Interventions to improve outdoor mobility among people living with disabilities: A systematic review

Background

Around 15% of the global population live with some form of disabilities and experience worse health outcomes, less participation in the community and are part of fewer activities outside the home. Outdoor mobility interventions aim to improve the ability to move, travel and orient outside the home and could influence the number of activities outside the home, participation and quality of life. However, outdoor mobility interventions may also lead to harm like falls or injuries or have unforeseen effects which could lead to mortality or hospitalization.

Objectives

To assess the efficacy of interventions aiming to improve outdoor mobility for adults living with disabilities and to explore if the efficacy varies between different conditions and different intervention components.

Search Methods

Standard, extensive Campbell search methods were used, including a total of 12 databases searched during January 2023, including trial registries.

Selection Criteria

Only randomized controlled trials were included, focusing on people living with disabilities, comparing interventions to improve outdoor mobility to control interventions as well as comparing different types of interventions to improve outdoor mobility.

Data Collection and Analysis

Standard methodological procedures expected by Campbell were used. The following important outcomes were 1. Activity outside the home; 2. Engagement in everyday life activities; 3. Participation; 4. Health-related Quality of Life; 5. Major harms; 6. Minor harms. The impact of the interventions was evaluated in the shorter (≤6 months) and longer term (≥7 months) after starting the intervention. Results are presented using risk ratios (RR), risk difference (RD), and standardized mean differences (SMD), with the associated confidence intervals (CI). The risk of bias 2-tool and the GRADE-framework were used to assess the certainty of the evidence.

Main Results

The screening comprised of 12.894 studies and included 22 studies involving 2.675 people living with disabilities and identified 12 ongoing studies. All reported outcomes except one (reported in one study, some concerns of bias) had overall high risk of bias. Thirteen studies were conducted in participants with disabilities due to stroke, five studies with older adults living with disabilities, two studies with wheelchair users, one study in participants with disabilities after a hip fracture, and one study in participants with cognitive impairments. Skill training interventions versus control interventions (16 studies) The evidence is very uncertain about the benefits and harms of skill training interventions versus control interventions not aimed to improve outdoor mobility among all people living with disabilities both in the shorter term (≤6 months) and longer term (≥7 months) for Activity outside the home; Participation; Health-related Quality of Life; Major harms; and Minor harms, based on very low certainty evidence. Skill training interventions may improve engagement in everyday life activities among people with disabilities in the shorter term (RR: 1.46; 95% CI: 1.16 to 1.84; I 2 = 7%; RD: 0.15; 95% CI: -0.02 to 0.32; I 2 = 71%; 692 participants; three studies; low certainty evidence), but the evidence is very uncertain in the longer term, based on very low certainty evidence. Subgroup analysis of skill training interventions among people living with disabilities due to cognitive impairments suggests that such interventions may improve activity outside the home in the shorter term (SMD: 0.44; 95% CI: 0.07 to 0.81; I 2 = NA; 118 participants; one study; low certainty evidence). Subgroup analysis of skill training interventions among people living with cognitive impairments suggests that such interventions may improve health-related quality of life in the shorter term (SMD: 0.49; 95% CI: 0.12 to 0.88; I 2 = NA; 118 participants; one study; low certainty evidence). Physical training interventions versus control interventions (five studies) The evidence is very uncertain about the benefits and harms of physical training interventions versus control interventions not aimed to improve outdoor mobility in the shorter term (≤6 months) and longer term (≥7 months) for: Engagement in everyday life activities; Participation; Health-related Quality of Life; Major harms; and Minor harms, based on very low certainty evidence. Physical training interventions may improve activity outside the home in the shorter (SMD: 0.35; 95% CI: 0.08 to 0.61; I 2 = NA; 228 participants; one study; low certainty evidence) and longer term (≥7 months) (SMD: 0.27; 95% CI: 0.00 to 0.54; I 2 = NA; 216 participants; one study; low certainty evidence). Comparison of different outdoor mobility interventions (one study) The evidence is very uncertain about the benefits and harms of outdoor mobility interventions of different lengths in the shorter term (≤6 months) and longer term (≥7 months) for Activity outside the home; Engagement in everyday life activities; Participation; Health-related Quality of Life; Major harms; and Minor harms, based on very low certainty evidence. No studies explored the efficacy of other types of interventions.

Authors’ Conclusions

Twenty-two studies of interventions to improve outdoor mobility for people living with disabilities were identified, but the evidence still remains uncertain about most benefits and harms of these interventions, both in the short- and long term. This is primarily related to risk of bias, small underpowered studies and limited reporting of important outcomes for people living with disabilities. For people with disabilities, skill training interventions may improve engagement in everyday life in the short term, and improve activity outside the home and health-related quality of life for people with cognitive impairments in the short term. Still, this is based on low certainty evidence from few studies and should be interpreted with caution. One study with low certainty evidence suggests that physical training interventions may improve activity outside the home in the short term. In addition, the effect sizes across all outcomes were considered small or trivial, and could be of limited relevance to people living with disabilities. The evidence is currently uncertain if there are interventions that can improve outdoor mobility for people with disabilities, and can improve other important outcomes, while avoiding harms. To guide decisions about the use of interventions to improve outdoor mobility, future studies should use more rigorous design and report important outcomes for people with disabilities to reduce the current uncertainty.

Non-pharmacological interventions on quality of life in stroke survivors: A systematic review and meta-analysis

BACKGROUND

Non-pharmacological interventions have been used in the rehabilitation of stroke survivors, but their effects on stroke survivors' quality of life (QoL) are unknown.

AIM

This review aimed to summarize the existing evidence regarding non-pharmacological interventions for QoL in stroke survivors and to evaluate the effectiveness of different types of interventions.

METHODS

We systematically searched databases including PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical Literature Database, China Science and Technology Journal Database, and Wanfang data from the earliest available records to March 2023. Randomized controlled trials which explored the effects of non-pharmacological interventions on QoL in stroke patients were included. The meta-analysis was conducted to evaluate the effectiveness of different interventions on QoL. The Review Manager 5.3 was used to conduct the meta-analysis and the revised Cochrane risk-of-bias tool was used to assess the methodological quality of trials.

RESULTS

A total of 93,245 records were identified, and 34 articles were reviewed and summarized, of which 20 articles were included in the meta-analysis. The summary of the findings of the included studies revealed fitness training, constraint-induced movement therapy (CIMT), physical exercise, music therapy (MT), and art-based interventions may have positive effects on QoL. The fitness training improved total QoL, especially in physical domains including physical functioning (mean difference [MD] = 10.90; 95% CI [7.20, 14.59]), role physical (MD = 10.63; 95% CI [6.71, 14.55]), and global health (MD = 8.76; 95% CI [5.14, 12.38]). The CIMT had a slight effect on general QoL (standardized mean difference [SMD] = 0.48, 95% CI [0.16, 0.80]), whereas significantly improved strength (MD = 8.84; 95% CI [1.31, 16.38]), activities of daily living/instrumental activities of daily living (ADL/IADL; MD = 10.42; 95% CI [2.98, 17.87]), and mobility (MD = 8.02; 95% CI [1.21, 14.83]). MT had a positive effect on the mental health domain (SMD = 0.54; 95% CI [0.14, 0.94]).

