualitative grounded theory approach informed all stages of the study. In-depth interviews were conducted with adult storytellers with severe acquired brain injury and facilitators of a storytelling advocacy programme.

Findings

Analysis of the intersection of data from 28 transcripts of interviews with eight storytellers and six facilitators was conducted. Two key relationships emerged to be central to the storytelling experience: (1) a collaborative partnership between the storytellers and the advocacy organisation, and (2) an intentional story-sharing relationship between the storytellers and facilitators. The advocacy context of helping others through story-sharing was central to the meaningfulness of the experience.

Conclusion

Narrative storytelling is a social relationship experience with much potential for building relationships in rehabilitation. Sharing stories of lived experience of disability presents an opportunity for meaningful occupational engagement, enabling social connectedness and contribution to society.

Feeling controlled or being in control? Apps for self-management among older people with neurological disability

PURPOSE

The aim of this paper was to describe how people living with a neurological disability such as multiple sclerosis, Parkinson's disease and stroke reason regarding using apps to facilitate self-management in everyday life.

MATERIAL AND METHODS

A qualitative research approach with a focus group methodology was used. The sample comprised 16 participants, 11 men and 5 women, with an average age of 64 years (ranging from 51-80 years). Six participants were diagnosed with multiple sclerosis, six with Parkinson's disease and four with stroke. Data were analyzed using thematic analysis, which is a method for identifying, analyzing and reporting patterns.

RESULTS

The results formed two themes. The first theme "using apps to have control of my health" comprises two subthemes; "monitor and take responsibility for a healthy lifestyle" and "compensate to facilitate everyday life". The second theme "using the app as a tool and means for communication" also comprised two subthemes; "dare to trust the app" and "feeling safe when sharing information with health care professionals".

CONCLUSIONS

The use of apps put increased responsibility on the person and had the possibility to make them more involved in their own care. The use of an app can facilitate a healthy lifestyle and help to monitor disease-specific symptoms. In order to be able to use apps for communication with the health care sector legislation and safety issues need to be considered.Implications for rehabilitationApps can be used for self-management if they are safe and can be trusted.People with neurological disabilities want to be involved in their healthcare and needs to be addressed by health care professionals.The use of apps grasp over a wide variety of areas this is something that may be considered in health care and something that can be addressed by interdisciplinary approaches.Ordinary health-oriented apps and disease-specific apps were used differently and for different purposes.

Finding the Way Forward: The Lived Experience of People With Stroke After Participation in a Complex Psychosocial Intervention

Stroke patients' well-being is threatened after stroke. A psychosocial intervention was developed for Norwegian stroke patients living in the community. Eight individual sessions between people with stroke and a trained health care professional were conducted 1 to 6 months post-stroke with one group of participants and 6 to 12 months post-stroke with another group. Subsequently, 19 of these stroke patients were interviewed to gain an in-depth understanding of their lived experience of the influence of the intervention on their adjustment process. Interview texts were analyzed using Ricoeur's interpretation theory. Two participants did not personally find the intervention useful. The remaining participants greatly appreciated dialogues with the empathetic intervention personnel, feeling free to discuss their fears and worries. The intervention raised these participants' awareness of their needs and resources. They were guided to resume their everyday life and adopt a future-oriented attitude. The intervention facilitated their meaning-making endeavors and post-stroke adjustment.

Recalibrating hope: A longitudinal study of the experiences of people with aphasia after stroke

Background

Hope is a critical resource for people with aphasia after stroke, sustaining people though times of distress and uncertainty and providing motivation. In the first months after stroke, hope is vulnerable to different influences, and people can struggle to identify and work towards hopes for the future. We have little knowledge about how people with aphasia experience hope in the longer term after stroke.

Objectives

To identify how people with aphasia experience hope 1 year after stroke and how hope may change in the year after stroke.

Methods

The study used an Interpretive Description methodology. Interviews were conducted with four people with aphasia who had been interviewed 1 year previously. These were analysed using content analysis.

Results

All people reported a broad sense of hope for the future. They described an active process of recalibrating their early poststroke hopes through a process of reflecting on past progress, current function and what they considered might be possible and desirable in the future. People were able to develop ‘new’ hopes that were meaningful and seemingly achievable when they had a sense of a possible, desirable future. Those who struggled to see a possible future maintained a hope that things will be good. Social supports, a sense of progress, engagement in meaningful activities and interactions appeared crucial in helping people (re)develop hopes for their future.

