Benchmarking as everyday functional assessment in stroke recovery

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Goals for living with a chronic condition: The relevance of temporalities, dispositions, and resources

INTRODUCTION

Premised on the idea that setting goals motivates action and allocation of resources toward a desired future state, goal-setting has become a key component of self-management support. The notions that underpin goal-setting situate self-management firmly within the control and responsibility of individuals. Yet, we argue that goals are not solely individual pursuits to be achieved if individuals have the right knowledge and enough motivation; rather, they are social products, influenced by individual and collective subjectivities, which are structured over time.

OBJECTIVE

Drawing primarily on Bourdieu's concept of habitus, along with capital and field, we examine how goals are constructed in self-management support encounters.

METHOD

Seventeen patient-professional dyads comprising 15 patients and 11 health professionals were interviewed on up to three occasions. In total 64 semi-structured interviews were conducted between 2015 and 2017 in Sydney, Australia.

RESULTS

Goals were manifested through patient participants' expressions of goal agency (as self-owned wants and opportunities; responsibilities to self and others; or necessities); goal-oriented dispositions (determined; responsible; or powerless); temporal orientations (past, present or future); and access to resources to support self-management. These characteristics were grouped into three typologies: 'Goals as opportunities'; 'From goals to responsibilities'; and 'Necessities when living precariously'.

CONCLUSIONS

The way goals were constructed was structured over time by present experiences superimposed on past experiences and access to resources. These findings help broaden understandings of the tensions between patient and professionals' goals for living well with chronic conditions and draw attention to the need for structural change to support people to live well with their chronic conditions.

Experiences of treadmill walking with non-immersive virtual reality after stroke or acquired brain injury - A qualitative study

Objectives

It is well known that physical activity levels for persons after stroke or acquired brain injuries do not reach existing recommendations. Walking training is highly important since the ability to walk is considered to be a meaningful occupation for most people, and is often reduced after a brain injury. This suggests a need to innovate stroke rehabilitation, so that forms of walking training that are user-friendly and enjoyable can be provided.

Method

An interview study was carried out with persons after stroke (n = 8), or acquired brain injury (n = 2) at a rehabilitation unit at Sahlgrenska University Hospital. We used a semi-structured interview guide to investigate experiences and thoughts about walking on a treadmill with non-immersive virtual reality feedback. The contents were analyzed through an inductive approach, using qualitative content analysis.

Results

The virtual reality experience was perceived as enjoyable, exciting, and challenging. Participants stressed that the visual and auditory feedback increased their motivation to walk on a treadmill. However, for some participants, the virtual reality experience was too challenging, and extreme tiredness or fatigue were reported after the walking session.

Conclusions

Participants’ thoughts and experiences indicated that the Virtual Reality walking system could serve as a complement to more traditional forms of walking training. Early after a brain injury, virtual reality could be a way to train the ability to handle individually adapted multisensory input while walking. Obvious benefits were that participants perceived it as engaging and exciting.

Patients' and Health Professionals' Experiences of Using Virtual Reality Technology for Upper Limb Training after Stroke: A Qualitative Substudy

Background

In recent years, virtual reality (VR) therapy systems for upper limb training after stroke have been increasingly used in clinical practice. Therapy systems employing VR technology can enhance the intensity of training and can also boost patients' motivation by adding a playful element to therapy. However, reports on user experiences are still scarce.

Methods

A qualitative investigation of patients' and therapists' perspectives on VR upper limb training. Semistructured face-to-face interviews were conducted with six patients in the final week of the VR intervention. Therapists participated in two focus group interviews after the completion of the intervention. The interviews were analyzed from a phenomenological perspective emphasizing the participants' perceptions and interpretations.

Results

Five key themes were identified from the patients' perspectives: (i) motivational factors, (ii) engagement, (iii) perceived improvements, (iv) individualization, and (v) device malfunction. The health professionals described the same themes as the patients but less positively, emphasizing negative technical challenges.

Conclusion

Patients and therapists mainly valued the intensive and motivational character of VR training. The playful nature of the training appeared to have a significant influence on the patients' moods and engagement and seemed to promote a "gung-ho" spirit, so they felt that they could perform more repetitions.

Health state descriptions to elicit stroke values: do they reflect patient experience of stroke?

Background

To explore whether stroke health state descriptions used in preference elicitation studies reflect patients’ experiences by comparing published descriptions with qualitative studies exploring patients’ lived experience.