LINKING EVIDENCE TO ACTION

Our findings suggest that fitness training and CIMT have a significant effect on improving physical QoL, while MT has a positive effect on improving psychological QoL. Future studies may use comprehensive and multicomponent interventions to simultaneously improve the patients' physical, psychological, and social QoL.

Evaluations of virtual exercise programmes for adults with mobility limitations: a scoping review protocol incorporating an equity lens to inform the development of strategies to optimise participation of under-represented groups

INTRODUCTION

For individuals with mobility limitations, virtual exercise programmes can address the challenges of in-person participation in community exercise programmes. A synthesis of studies of virtual exercise programmes targeting mobility limitations provided outside of conventional rehabilitation services and strategies used to optimise equitable access and inclusivity in these programmes is lacking. We aim to characterise evaluations of virtual exercise programmes for adults with mobility limitations, and the nature of and extent to which equity, diversity and inclusion considerations are integrated in the research process.

METHODS AND ANALYSIS

A scoping review following a six-stage methodological framework, including a consultation exercise, is proposed. A comprehensive strategy will be used to search Medline, Embase, PEDro, CINAHL and Scopus to identify peer-reviewed studies evaluating virtual exercise programmes for adults with mobility limitations living in the community. Three trained reviewers will select studies independently. Data (eg, study methodology, programme structure and content, participant characteristics) will be extracted using a standardised form, and collated and summarised using quantitative and qualitative methods. The PROGRESS-Plus and International Classification of Functioning, Disability and Health frameworks will be used to classify participant characteristics and study outcomes, respectively. During the consultation exercise, key knowledge users, including exercise participants, programme providers and coordinators, and members of community organisations for persons living with disabilities and under-represented groups, will be asked to provide insights regarding the applicability of review findings. A directed content analysis of data from the consultation exercise will be performed.

ETHICS AND DISSEMINATION

The research ethics board at the University of Toronto approved the consultation exercise. Findings will be disseminated through peer-reviewed publications and conference presentations. Findings will enhance understanding of current research evaluating virtual exercise programmes and inform future research and strategies for promoting equitable access and outcomes for individuals with mobility limitations.

REGISTRATION DETAILS

https://doi.org/10.17605/OSF.IO/X5JMA.

Impact of Active Physiotherapy on Physical Activity Level in Stroke Survivors: A Systematic Review and Meta-Analysis

BACKGROUND

Stroke survivors are frequently physically inactive. However, evidence of the effectiveness of active physiotherapy on physical activity level in stroke survivors is scarce.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, covering electronic searches from inception to March 16, 2022. Participants: Stroke survivors living in the community. Intervention: Any active physiotherapy, that is, involving exercises that require voluntary effort. Outcome measure: Objective and subjective physical activity level.

RESULTS

Of 5590 identified references, 25 randomized controlled trials were eligible, and 21 had available data. The random-effects meta-analysis resulted in a small, significant effect size in favor of active physiotherapy measured using objective or subjective tools (21 studies, 1834 participants, standardized mean difference, 0.22 [95% CI, 0.04-0.40]; heterogeneity I2=65%), and a medium significant effect when objective tools were used (9 studies, 424 participants, standardized mean differences, 0.48 [95% CI, 0.03-0.92]; I2=73%). Meta-regression showed that 35% of the variance in trial outcome was explained by the measurement tool (objective or subjective) and 23% by age. None of the variances were associated with a specific dosage in terms of frequency, time, exercise duration, or the severity of the disability.

CONCLUSIONS

Active physiotherapy seems to increase objective physical activity in community-dwelling stroke survivors. However, the evidence is of very low certainty.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022315639.

Economic Evaluation of Exercise or Cognitive and Social Enrichment Activities for Improved Cognition After Stroke

Importance

Cognitive impairment is prevalent in survivors of stroke, affecting approximately 30% of individuals. Physical exercise and cognitive and social enrichment activities can enhance cognitive function in patients with chronic stroke, but their cost-effectiveness compared with a balance and tone program is uncertain.

Objective

To conduct a cost-effectiveness and cost-utility analysis of multicomponent exercise or cognitive and social enrichment activities compared with a balance and tone program.

Design, Setting, and Participants

This economic evaluation used a Canadian health care systems perspective and the Vitality study, a randomized clinical trial aimed at improving cognition after stroke with a 6-month intervention and a subsequent 6-month follow-up (ie, 12 months). The economic evaluation covered the duration of the Vitality trial, between June 6, 2014, and February 26, 2019. Participants were community-dwelling adults aged 55 years and older who experienced a stroke at least 12 months prior to study enrollment in the Vancouver metropolitan area, British Columbia, Canada. Data were analyzed from June 1, 2022, to March 31, 2023.

Interventions

Participants were randomly assigned to twice-weekly classes for 1 of the 3 groups: multicomponent exercise program, cognitive and social enrichment activities program, or a balance and tone program (control).

Main Outcomes and Measures

The primary measures for the economic evaluation included cost-effectiveness (incremental costs per mean change in cognitive function, evaluated using the Alzheimer Disease Assessment Scale-Cognitive-Plus), cost-utility (incremental cost per quality-adjusted life-year gained), intervention costs, and health care costs. Since cognitive benefits 6 months after intervention cessation were not observed in the primary randomized clinical trial, an economic evaluation at 12 months was not performed.

Results

Among 120 participants (mean [SD] age, 71 [9] years; 74 [62%] male), 34 were randomized to the multicomponent exercise program, 34 were randomized to the social and cognitive enrichment activities program, and 52 were randomized to the balance and tone control program. At the end of the 6-month intervention, the cost per mean change in Alzheimer Disease Assessment Scale-Cognitive-Plus score demonstrated that exercise was more effective and costlier compared with the control group in terms of cognitive improvement with an incremental cost-effectiveness ratio of CAD -$8823. The cost per quality-adjusted life-year gained for both interventions was negligible, with exercise less costly (mean [SD] incremental cost, CAD -$32 [$258]) and cognitive and social enrichment more costly than the control group (mean [SD] incremental cost, CAD $1018 [$378]). The balance and tone program had the lowest delivery cost (CAD $777), and the exercise group had the lowest health care resource utilization (mean [SD] $1261 [$1188]) per person.

Conclusions and Relevance

The findings of this economic evaluation suggest that exercise demonstrated potential for cost-effectiveness to improve cognitive function in older adults with chronic stroke during a 6-month intervention.

What matters to program partners when implementing a community-based exercise program for people post-stroke? A theory-based qualitative study and cost analysis

Background

Community-based exercise programs integrating a healthcare-community partnership (CBEP-HCP) can facilitate lifelong exercise participation for people post-stroke. Understanding the process of implementation from multiple perspectives can inform strategies to promote program sustainability.