Conclusions

Hope and hopes for the future gradually changed after stroke. Hope, identity and social connectedness were closely entwined and could enable people to both dwell in the present and move towards desired futures. This research suggests clinicians should prioritise creating hope‐fostering environments which support people to develop hope for their future.

The experience of occupational identity disruption post stroke: a systematic review and meta-ethnography

PURPOSE

After a stroke, most individuals cannot participate in some of their valued occupations, disrupting their occupational identity. The aim of this interpretive synthesis is to systematically review the existing body of research to develop an understanding of the experience of occupational identity disruption post-stroke.

METHODS

A systematic review of the literature that included nine electronic databases, reference lists screening and grey literature checking was completed. Ten studies published between January 2012 and October 2018 were included. Meta-ethnography was used for the interpretive synthesis.

FINDINGS

A three-staged process model was created. Stage 1 illustrates the four factors involved in occupational identity disruption: "A fragmented and externalized body", "losing control, freedom and independence", "changed social and familial interactions", and "occupational participation loss". Stage two explains the experience of occupational identity disruption: "Occupational identity loss", "a de-valued self", and "threat to identity continuity". Stage three shows the individual's coping strategies: "protecting one's self", "social isolation", and "re-inventing one's occupational self".

CONCLUSIONS

Stroke impacts on an individual's occupational identity, compromising the continuity of a stroke survivor's sense of self. However, occupational identity is fluid; this can be used to support individuals to re-invent the occupational self. A conceptual model was developed to support the application of these results in clinical practice.Implications for rehabilitationOccupational identity disruption impacts on stroke survivors' self-value and sense of self continuity.Health care professionals' understanding of stroke survivors experience of occupational identity disruption could contribute to realign stroke survivors and clinicians' rehabilitation goals.Occupational participation and social interaction should be core aspects of stroke rehabilitation.Occupation-focus rehabilitation could provide opportunities for stroke survivors to pursue their desired occupational identity.

HeART of Stroke: randomised controlled, parallel-arm, feasibility study of a community-based arts and health intervention plus usual care compared with usual care to increase psychological well-being in people following a stroke

INTRODUCTION

People often experience distress following stroke due to fundamental challenges to their identity.

OBJECTIVES

To evaluate (1) the acceptability of 'HeART of Stroke' (HoS), a community-based arts and health group intervention, to increase psychological well-being; and (2) the feasibility of a definitive randomised controlled trial (RCT).

DESIGN

Two-centre, 24-month, parallel-arm RCT with qualitative and economic components. Randomisation was stratified by centre and stroke severity. Participant blinding was not possible. Outcome assessment blinding was attempted.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults ≤2 years poststroke recruited via hospital clinical teams/databases or community stroke/rehabilitation teams.

INTERVENTIONS

Artist-facilitated arts and health group intervention (HoS) (ten 2-hour sessions over 14 weeks) plus usual care (UC) versus UC.

OUTCOMES

The outcomes were self-reported measures of well-being, mood, capability, health-related quality of life, self-esteem and self-concept (baseline and 5 months postrandomisation). Key feasibility parameters were gathered, data collection methods were piloted, and participant interviews (n=24) explored the acceptability of the intervention and study processes.

RESULTS

Despite a low recruitment rate (14%; 95% CI 11% to 18%), 88% of the recruitment target was met, with 29 participants randomised to HoS and 27 to UC (57% male; mean (SD) age=70 (12.1) years; time since stroke=9 (6.1) months). Follow-up data were available for 47 of 56 (84%; 95% CI 72% to 91%). Completion rates for a study-specific resource use questionnaire were 79% and 68% (National Health Service and societal perspectives). Five people declined HoS postrandomisation; of the remaining 24 who attended, 83% attended ≥6 sessions. Preliminary effect sizes for candidate primary outcomes were in the direction of benefit for the HoS arm. Participants found study processes acceptable. The intervention cost an estimated £456 per person and was well-received (no intervention-related serious adverse events were reported).

CONCLUSIONS

Findings from this first community-based study of an arts and health intervention for people poststroke suggest a definitive RCT is feasible. Recruitment methods will be revised.