Methods

Two literature reviews were conducted: on stroke health state descriptions used in direct preference elicitation studies and the qualitative literature on patients’ stroke experience. Content and comparative thematic analysis was used to identify characteristics of stroke experience in both types of study which were further mapped onto health related quality of life (HRQOL) domains relevant to stroke. Two authors reviewed the coded text, categories and domains.

Results

We included 35 studies: seven direct preference elicitation studies and 28 qualitative studies on patients’ experience. Fifteen coded categories were identified in the published health state descriptions and 29 in the qualitative studies. When mapped onto domains related to HRQOL, qualitative studies included a wider range of categories in every domain that were relevant to the patients’ experience than health state descriptions.

Conclusions

Variation exists in the content of health state descriptions for all levels of stroke severity, most critically with a major disjuncture between the content of descriptions and how stroke is experienced by patients. There is no systematic method for constructing the content/scope of health state descriptions for stroke, and the patient perspective is not incorporated, producing descriptions with major deficits in reflecting the lived experience of stroke, and raising serious questions about the values derived from such descriptions and conclusions based on these values.

Long-term recovery trajectory after stroke: an ongoing negotiation between body, participation and self

PURPOSE

Research has mainly focused on the first year of recovery trajectory after stroke, but there is limited knowledge about how stroke survivors manage their long-term everyday lives. This study seeks to fill this gap by exploring the long-term (1-13 years) negotiations of stroke survivors when they experience progress, wellbeing and faith in the future.

METHOD

Repeated in-depth interviews were conducted with nine people living with moderate impairment after stroke and their closest relatives. Concepts from phenomenology and critical psychology constituted the frame of reference of the study.

RESULTS

The long-term stroke recovery trajectory can be understood as a process of struggling to overcome tensions between three phenomena under ongoing change: the lived body, participation in everyday life and sense of self. During the recovery process, stroke survivors experience progress, well-being and faith in the future when moving towards renewed relationships, characterised by (1) a modified habitual body, (2) repositioned participation in specific everyday life contexts and (3) a transformed sense of self.

CONCLUSIONS

This study stresses the importance of developing new forms of professional support during the long-term recovery trajectory, to stimulate and increase interaction and coherence in the relationship between the stroke survivor's bodily perception, participation in everyday life and sense of self.

IMPLICATIONS FOR REHABILITATION

The study deepening how the long-term recovery trajectory after stroke is about ongoing embodied, practical and socially situated negotiations. The study demonstrates that the recovery trajectory is a long term process of learning where the stroke survivor, as an embodied agent, gradually modifies new bodily habits, re-position participation and transforming of the self. Health personnel are usually available in the acute and early rehabilitation period. The three phenomenons under ongoing change; "body", "participation" and "self" are at this point just about being moved toward a renewed and a more coherent relationship in the stroke survivor long-lasting everyday life situated recovery trajectory. Available rehabilitation services at the municipal level supporting stroke survivors and relatives practical, social and interpersonal long-term challenges in everyday life can be important for minimizing their struggles and for promoting the experience progress, wellbeing and faith in the future.

Residential normalcy and the enriched coping repertoires of successfully aging older adults

An earlier theoretical model equated the construct of residential normalcy with older persons positively appraising their residential environments. Failing to achieve congruent places to live, they initiate assimilative (action) or accommodative (mind) coping strategies. This paper theorizes that the assimilative coping strategies of older persons depend on their secondary appraisal processes whereby they judge the availability, efficaciousness, and viability of their coping options. Older persons with more enriched coping repertoires are theorized as more resilient, making their own decisions, and with access to more resource-rich objectively defined resilient environments. Successful aging formulations infrequently examine how residential environmental adaptations of people influence the quality of their lives. Programmatically, the theory emphasizes the potential of individual and environmental interventions targeting older persons who are not aging successfully.

Residential normalcy and the enriched coping repertoires of successfully aging older adults

An earlier theoretical model equated the construct of residential normalcy with older persons positively appraising their residential environments. Failing to achieve congruent places to live, they initiate assimilative (action) or accommodative (mind) coping strategies. This paper theorizes that the assimilative coping strategies of older persons depend on their secondary appraisal processes whereby they judge the availability, efficaciousness, and viability of their coping options. Older persons with more enriched coping repertoires are theorized as more resilient, making their own decisions, and with access to more resource-rich objectively defined resilient environments. Successful aging formulations infrequently examine how residential environmental adaptations of people influence the quality of their lives. Programmatically, the theory emphasizes the potential of individual and environmental interventions targeting older persons who are not aging successfully.