Purpose

To explore stakeholders' experiences with undertaking first-time implementation of a group, task-oriented CBEP-HCP for people post-stroke and describe associated personnel and travel costs.

Methods

We conducted a descriptive qualitative study within a pilot randomized controlled trial. In three cities, trained fitness instructors delivered a 12-week CBEP-HCP targeting balance and mobility limitations to people post-stroke at a recreation centre with support from a healthcare partner. Healthcare and recreation managers and personnel at each site participated in semi-structured interviews or focus groups by telephone post-intervention. Interviews and data analysis were guided by the Consolidated Framework of Implementation Research and Theoretical Domains Framework, for managers and program providers, respectively. We estimated personnel and travel costs associated with implementing the program.

Results

Twenty individuals from three sites (4 recreation and 3 healthcare managers, 7 fitness instructors, 3 healthcare partners, and 3 volunteers) participated. We identified two themes related to the decision to partner and implement the program: (1) Program quality and packaging, and cost-benefit comparisons influenced managers' decisions to partner and implement the CBEP-HCP, and (2) Previous experiences and beliefs about program benefits influenced staff decisions to become instructors. We identified two additional themes related to experiences with training and program delivery: (1) Program staff with previous experience and training faced initial role-based challenges that resolved with program delivery, and (2) Organizational capacity to manage program resource requirements influenced managers' decisions to continue the program. Participants identified recommendations related to partnership formation, staff/volunteer selection, training, and delivery of program activities. Costs (in CAD) for first-time program implementation were: healthcare partner ($680); fitness coordinators and instructors ($3,153); and participant transportation (personal vehicle: $283; public transit: $110).

Conclusion

During first-time implementation of a CBEP-HCP, healthcare and hospital managers focused on cost, resource requirements, and the added-value of the program, while instructors and healthcare partners focused on their preparedness for the role and their ability to manage individuals with balance and mobility limitations. Trial Registration: ClinicalTrials.gov, NCT03122626. Registered April 17, 2017-Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03122626.

Intervention patterns and preliminary effectiveness on Social Participation following stroke: a scoping review

BACKGROUND

Stroke survivors suffer an overall loss of social participation. However, the interventions aiming at improving social participation have not yet been well-established. There is a need to synthesize existing knowledge on clinical interventions aiming at improving social participation among people with stroke.

OBJECTIVE

To describe the patterns of intervention that have been applied to stroke survivors to improve social participation and to determine the preliminary effects of these patterns.

METHODS

Eight online databases, including Cochrane Library, PubMed, Web of Science, Embase, Medline, CINAHL plus, PsycINFO, and Scoups were searched with predefined search terms from inception to September 22, 2022. References of included articles and previous reviews were also checked to identify additional studies. Two reviewers independently selected eligible studies and extracted data from the included articles.

RESULTS

A total of 98 studies were included, of which only 25 studies considered social participation as primary outcome of clinical interventions. The patterns of intervention were various, consisting of exercise-based intervention, occupational therapy, self-management program, and complex intervention. Of the 25 studies, eight studies found a positive effect of relative clinical intervention on social participation for stroke survivors. Of note, the same modality of intervention such as exercise-based intervention and self-management program produced paradoxical conclusion on social participation.

CONCLUSION

Exercised-based intervention, occupational therapy, self-management program, and complex intervention were important intervention modalities for the improvement of social participation among stroke survivors. Even though the preliminary effectiveness on social participation seems to be potentially positive, further high-quality researches are still required to reach a consensus to achieve optimal social participation among stroke survivors.

Effectiveness of Occupational Therapy Interventions to Improve Performance and Participation in Instrumental Activities of Daily Living (IADL) Among Adult Stroke Survivors (2009-2019)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme and/or subthemes, related to a specific topic. This Systematic Review Brief summarizes findings from the systematic review on interventions to improve performance and participation in instrumental activities of daily living among adult stroke survivors. This theme reports on the effectiveness of virtual reality, exercise, vision rehabilitation, and community-based stroke empowerment group interventions.

Exercise for Adults With Stroke to Improve ADL and/or Functional Mobility Performance (2012-2019)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on interventions to improve activities of daily living (ADL) and functional mobility performance for people with stroke. This theme reports on exercise interventions.

Impact of community-based rehabilitation on the physical functioning and activity of daily living of stroke patients: a systematic review and meta-analysis

PURPOSE

This study aimed at establishing the impact of community-based rehabilitation (CBR) on the physical functioning and activity of daily living (ADL) of patients with stroke (PWS).

MATERIALS AND METHODS

Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, an electronic search was conducted in five databases, including PubMed, OVID Embase, OVID Medline, Cochrane Library, and Web of Science between May 2010 and 2020. Meta-analysis was performed using the Comprehensive Meta-Analysis Version 2 software to establish whether the studies were sufficiently homogenous.

RESULTS

Twenty studies out of 828 publications were included in the present systematic review. A significant difference between CBR intervention and control groups was identified about the physical functional capacity in mobility, 6-metre walk test (6MWT) (g = 0.351, 95% CI (0.110, 0.592)), community walking test (g= -0.473, 95% CI (-0.926, -0.020)) and on the other hand a significant improvement in ADL was found (g = 0.138, 95% CI(0.051, 0.224)).

CONCLUSIONS

CBR is revealed to be effective in improving the physical functioning and ADL for PWS and is drawn based on eligible studies which were conducted in high-income countries (HICs). This highlights a gap between developed and less-resourced countries as far as CBR for PWS is concerned and calls for a further study. Protocol Registration: CRD42020159683Implication for rehabilitationCommunity-based rehabilitation (CBR) is recommended as one of the best programme for treating stroke patients with stroke (PWS) after they are discharged from hospitals.CBR is effective in improving the physical functioning and activity of daily living of PWS.Further research should be carried out to compare between CBR and institution-based rehabilitation for PWS, especially the less-resourced settings which are grappling with a challenge of limited skilled rehabilitation professionals.

Interventions to Improve Social Participation, Work, and Leisure Among Adults Poststroke: A Systematic Review

IMPORTANCE

Sustaining a stroke frequently leads to difficulties in returning to work, leisure, and social participation. These outcomes are important for occupational therapy practitioners to address.

OBJECTIVE

To determine the current evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve social participation, work, and leisure among adults poststroke.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases.

STUDY SELECTION AND DATA COLLECTION

Primary inclusion criteria were peer-reviewed journal articles published between January 1, 2009, and December 31, 2019, within the scope of occupational therapy that evaluated an intervention to address work, leisure, or social participation poststroke (levels of evidence ranged from Level 1b to Level 2b). Reviewers assessed records for inclusion, quality, and validity following Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

FINDINGS

Forty-seven articles met the inclusion criteria. Forty-four articles related to social participation were categorized as follows: occupation-based approaches, metacognitive strategy training, education and training approaches, impairment-based approaches, and enriched environment approaches. Three articles related to work and 3 articles related to leisure were not further categorized (2 articles were each included in two categories). Seventeen Level 1b and 30 Level 2b articles were included. The strength of evidence to support occupational therapy interventions for social participation, work, and leisure outcomes is predominantly low.