TRIAL REGISTRATION NUMBER

ISRCTN99728983.

The personal and social experiences of community-dwelling younger adults after stroke in Australia: a qualitative interview study

OBJECTIVES

To examine the personal and social experiences of younger adults after stroke.

DESIGN

Qualitative study design involving in-depth semi-structured interviews and rigorous qualitative descriptive analysis informed by social constructionism.

PARTICIPANTS

Nineteen younger stroke survivors aged 18 to 55 years at the time of their first-ever stroke.

SETTING

Participants were recruited from urban and rural settings across Australia. Interviews took place in a clinic room of the Florey Institute of Neuroscience and Mental Health (Melbourne, Australia), over an online conference platform or by telephone.

RESULTS

Four main themes emerged from the discourses: (1) psycho-emotional experiences after young stroke; (2) losing pre-stroke life construct and relationships; (3) recovering and adapting after young stroke; and (4) invalidated by the old-age, physical concept of stroke. While these themes ran through the narratives of all participants, data analysis also drew out interesting variation between individual experiences.

CONCLUSIONS

For many younger adults, stroke is an unexpected and devastating life event that profoundly diverts their biography and presents complex and continued challenges to fulfilling age-normative roles. While adaptation, resilience and post-traumatic growth are common, this study suggests that more bespoke support is needed for younger adults after stroke. Increasing public awareness of young stroke is also important, as is increased research attention to this problem.

Exploring challenges at 6 months after stroke: what is important to patients for self-management?

Background/Aims:

Self-management models have recently been applied to stroke, but the most effective components are yet to be determined. To inform the ongoing refinement of stroke self-management programmes, this study explored challenges at 6 months after stroke.

Methods:

A total of 53 stroke survivors and 26 significant others were interviewed 6 months after stroke. Results were analysed qualitatively using thematic analysis.

Findings:

Stroke was experienced as a shocking and frightening event regardless of severity, and participants struggled to manage the consequences of their stroke. The stroke experience occurred within the context of more than one chronic condition and with competing demands of everyday life. Participants struggled to formulate a model of causation for their stroke, yet this appeared a necessary basis for action.

Conclusions:

The findings suggest that health care targeted at enhancing self-management, including self-management programmes, may benefit from encompassing a specific focus on participants' beliefs as an important foundation for recovery after stroke.

Meaning Making Process and Recovery Journeys Explored Through Songwriting in Early Neurorehabilitation: Exploring the Perspectives of Participants of Their Self-Composed Songs Through the Interpretative Phenomenological Analysis

Objectives: This pilot study examined how 15 participants in early rehabilitation described their self-composed Songs 6- to 12-months following participation in a 6-week identity-focused songwriting program. Specific focus was given to the process of meaning making and identity reconstruction in the participants’ self-composed songs.

Methods: Data were collected through individual semi-structured interviews (n = 15) and analyzed using interpretative phenomenological analysis. Findings were developed idiographically as super-ordinate themes unique to each participant, then analyzed across cases to identify recurrent themes and subthemes.

Results: Participants described the songwriting process as taking them through one of four distinct recovery journeys described by individuals following acquired neurodisability who underwent a focused therapeutic songwriting program. These included (1) re-conceptualizing values and shifting perspectives about self (my body is broken but my mind has been set free); (2) recognizing acquired inner resources to negotiate discrepancies in self (hope is there); (3) confirming existing values and identifying resources and coping strategies (I have what I need to move forward); (4) confirming previously held values and ongoing process of negotiating discrepancies in self (I don’t yet have the answers).

Conclusion: The current study provides insight into the nature and process of meaning making and recovery journeys perceived by individuals with neurodisability. Our findings suggest that songwriting could be a therapeutic tool to facilitate identity reconstruction in neurorehabilitation.

"I'm still me - I'm still here!" Understanding the person's sense of self in the provision of self-management support for people with progressive neurological long-term conditions

PURPOSE

There is increasing interest in tailoring self-management support, but little detail is available on the relevance and impact of such approaches for people with progressive neurological conditions. The aim of this study was to draw on individuals' experiences to inform the practice of self-management support for these groups.