The art of (re)learning to walk: trust on the rehabilitation ward

Although trust has significant implications for health outcomes, the mechanisms by which its presence or absence influences these outcomes require elucidation. Drawing on ethnographic research conducted in southeast Australia, we explore the tasks of rehabilitation for people who lost a limb because of vascular disease, and the importance of trust in the relationships of patients with their health professionals. Trust underpins procedures and practices designed to minimize problems that might delay rehabilitation or result in the continuing need for medical support and surveillance. Patients develop trust in the rehabilitation team based on three factors: competence, agency, and caring. Our findings emphasize how social skills, as well as technical competence, enable health professionals to gain and maintain their patients' trust.

Understanding the experience of stroke: a mixed-method research agenda

The use of both quantitative and qualitative strategies to examine a single research question has been a subject of considerable controversy and still remains a largely uncommon practice in the sociology of health and illness. Yet, when seeking to understand the meaning of a chronic disabling condition in later life from a social psychological perspective, a mixed-method approach is likely to provide the most comprehensive picture. This article provides an overview of the usefulness and appropriateness of a mixed-method approach to understanding the stroke experience. I comment on the current state of research on the experience of stroke, including epistemological and ontological orientations. Using real data examples, I address paradigmatic assumptions, methods of integration, as well as challenges and pitfalls in integrating methods. I conclude by considering future directions in this field of research.

Communication in Assisted Living

This study of communication in an Assisted Living Facility (ALF) focuses on staff's interpretive frameworks and situational tactics for managing elderly residents. It is based on interviews with staff and residents in an ALF together with ethnographic fieldwork. As in other quasi-total institutions, staff members engage in control as well as care, monitoring residents for compliance with rules and directives. Residents, aware of the threat of being moved to a nursing home, also monitor their own behavior and cognition in comparison to other residents. Other communication issues include the infantilization of the elderly by staff, and the race, class, and ethnic prejudices of residents.

The Stroke Self-Efficacy Questionnaire: measuring individual confidence in functional performance after stroke

AIMS AND OBJECTIVES

The aim was to develop a questionnaire for use by practitioners working in stroke care to measure self-efficacy judgements in specific domains of functioning relevant to individuals following stroke.

BACKGROUND

The prevalence of stroke is set to rise across the developed world especially amongst the elderly population. Recovery and adjustment in the longer term can be affected by many different factors. Current objective measures of functional performance used in many stroke programmes may not fully explain the extent of personal levels of confidence that could ultimately influence outcome.

METHODS

Three separate studies were conducted to develop the Stroke Self-Efficacy Questionnaire. A total of 112 stroke survivors, between 2 and 24 weeks, poststroke participated in the study. Development of the scale was undertaken between 2004 and 2006.

RESULTS

The final 13-item Stroke Self-Efficacy Questionnaire was found to have good face validity and feasibility to use in the recovery period following stroke. Cronbach Alpha was 0.90 suggesting good internal consistency, and criterion validity was high compared with the Falls Efficacy Scale, r = 0.803, p < 0.001. The Stroke Self-Efficacy Questionnaire was also able to discriminate between those participants walking and not walking.

CONCLUSIONS

Preliminary psychometric testing of the new Stroke Self-Efficacy Questionnaire has indicated that it is a valid measure of confidence for functional performance and aspects of self-management relevant for individuals recovering from stroke.

RELEVANCE TO CLINICAL PRACTICE

The Stroke Self-Efficacy Questionnaire could assist clinicians and researchers working in acute stroke care and rehabilitation to screen levels of confidence of stroke survivors in relation to functional performance and self-management. The Stroke Self-Efficacy Questionnaire could be used as part of battery of stroke outcome measures to provide a more comprehensive overview of factors influencing performance in the individuals recovering from a stroke.

Evaluative criteria for qualitative research in health care: controversies and recommendations

PURPOSE

We wanted to review and synthesize published criteria for good qualitative research and develop a cogent set of evaluative criteria.

METHODS

We identified published journal articles discussing criteria for rigorous research using standard search strategies then examined reference sections of relevant journal articles to identify books and book chapters on this topic. A cross-publication content analysis allowed us to identify criteria and understand the beliefs that shape them.