CONCLUSIONS AND RELEVANCE

Occupational therapy interventions may improve work, leisure, and social participation outcomes poststroke, with the strongest evidence existing for client education, upper extremity training, and cognitive training for improving social participation. What This Article Adds: Occupational therapy practitioners may use the available literature along with clinical reasoning to improve work, leisure, and social participation outcomes among clients poststroke. Additional research is required to build stronger evidence to support clinical decision making in stroke rehabilitation in these areas.

Reporting dose in complex self-management support interventions for long-term conditions: is it defined by researchers and received by participants? A systematic review

BACKGROUND

The minimum clinically effective dose, and whether this is received in randomised controlled trials (RCTs) of complex self-management interventions in long-term conditions (LTCs), can be unclear. The Template for Intervention Description and Replication (TIDieR) checklist states that dose should be clearly reported to ensure validity and reliable implementation.

OBJECTIVES

To identify whether the expected minimum clinically effective dose, and the dose participants received is reported within research articles and if reporting has improved since the TIDieR checklist was published.

METHODS

Four databases were systematically searched (MEDLINE, PsycINFO, AMED and CINAHL) to identify published reports between 2008 and 2022 for RCTs investigating complex self-management interventions in LTCs. Data on reporting of dose were extracted and synthesised from the eligible articles.

RESULTS

94 articles covering various LTCs including diabetes, stroke and arthritis were included. Most complex interventions involved behaviour change combined with education and/or exercise. The maximum dose was usually reported (n=90; 97.8%), but the expected minimum clinically effective dose and the dose received were reported in only 28 (30.4%) and 62 (67.4%) articles, respectively. Reporting of the expected minimum clinically effective dose and the dose participants received did not improve following the publication of the TIDieR checklist in 2014.

CONCLUSIONS

Interpreting results and implementing effective complex self-management interventions is difficult when researchers' reporting of dose is not in line with guidelines. If trial findings indicate benefit from the intervention, clear reporting of dose ensures reliable implementation to standard care. If the results are non-significant, detailed reporting enables better interpretation of results, that is, differentiating between poor implementation and lack of effectiveness. This ensures quality of interventions and validity and generalisability of trial findings. Therefore, wider adoption of reporting the TIDieR checklist dose aspects is strongly recommended. Alternatively, customised guidelines for reporting dose in complex self-management interventions could be developed.

PROSPERO REGISTRATION NUMBER

CRD42020180988.

Impairment-Based Interventions to Improve Social Participation Outcomes for Adults Poststroke (January 1, 2009-December 31, 2019)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on stroke and impairment-based interventions to improve social participation for adults poststroke.

Community-Based Rehabilitation Promotes the Functional Recovery of Patients After Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH), a severe disorder with the high death rate, high recurrence rate and high disability rate, affected the quality of human life. Community-based rehabilitation (CBR) helps disabled people at both community and family levels. However, the effect of CBR on the recovery of people after ICH remains unclear.

METHODS

Patients were treated with the CBR training program, subsequently, medication compliance test, clinical neural impairment measurements, functional comprehensive assessments, improved Barthel index score, and life qualities assessments were to performed at 3-month or 6-month intervention of CBR to evaluate the influence of CBR on the medication compliance, physical function and life quality of patients after ICH.

RESULTS

After the treatment of CBR, we observed that, the rate of medication compliance, motor function, functional comprehensive rating scale score, modified Barthel index score, and generic quality of life inventory-74 in the CBR-treated group were significantly higher than that in the control group; the neural impairment measure score in the CBR-treated group was significantly decreased in comparison to the control group.

CONCLUSION

CBR increased the medication compliance, promoted the recovery of the neurological function and improved the life qualities of ICH patients.

Community-based exercise programs incorporating healthcare-community partnerships to improve function post-stroke: feasibility of a 2-group randomized controlled trial

Background

Despite the potential for community-based exercise programs supported through healthcare-community partnerships (CBEP-HCPs) to improve function post-stroke, insufficient trial evidence limits widespread program implementation and funding. We evaluated the feasibility and acceptability of a CBEP-HCP compared to a waitlist control group to improve everyday function among people post-stroke.

Methods

We conducted a 3-site, pilot randomized trial with blinded follow-up evaluations at 3, 6, and 10 months. Community-dwelling adults able to walk 10 m were stratified by site and gait speed and randomized (1:1) to a CBEP-HCP or waitlist control group. The CBEP-HCP involved a 1-h, group exercise class, with repetitive and progressive practice of functional balance and mobility tasks, twice a week for 12 weeks. We offered the exercise program to the waitlist group at 10 months. We interviewed 13 participants and 9 caregivers post-intervention and triangulated quantitative and qualitative results. Study outcomes included feasibility of recruitment, interventions, retention, and data collection, and potential effect on everyday function.

Results

Thirty-three people with stroke were randomized to the intervention (n = 16) or waitlist group (n = 17). We recruited 1–2 participants/month at each site. Participants preferred being recruited by a familiar healthcare professional. Participants described a 10- or 12-month wait in the control group as too long. The exercise program was implemented per protocol across sites. Five participants (31%) in the intervention group attended fewer than 50% of classes for health reasons. In the intervention and waitlist group, retention was 88% and 82%, respectively, and attendance at 10-month evaluations was 63% and 71%, respectively. Participants described inclement weather, availability of transportation, and long commutes as barriers to attending exercise classes and evaluations. Among participants in the CBEP-HCP who attended ≥ 50% of classes, quantitative and qualitative results suggested an immediate effect of the intervention on balance, balance self-efficacy, lower limb strength, everyday function, and overall health.

Conclusion

The CBEP-HCP appears feasible and potentially beneficial. Findings will inform protocol revisions to optimize recruitment, and program and evaluation attendance in a future trial.

Trial registration

ClinicalTrials.gov, NCT03122626. Registered April 21, 2017 — retrospectively registered.

Evaluating and Characterizing an Individually-Tailored Community Exercise Program for Older Adults With Chronic Neurological Conditions: A Mixed-Methods Study

A mixed-methods approach was used to study an individually-tailored community exercise program for people with a range of chronic neurological conditions (e.g., stroke, spinal cord injury, brain injury, multiple sclerosis, Parkinson's disease) and abilities. The program was delivered to older adults (mean age: 62 ± 9 years) with chronic neurological conditions across a 12-week and an 8-week term. Participants attended 88% of sessions and completed 89% of prescribed exercises in those sessions. There were no adverse events. Clinically important improvements were achieved by all evaluated participants (n = 8) in at least one testing domain (grip strength, lower-extremity strength, aerobic endurance, and balance). Interviews with participants identified key program elements as support through supervision, social connection, individualized programming, and experiential learning. Findings provide insight into elements that enable a community exercise program to meet the needs of a complex and varied group. Further study will support positive long-term outcomes for people aging with neurological conditions.