METHOD

Community rehabilitation service users were purposively recruited and took part in in-depth qualitative interviews. Interviews were audio-recorded and transcribed. Data analysis was iterative and interpretative, taking a phenomenological approach. Strategies to enhance rigor were auditability, peer review, and researcher reflexivity.

RESULTS

The sample consisted of 10 adults (age 20-79 years) who were living with a range of progressive neurological conditions. Individuals demonstrated resourcefulness in developing practice-based self-management strategies. Beyond practical strategies, interviewees' experiences were signified by reflecting on and upholding a sense of identity and a desire for purpose against the background of losses and gains over time. Linking with this overarching theme of "Sense of self" were aspects of "My body and mind", "Time", "Space", "Relationships", and "What I do".

CONCLUSIONS

Self-management approaches for individuals with progressive neurological conditions will benefit from incorporating ways of recognizing, articulating, and supporting the person's sense of identity and purpose. Implications for rehabilitation Self-management approaches for people with progressive neurological conditions need to take account of individuals' wishes to contribute, connect with others, and be valued as a person. Person-centred self-management support can be realized through a broader approach than solely managing disease progression. The experiences and words of people with progressive neurological conditions can be used to inform meaningful evaluation of self-management support to drive service delivery by measuring what really matters. Rehabilitation practitioners need to adapt their conceptualisations of goal setting to account for how people with progressive neurological conditions themselves interpret "progress" and "improvement". Person-centred conversation that values who the person is can be an effective starting point for self-management interventions in people with progressive neurological conditions.

Enjoyable company in sharing stroke experiences; - lifestyle groups after stroke

BACKGROUND

Even people with mild to moderate stroke will experience changes in their abilities to perform everyday occupations. Group interventions may be appropriate in late-stage rehabilitation. The aim of this study was to explore how the participants involved themselves in person-centered lifestyle groups after stroke in Norway.

METHOD

Semi-structured interviews were performed with six older adults with mild-to-moderate stroke who had participated in lifestyle groups over a period of nine months. The interviews were analyzed using qualitative content analysis.

RESULTS

The participants involved themselves in the lifestyle groups in a variety of ways by creating enjoyable company in sharing stroke experiences, sharing knowledgeable interest, pushing and forcing each other forward and reflecting on self-worth. Through doing group activities together, they created various ways of being, belonging and becoming, addressing development of strategies for regaining self-belief and a sense of autonomy, and for adapting to everyday life post-stroke.

CONCLUSION

The participants were active contributors in the groups and pushed each other and themselves regarding involvement in meaningful occupations. This active participation seemed to bring the participants' resources into focus and contrasted with the frequent negative perceptions of people post-stroke as 'victims'.

Constructing robust selves after brain injury: positive identity work among members of a female self-help group

Despite common experiences of identity damage, decline, and deterioration, many brain injury survivors succeed in reconstructing robust identities in the wake of injury. Yet, while this accomplishment greatly benefits survivors' quality of life, little is known about how positive identity work might be facilitated or enhanced in therapeutic institutions. Drawing on data from a women's self-help group, we argue that an egalitarian, reflective, strength-focused, and gender-segregated environment can provide female ABI (acquired brain injury) survivors with a fertile scene for identity enhancement and offer unique opportunities for collective identity development. Sociolinguistic interactional analysis revealed four types of positive identity work undertaken within the group: constructing competent selves; tempering the threat of loss and impairment; resisting infantilisation and delegitimisation; and asserting a collective gender identity. This identity work was facilitated by specific programme attributes and activities and contributed to the global project of decentring disability and destigmatising impairments and losses. We call for increased attention to identity issues in brain injury rehabilitation and argue that gender-segregated programming can provide a unique space for female survivors to construct empowering individual and collective identities after injury.

Body, Person and Environment: Why Promoting Physical Activity (PA) with Stroke Survivors Requires Holistic Thinking

The role of physical activity (PA) after stroke is increasingly recognised as important for function, fitness and wellbeing. Current evidence shows that targeted PA after stroke improves cardiovascular fitness, walking ability and muscle strength and may ameliorate depression and improve quality of life. Secondary stroke prevention and management of cardiovascular risk factors are further health benefits. Despite increasing emphasis on organised exercise classes for stroke, PA levels remain low and effects of organised exercise interventions are not maintained once programmes have finished. Barriers to PA after stroke are complex and innovative approaches to maintaining and promoting long-term engagement in activity are required. This commentary proposes that using the International Classification of Disability and Functioning (ICF) to guide thinking about PA after stroke may help us develop and apply comprehensive solutions that increase PA levels. This approach considers stroke survivors’ PA engagement in terms of Body – the physical impairments imposed by stroke; Person – the role of identity, and psychological factors on PA; and Environment – the physical and social environments that influence PA engagement. The commentary discusses how innovative solutions addressing these issues may enable stroke survivors to be better supported to lead active lifestyles.