RESULTS

Seven criteria for good qualitative research emerged: (1) carrying out ethical research; (2) importance of the research; (3) clarity and coherence of the research report; (4) use of appropriate and rigorous methods; (5) importance of reflexivity or attending to researcher bias; (6) importance of establishing validity or credibility; and (7) importance of verification or reliability. General agreement was observed across publications on the first 4 quality dimensions. On the last 3, important divergent perspectives were observed in how these criteria should be applied to qualitative research, with differences based on the paradigm embraced by the authors.

CONCLUSION

Qualitative research is not a unified field. Most manuscript and grant reviewers are not qualitative experts and are likely to embrace a generic set of criteria rather than those relevant to the particular qualitative approach proposed or reported. Reviewers and researchers need to be aware of this tendency and educate health care researchers about the criteria appropriate for evaluating qualitative research from within the theoretical and methodological framework from which it emerges.

Reasons for recovery after stroke: a perspective based on personal experience

PURPOSE

The purpose of this study was to learn more about individual beliefs and personal strategies used to support the period of recovery after stroke. It sought to identify the factors that were perceived to be enablers as well as challenges to recovery. Personal actions or experiences, which were perceived to be effective in influencing progress, would be identified.

METHOD

Qualitative in-depth interviews were carried out with 10 participants (mean age 61.8 years). Time following stroke onset ranged between 6 weeks and 13 months. All participants had some residual activity limitation and three participants had varying degrees of aphasia. The interviews were approximately 60 - 90 minutes and all data was subjected to content analysis.

RESULTS

Analyses of interview data identified two main themes which were perceived to have influenced progress after stroke. The first related to internal factors such as personal control over progress, optimism and fears of dependency and the second included more external factors, such as the influence of therapeutic interactions and success with a specified marker of independence such as dressing, washing and walking.

CONCLUSION

An important finding of this study was that individuals all identified a number of specific factors which had supported or hindered their own recovery. There were a diversity of both internal/personal and external factors which may not be surprising, given the complexity of stroke, but all participants stressed the importance of both factors. The findings from this study are preliminary and relate only to this particular group of participants, as such they cannot be generalizable to the stroke population as a whole. However, the interaction between the two themes identified requires further exploration, especially in relation to therapy which could have both a positive and negative influence on personal control. There is a clear need to understand how professionals can, in the first place, take time to identify each individual's preferences and personal goals and secondly, make sure that these are fully addressed in a planned treatment programme. This will ensure that progress in individuals after stroke is supported by professionals with a more eclectic, individualized approach.

Constructing the stroke: sudden-onset narratives of stroke survivors

In this article, the authors explore the narrative production of stroke from the perspectives of survivors, that is, the stroke itself, not its implications for the individual poststroke. In the vast amount of literature on both sudden onset and chronic illness, the narrative construction of the onset of the illness, for the most part, has been ignored by social scientists, most notably in qualitative research. This is certainly true of stroke. Drawing on existing literature in both chronic illness and the body, the authors extend this to explore the phenomenological construction of stroke onset. Using data gathered from in-depth interviews with 111 stroke survivors postdischarge, they suggest three narrative mechanisms are used in the construct of the sudden-onset event itself: the use of typifications to construct the body during stroke, stroke as an internal communicative act, and stroke as a physical sensation and the mechanisms used to minimize bodily concerns.

Sudden illness and biographical flow in narratives of stroke recovery

The conceptual framework of biographical disruption has dominated studies into the everyday experience of chronic illness. Biographical disruption assumes that the illness presents the person with an intense crisis, regardless of other mitigating factors. However, our data suggests that the lives of people who have a particular illness that is notably marked by sudden onset are not inevitably disrupted. Extensive qualitative interviews were conducted with a sample of veteran non-Hispanic white, African-American, and Puerto Rican Hispanic stroke survivors, at one month, six months and twelve months after being discharged home from hospital. Narrative excerpts are presented to describe specific discursive resources these people use that offset the disrupting connotations of stroke. Our findings suggest a biographical flow more than a biographical disruption to specific chronic illnesses once certain social indicators such as age, other health concerns and previous knowledge of the illness experience, are taken into account. This difference in biographical construction of the lived self has been largely ignored in the literature. Treating all survivor experiences as universal glosses over some important aspects of the survival experience, resulting in poorly designed interventions, and in turn, low outcomes for particular people.