Adaptação transcultural do Subjective Index of Physical and Social Outcome (SIPSO) para aplicação no Brasil

Objetivo: A restrição na participação é uma consequência significativa para indivíduos pós-Acidente Vascular Cerebral (AVC). No Brasil, não há instrumentos disponíveis que contemplem de forma abrangente a participação nesta população. Portanto, o objetivo deste estudo foi adaptar transculturalmente o Subjective Index of Physical and Social Outcome(SIPSO) para uso no Brasil. O SIPSO é um questionário com 10 itens, abrangendo questões de participação consideradas significativas para indivíduos pós-AVC. Métodos: O processo de adaptação transcultural envolveu as seguintes etapas: tradução, retrotradução, síntese das traduções, análise por um comitê de especialistas e teste da versão pré-final. Resultados: Observou-se equivalência semântica adequada entre as versões original e retrotraduzida. Durante a reunião de especialistas, foi realizada adequação dos itens às regras gramaticais da língua portuguesa. No teste da versão pré-final, em um item do instrumento foi reportada dificuldade de compreensão, sendo acrescentado um exemplo para ampliar a possibilidade de compreensão do item. Conclusão: O SIPSO-Brasil apresentou satisfatório grau de equivalência semântica, idiomática, cultural, conceitual e operacional. Contudo, estudos posteriores devem ser realizados para a continuidade da investigação da validade da versão adaptada do instrumento.

Information provision for stroke survivors and their carers

BACKGROUND

A stroke is a sudden loss of brain function caused by lack of blood supply. Stroke can lead to death or physical and cognitive impairment and can have long lasting psychological and social implications. Research shows that stroke survivors and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues.

OBJECTIVES

The primary objective is to assess the effects of active or passive information provision for stroke survivors (people with a clinical diagnosis of stroke or transient ischaemic attack (TIA)) or their identified carers. The primary outcomes are knowledge about stroke and stroke services, and anxiety.

SEARCH METHODS

We updated our searches of the Cochrane Stroke Group Specialised Register on 28 September 2020 and for the following databases to May/June 2019: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5) and the Cochrane Database of Systematic Reviews (CDSR; 2019, Issue 5) in the Cochrane Library (searched 31 May 2019), MEDLINE Ovid (searched 2005 to May week 4, 2019), Embase Ovid (searched 2005 to 29 May 2019), CINAHL EBSCO (searched 2005 to 6 June 2019), and five others. We searched seven study registers and checked reference lists of reviews.

SELECTION CRITERIA

Randomised trials involving stroke survivors, their identified carers or both, where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone, or where the comparison was between active and passive information provision without other differences in treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We categorised interventions as either active information provision or passive information provision: active information provision included active participation with subsequent opportunities for clarification and reinforcement; passive information provision provided no systematic follow-up or reinforcement procedure. We stratified analyses by this categorisation. We used GRADE methods to assess the overall certainty of the evidence.

MAIN RESULTS

We have added 12 new studies in this update. This review now includes 33 studies involving 5255 stroke-survivor and 3134 carer participants. Twenty-two trials evaluated active information provision interventions and 11 trials evaluated passive information provision interventions. Most trials were at high risk of bias due to lack of blinding of participants, personnel, and outcome assessors where outcomes were self-reported. Fewer than half of studies were at low risk of bias regarding random sequence generation, concealment of allocation, incomplete outcome data or selective reporting. The following estimates have low certainty, based on the quality of evidence, unless stated otherwise. Accounting for certainty and size of effect, analyses suggested that for stroke survivors, active information provision may improve stroke-related knowledge (standardised mean difference (SMD) 0.41, 95% confidence interval (CI) 0.17 to 0.65; 3 studies, 275 participants), may reduce cases of anxiety and depression slightly (anxiety risk ratio (RR) 0.85, 95% CI 0.68 to 1.06; 5 studies, 1132 participants; depression RR 0.83, 95% CI 0.68 to 1.01; 6 studies, 1315 participants), may reduce Hospital Anxiety and Depression Scale (HADS) anxiety score slightly, (mean difference (MD) -0.73, 95% CI -1.10 to -0.36; 6 studies, 1171 participants), probably reduces HADS depression score slightly (MD (rescaled from SMD) -0.8, 95% CI -1.27 to -0.34; 8 studies, 1405 participants; moderate-certainty evidence), and may improve each domain of the World Health Organization Quality of Life assessment short-form (WHOQOL-BREF) (physical, MD 11.5, 95% CI 7.81 to 15.27; psychological, MD 11.8, 95% CI 7.29 to 16.29; social, MD 5.8, 95% CI 0.84 to 10.84; environment, MD 7.0, 95% CI 3.00 to 10.94; 1 study, 60 participants). No studies evaluated positive mental well-being. For carers, active information provision may reduce HADS anxiety and depression scores slightly (MD for anxiety -0.40, 95% CI -1.51 to 0.70; 3 studies, 921 participants; MD for depression -0.30, 95% CI -1.53 to 0.92; 3 studies, 924 participants), may result in little to no difference in positive mental well-being assessed with Bradley's well-being questionnaire (MD -0.18, 95% CI -1.34 to 0.98; 1 study, 91 participants) and may result in little to no difference in quality of life assessed with a 0 to 100 visual analogue scale (MD 1.22, 95% CI -7.65 to 10.09; 1 study, 91 participants). The evidence is very uncertain (very low certainty) for the effects of active information provision on carers' stroke-related knowledge, and cases of anxiety and depression. For stroke survivors, passive information provision may slightly increase HADS anxiety and depression scores (MD for anxiety 0.67, 95% CI -0.37 to 1.71; MD for depression 0.39, 95% CI -0.61 to 1.38; 3 studies, 227 participants) and the evidence is very uncertain for the effects on stroke-related knowledge, quality of life, and cases of anxiety and depression. For carers, the evidence is very uncertain for the effects of passive information provision on stroke-related knowledge, and HADS anxiety and depression scores. No studies of passive information provision measured carer quality of life, or stroke-survivor or carer positive mental well-being.

AUTHORS' CONCLUSIONS

Active information provision may improve stroke-survivor knowledge and quality of life, and may reduce anxiety and depression. However, the reductions in anxiety and depression scores were small and may not be important. In contrast, providing information passively may slightly worsen stroke-survivor anxiety and depression scores, although again the importance of this is unclear. Evidence relating to carers and to other outcomes of passive information provision is generally very uncertain. Although the best way to provide information is still unclear, the evidence is better for strategies that actively involve stroke survivors and carers and include planned follow-up for clarification and reinforcement.

Cost-effectiveness of patient navigation programs for stroke patients-A systematic review

OBJECTIVE

Stroke remains a leading cause of premature death, impairment and reduced quality of life. Its aftercare is performed by numerous different health care service providers, resulting in a high need for coordination. Personally delivered patient navigation (PN) is a promising approach for managing pathways through health care systems and for improving patient outcomes. Although PN in stroke care is evolving, no summarized information on its cost-effectiveness in stroke survivors is available. Hence, the aim of this systematic review is to analyze the level of evidence on the cost-effectiveness of PN for stroke survivors.