Negotiating role management through everyday activities: narratives in action of two stroke survivors and their spouses

PURPOSE

To manage social roles is a challenging part of self-management post-stroke. This study explored how stroke survivors act as role managers with their spouses in the context of everyday activities.

METHOD

Two stroke survivors with a first time stroke living at home with a spouse were included. Data were generated through participant observations at their own environment at 3, 6, 9, 15 and 21 months post-discharge. The narrative analysis focused on the actions of participants.

RESULTS

Daily activities can be understood as an arena where role management and a meaningful live is negotiated and co-constructed with others. Everyday activities gave stroke survivors and their spouses insight into stroke survivors' capacities in daily situations. This was sometimes empowering, and other times conflicting when a spouse had negative perceptions of the abilities of the stroke survivors.

CONCLUSION

The findings add to the current understanding of self-management and role management with regard to how these are situated in everyday activities. Daily activities can help both spouses to reflect and understand about self-management, role management and comanagement in daily life. Moreover, observing stroke survivors in everyday situations provides professionals with concrete pictures of stroke survivors' performance and self-management in interaction with their spouses. Implications for Rehabilitation Self-management is a dynamic process in which individuals actively manage a chronic condition and finally live a meaningful life with a long-term chronic condition; self-management can be divided into medical, role, and emotional management; comanagement is when individuals activate resources and use the capacities of other persons to manage a situation together. Self-management is situated in everyday activities. Everyday activities give stroke survivors ánd their partners impressions about stroke survivors' self-management abilities post-stroke in an everyday context. Everyday activities give stroke survivors ánd their partners an arena where role management and a meaningful life are negotiated and coconstructed through doing. Observing stroke survivors in everyday situations provides professionals a concreter picture of stroke survivors' self-management and comanagement with their partners than can be obtained from an informal interview.

'HeART of Stroke (HoS)', a community-based Arts for Health group intervention to support self-confidence and psychological well-being following a stroke: protocol for a randomised controlled feasibility study

INTRODUCTION

Over 152,000 people in the UK have strokes annually and a third experience residual disability. Low mood also affects a third of stroke survivors; yet psychological support is poor. While Arts for Health interventions have been shown to improve well-being in people with mild-to-moderate depression post-stroke, their role in helping people regain sense of self, well-being and confidence has yet to be evaluated. The main aim of this study is to explore the feasibility of conducting a pragmatic multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of an Arts for Health group intervention ('HeART of Stroke' (HoS)) for stroke survivors. HoS is a 10-session artist-facilitated group intervention held in the community over 14 weeks. It offers a non-judgemental, supportive environment for people to explore sense of self, potentially enhancing well-being and confidence.

METHODS AND ANALYSIS

Sixty-four people, up to 2 years post-stroke, recruited via secondary care research staff or community stroke/rehabilitation teams in two UK centres will be randomised to either HoS plus usual care or usual care only. Self-reported outcomes, measured at baseline and approximately 5 months postrandomisation, will include stroke-related, well-being, mood, self-esteem, quality of life and process measures. Analyses will focus on estimating key feasibility parameters (eg, rates of recruitment, retention, intervention attendance). We will develop outcome and resource use data collection methods to inform an effectiveness and cost-effectiveness analysis in the future trial. Interviews, with a sample of participants, will explore the acceptability of the intervention and study processes, as well as experiences of the HoS group.

ETHICS AND DISSEMINATION

National Health Service (NHS), Research and Development and University ethical approvals have been obtained. Two peer-reviewed journal publications are planned plus one service user led publication. Findings will be disseminated at key national conferences, local stakeholder events and via institutional websites.

TRIAL REGISTRATION NUMBER

ISRCTN99728983.