METHODS

A systematic literature search without time limitations was carried out in PubMed, EMBASE, CENTRAL, CINAHL as well as PsycINFO and supplemented by a manual search. Randomized controlled trials published prior to April 2020 in English or German were considered eligible if any results regarding the cost-effectiveness of PN for stroke survivors were reported. The review was conducted according to PRISMA guidelines. Quality of included studies was assessed with the RoB2 tool. Main study characteristics and cost-effectiveness results were summarized and discussed.

RESULTS

The search identified 1442 records, and two studies met the inclusion criteria. Quality of included studies was rated moderate and high. Programs, settings and cost-effectiveness results were heterogeneous, with one study showing a 90% probability of being cost-effective at a willingness to pay of $25600 per QALY (health/social care perspective) and the other showing similar QALYs and higher costs.

CONCLUSIONS

Since only two studies were eligible, this review reveals a large gap in knowledge regarding the cost-effectiveness of PN for stroke survivors. Furthermore, no conclusive statement about the cost-effectiveness can be made. Future attempts to evaluate PN for stroke survivors are necessary and should also involve cost-effectiveness issues.

Design characteristics and inclusion of evidence-based exercise recommendation in fall prevention community exercise programs for older adults in Canada: a national descriptive self-report study

BACKGROUND

Training balance through exercise is an effective strategy to reduce falls in community-dwelling older adults. Evidence-based fall prevention exercise recommendations have been proposed, specifying that exercise programs should: (1) provide a high challenge to balance, (2) be offered for a least three hours per week, (3) be provided on an ongoing basis. Community exercise programs have the potential to deliver effective fall prevention exercise; however, current design characteristics and whether they include the recommendations is not known. This study described design characteristics of fall prevention community exercise programs for older adults (50 years and older) across Canada, and explored whether these programs included the three evidence-based exercise recommendations.

METHODS

Instructors of fall prevention community exercise programs completed electronic self-report questionnaires following a modified Dillman recruitment approach. Questions explored program characteristics, exercise content, target population, and program and instructor demographic information. Using a previously developed coding scheme based on recommendations, exercises were coded for balance challenge.

RESULTS

One hundred fourty completed eligible questionnaires were analyzed (74% response rate). One hundred thirty-three programs (95%) included the challenge recommendation by prescribing mostly moderate or high challenge balance exercises, 16 programs (11%) included at least three hours of exercise a week, and 59 programs (42%) were offered on an ongoing basis. Eight programs (6%) included all three recommendations.

CONCLUSIONS

Most programs included at least one recommendation for effective fall prevention exercise. Future studies should examine organizational barriers and facilitators to incorporating evidence-based exercise recommendations and explore the use of mixed home/in-class strategies to include the recommendations.

Exercise-based interventions for post-stroke social participation: A systematic review and network meta-analysis

BACKGROUND

Resuming participation in society is an important goal of post-stroke rehabilitation. Exercise-based interventions have been shown to be effective non-pharmacological methods for improving social participation in post-stroke survivors, however it is unclear what the most effective types of exercise interventions are.

OBJECTIVE

To assess the comparative effects and ranks of all exercise-based interventions in improving social participations in patients after a stroke.

METHODS

A random-effects network meta-analysis was performed to identify evidence from relevant randomized control trials. We searched MEDLINE, CINAHL, EMBASE, PsycINFO, CINHAL, Cochrane Library, AMED, SPORTDiscus, Web of Science and Clinical Trials.gov from their earliest records to January 2020. Included trials must include at least one types of exercise for patients with stroke. The primary e was social participation. Bias will be assessed according to the revised Cochrane risk of bias tool. Data were analysed using Stata v14.0. Registration number of this study is CRD42020152523.

RESULTS

A total of 16 randomized control trials involving 1704 patients and 12 intervention arms were included in our study. We performed three subgroup analyses divided based on follow up time (1 to <6 months post-treatment, and ≥6 months post-treatment), and intervention adherence. Based on the ranking probabilities, motor relearning programme was ranked as the most effective among all exercise interventions (surface under cumulative ranking curve values [SUCRCV]: 95.6%, standardized mean difference [SMD]: 2.72, 95% confidence interval [CI]: 1.76 to 3.69) in overall and short-term treatment efficacy. In the long-term subgroup, home-based combined exercise ranked the best for the efficacy of social participation improvements among stroke survivors (SUCRCV: 71.8%, SMD: -0.23, 95% CI: -0.61 to 0.15). In the analysis of all interventions with adherence of >90%, cognitive-based exercise ranked the best (SUCRCV: 100%, SMD: 2.64, 95% CI: 1.62 to 3.66).

CONCLUSIONS

Interventions that emerged with the highest ranks in our analysis might be considered in practice when resources allow. More large, well-designed multicentre trials are needed to support the conclusion of this study.

Influence of peer-based rehabilitation interventions for improving mobility and participation among adults with mobility disabilities: a systematic review

Purpose: The prevalence of mobility disability reaches up to 20.5% among older adults. Mobility is a key factor of participation, thus rehabilitation interventions often aim to improve mobility and participation. Peer-based approaches to intervention delivery have become increasingly common. This study aims to identify peer-based rehabilitation interventions and summarize their influence on mobility and participation among individuals with mobility disabilities.Method: A systematic review was conducted using CINALH, EMBASE, MEDLINE, and PsycINFO. Articles that evaluated peer-based rehabilitation interventions for individuals with a mobility disability and assessed mobility or participation, as defined in the International Classification of Functioning, Disability and Health framework, were included. Study quality was assessed using the Physical Therapy Evidence Database and the Quality Assessment Tool for Before-After Studies With No Control Group.Results: Thirteen peer-based studies were identified. Six peer-led studies evaluated participation and two evaluated mobility. Seven professional-led studies evaluated participation and six evaluated mobility. Randomized controlled trials had fair to high quality. The quality of pre-post studies ranged from poor to good.Conclusion: Peer-based interventions should not be overlooked as a potential intervention strategy, but further research is needed to establish their influence on mobility and participation.Implications for rehabilitationPeers offer a unique model of intervention that could support clinicians in their effort to improve mobility and participation outcomes for individuals with disabilities.There are currently two main models of peer-based interventions in rehabilitation: professional-led (peers assist professionals to facilitate the intervention) and peer-led interventions (peers facilitate the intervention).Both professional-led and peer-led models of intervention could be helpful in facilitating participation and in increasing mobility.

Effect of Community Exercise for Patients with Stroke: A Systematic Review and Meta-analysis

Background Community exercise might be beneficial to stroke recovery. However, the results remained controversial. We conducted a systematic review and meta-analysis to explore the effect of community exercise on stroke patients.

Methods PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of community exercise vs. usual care on stroke were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcome were 6-Minute walk test and walking speed. Metaanalysis was performed using random-effect model.

Results Four RCTs involving 497 patients were included in the metaanalysis. Overall, compared with control intervention, community exercise intervention was found to significantly improve 6-Minute walk distance (Std. mean difference=0.48; 95% CI=0.22 to 0.74; P=0.0003), and walking speed (Std. mean difference=0.40; 95% CI=0.10 to 0.70; P=0.009) in stroke patients, but resulted in no influence on Berg Balance Scale (Std. mean difference=0.39; 95% CI=−0.29 to 1.07; P=0.26), muscle strength (Std. mean difference=0.05; 95% CI=-0.34 to 0.43; P=0.82) and mental quality of life (Std. mean difference=0.04; 95% CI=−0.25 to 0.34; P=0.77).

Conclusions Compared to control intervention, community exercise was found to significantly increase 6-Minute walk test, walking speed and Berg Balance Scale, but showed no influence on Berg Balance Scale, muscle strength and mental quality of life.

A psychosocial intervention for stroke survivors and carers: 12-month outcomes of a randomized controlled trial

Background and Purpose: Stroke can have a devastating impact on the mental and physical health of stroke survivors and their carers. We aimed to evaluate the effectiveness of a novel psychosocial intervention designed to improve health outcomes in both groups.Methods: We conducted a randomized controlled trial of a personalized psychosocial intervention (eight 1-hour weekly sessions plus one booster) compared to usual care for adult stroke survivors and carers. Participants recruited from hospital services and community referrals completed questionnaires at baseline, 3, 6, and 12 months. Primary outcomes were quality of life and self-efficacy; secondary outcomes were depressive and anxiety symptoms, coping, illness perception, work and social adjustment, carer strain, and carer satisfaction. Mixed-effect model repeated measures analysis between groups and across time was conducted.Results: Of the 173 participants recruited (89 stroke survivors; 84 carers), a total of 137 participants - 73 stroke survivors (intervention n = 42; usual care n = 31) and 64 carers (intervention n = 35; usual care n = 29) - underwent analysis up to 12 months. No statistically significant differences were found in the primary outcomes between groups over time, though a significant improvement in carer satisfaction was found at 6 months in the intervention group compared to the usual care group.Conclusion: A personalized psychosocial intervention resulted in a significant improvement in carer satisfaction at 6 months but in no other outcomes. A lack of available services and barriers to social engagement may have impeded the effectiveness of this intervention.

The perceived benefits of community-based group exercise sessions for survivors of stroke

Background/aims

Post-stroke physical disability, cognitive impairment and emotional trauma can adversely affect the wellbeing of people who have survived stroke. Active participation in group exercise programmes has been advocated as an intervention to potentially enhance wellbeing. This study adopted a qualitative approach to explore the experiences of survivors of stroke who were participating in ongoing community-based group exercise sessions and their impact on subjective wellbeing.

Methods

Interviews were conducted with 12 participants from four community-based group exercise sessions. Of these, 6 were survivors of stroke (44–60 years) and the remaining 6 participants comprised caregivers, group coordinators and/or instructors, who were closely involved with sessions attended by the stroke survivors.

Results

Thematic analysis revealed that participation in community-based group exercise sessions offered survivors opportunities for building confidence; enhancing motivation; improving physical ability of affected limbs; enhancing interpersonal relationships; and providing support and knowledge. Participants all agreed that these physical and psychosocial benefits contributed to improved wellbeing and this supported previous research on the benefits of group work.

Conclusions

Participants explained how community-based group exercise sessions had facilitated their recovery journey and hence it is recommended that such programmes are made available, accessible and affordable to survivors of stroke.

Psychosocial interventions for stroke survivors, carers and survivor-carer dyads: a systematic review and meta-analysis

Objective: To evaluate the effectiveness of psychosocial interventions on depressive symptoms, anxiety symptoms, quality of life, self-efficacy, coping, carer strain and carer satisfaction among stroke survivors, carers and survivor-carer dyads. Data sources: MEDLINE, CINAHL, PsycINFO, SocINDEX, Cochrane Library, Web of Science and Scopus databases and the grey literature were searched up to September 2018. Methods: A systematic review and meta-analysis of randomized controlled trials of psychosocial interventions for stroke survivors, carers and survivor-carer dyads, compared to usual care. Outcomes measured were depressive symptoms, anxiety symptoms, quality of life, coping, self-efficacy, carer strain, and carer satisfaction. Results: Thirty-one randomized controlled trials (n = 5715) were included in the systematic review which found improvements in depressive symptoms, anxiety symptoms, quality of life and coping, though the number of trials assessing each outcome varied. A meta-analysis (11 trials; n = 1280) on depressive symptoms found that in seven trials psychosocial interventions reduced depressive symptoms in stroke survivors (SMD: -0.36, 95% CI -0.73 to 0.00; p = .05) and in six trials reduced depressive symptoms in carers (SMD: -0.20, 95% CI -.40 to 0.00; p = .05). Conclusion: Psychosocial interventions reduced depressive symptoms in stroke survivors and their carers. There was limited evidence that such interventions reduced anxiety symptoms, or improved quality of life and coping for stroke survivors and carers and no evidence that they improved self-efficacy, carer strain or carer satisfaction.

Economic evaluation of a phase III international randomised controlled trial of very early mobilisation after stroke (AVERT)

OBJECTIVES

While very early mobilisation (VEM) intervention for stroke patients was shown not to be effective at 3 months, 12 month clinical and economical outcomes remain unknown. The aim was to assess cost-effectiveness of a VEM intervention within a phase III randomised controlled trial (RCT).

DESIGN

An economic evaluation alongside a RCT, and detailed resource use and cost analysis over 12 months post-acute stroke.

SETTING

Multi-country RCT involved 58 stroke centres.

PARTICIPANTS

2104 patients with acute stroke who were admitted to a stroke unit.

INTERVENTION

A very early rehabilitation intervention within 24 hours of stroke onset METHODS: Cost-utility analyses were undertaken according to pre-specified protocol measuring VEM against usual care (UC) based on 12 month outcomes. The analysis was conducted using both health sector and societal perspectives. Unit costs were sourced from participating countries. Details on resource use (both health and non-health) were sourced from cost case report form. Dichotomised modified Rankin Scale (mRS) scores (0 to 2 vs 3 to 6) and quality adjusted-life years (QALYs) were used to compare the treatment effect of VEM and UC. The base case analysis was performed on an intention-to-treat basis and 95% CI for cost and QALYs were estimated by bootstrapping. Sensitivity analysis were conducted to examine the robustness of base case results.

RESULTS

VEM and UC groups were comparable in the quantity of resource use and cost of each component. There were no differences in the probability of achieving a favourable mRS outcome (0.030, 95% CI -0.022 to 0.082), QALYs (0.013, 95% CI -0.041 to 0.016) and cost (AUD1082, 95% CI -$2520 to $4685 from a health sector perspective or AUD102, 95% CI -$6907 to $7111, from a societal perspective including productivity cost). Sensitivity analysis achieved results with mostly overlapped CIs.

CONCLUSIONS

VEM and UC were associated with comparable costs, mRS outcome and QALY gains at 12 months. Compared with to UC, VEM is unlikely to be cost-effective. The long-term data collection during the trial also informed resource use and cost of care post-acute stroke across five participating countries.

TRIAL REGISTRATION NUMBER

ACTRN12606000185561; Results.

Trained volunteers to support chronically ill, multimorbid elderly between hospital and domesticity - a systematic review of one-on-one-intervention types, effects, and underlying training concepts

BACKGROUND

New approaches are needed to address the challenges of demographic change, staff shortages, and societal change in the care of the elderly. While volunteering has barely been established as a pillar of the welfare state in several countries, legislators and nonprofit or community-based organizations in some countries favor the increased integration of volunteers, as they can rely on many dedicated people. When caring for the multimorbid elderly, the transition from hospital to domesticity involves certain risks. Currently, no systematic knowledge exists on whether and how elderly benefit from volunteer support after a hospital stay. Objectives of this systematic review were to (1) identify evaluated approaches with trained volunteers supporting chronically ill, multimorbid elderly one-on-one at the interface between hospital and domesticity; (2) investigate the patient-related effectiveness of the approaches; (3) present the characteristics of the supporting volunteers; and (4) present the underlying teaching and training concepts for the volunteers.

METHODS

A systematic search of the following online databases was conducted in April 2017: the Cochrane Library, Medline (PubMed), CINAHL, and PsycINFO (Ebscohost). We included (cluster/quasi-) randomized controlled trials, controlled clinical trials and single-group pre-post design. An institutional search was conducted on eight national institutions from research and practice in Germany. Screening was conducted by one researcher, risk of bias was assessed. Study authors were contacted for study and training details.

RESULTS

We identified a total of twelve studies, eight of which evaluated treatment following hospital stay: psychosocial-coordinative support (n = 2), physical-cognitive activation (n = 4), and assistance with medication intake (n = 2). We saw short-term effects with small and medium effect sizes. Most volunteers were women aged between 45 and 61 years. Their training lasted 12-26 h and took place prior to first patient contact. During the intervention, volunteers could rely on permanent supporting structures.

CONCLUSIONS

Few studies exist that have evaluated one-on-one-volunteer support following hospitalization, and the effects are inconsistent. As such, further, well-designed studies are needed. The suitability and transferability of the interventions in country-specific settings should be examined in feasibility studies. Furthermore, an international discussion on the appropriate theoretical backgrounds of volunteer training is needed.

Factors Influencing Quality of Life in Stroke Patients: Focus on Eating Habits

BACKGROUND

Adherence to healthy lifestyle factors has been shown to improve outcomes after stroke. This study aimed to identify lifestyle factors about eating habits that may affect the quality of life (QOL) in elderly stroke patients.

METHODS

Fifty elderly patients with a first-ever stroke were enrolled. QOL was assessed by the Stroke and Aphasia QOL Scale-39-J. Lifestyle factors about eating habits were collected using questionnaires (Questions 1-17) for the intake of salt, calcium, magnesium, potassium, taurine, fiber, and protein, and the frequency of breakfast.

RESULTS

QOL of physical, communication, and psychosocial subdomains was better in the low (healthy) tertile of poststroke eating habits (Questions 1-17) compared with the high tertile of post-troke eating habits (Questions 1-17). This relationship appeared in eating habits except for salt intake but not in eating habits of salt intake and directly measured salt intake. Compared with prestroke eating habits score, poststroke eating habits score was decreased (improved) in 36 patients concerning eating habits of salt intake, but only in 12 patients concerning eating habits except for salt intake (P < .05 by chi-square test). Poststroke eating habits of calcium and magnesium were associated with better psychosocial QOL and better physical or energy QOL, respectively.

CONCLUSIONS

Poststroke eating habits of calcium and magnesium were associated with QOL in elderly patients with a first-ever stroke. Since eating habits except for salt intake was poorly improved after stroke, intensive interventions regarding eating habits might be important.

Content Reporting in Post-Stroke Therapeutic Circuit-Class Exercise Programs in randomized control trials

BACKGROUND

Therapeutic exercise in the form of group circuit-class training can improve mobility and gait while being cost-effective among patients who survived a stroke. Accurate clinical replication of interventions, especially when they are effective, is needed to advance research and treatment. However, replication is difficult when reporting is not detailed.

OBJECTIVE

The objective of this study was to assess the quality of reporting of interventions within the selected studies using three different scales and to assess the criterion validity between the scales.

METHODS

Two independent assessors used the CERT, the CONTENT scale, and TIDieR checklist to review the quality of reporting of 16 randomized controlled trials (RCTs) from a recent Cochrane Review. Assessments were done independently before a consensus was reached with an experienced third reviewer mediating any disagreements. Criterion validity between the three quality reporting tools was measured using weighted Cohen's kappa coefficients.

RESULTS

The mean (±SD) for the CERT was 9.31 (±1.66) out of 19 points; the TIDieR checklist was 8.81 (±1.33) out of 12 points; and the CONTENT was 4.82 (±1.22) out of 9 points for the 16 included RCTs. The CERT and CONTENT scale had a fair agreement (k = 0.455, p = 0.064), while both CERT and CONTENT had only slight agreement with TIDieR (k = 0.143, p = 0.267; k = 0.200, p = 0.182, respectively).

CONCLUSIONS

The results of this study indicate a lack of reporting from the 16 RCTs on post-stroke therapeutic circuit-class exercise programs. This presents a major barrier to knowledge translation and clinical implementation of effective exercise programs for stroke rehabilitation.

Self-perceived occupational performance of community-dwelling adults living with stroke

Background.

Stroke has long-term consequences for functional performance of daily activities. Evaluating client-perceived occupational performance provides insight for designing stroke-specific programs supporting home and community participation.

Purpose.

This study describes the personal characteristics and self-perceived occupational performance in community-dwelling adults with stroke.

Method.

A retrospective chart review was undertaken of 25 stroke survivors who sought services at a community-based centre. The outcome measures were the Canadian Occupational Performance Measure (COPM) to evaluate self-perceived occupational performance and the Montreal Cognitive Assessment (MoCA) to screen for cognitive impairment. The analysis used descriptive statistics.

Findings.

Mean participant age was 64 years, and most participants were Caucasian males (72%). The mean cognitive function score was 22.1 on MoCA, and the mean COPM performance and satisfaction subscores were 4.1 and 3.9, respectively. The top three challenging daily activities were driving, seeking employment, and functional mobility.

Implications.

Stroke-specific community programs should emphasize the diverse performance concerns important to stroke survivors.

Fitness coordinators' and fitness instructors' perspectives on implementing a task-oriented community exercise program within a healthcare-recreation partnership for people with balance and mobility limitations: a qualitative study

Background: Healthcare organizations are partnering with recreation organizations to support the delivery of community-based exercise programs for people with balance and mobility limitations. The value and impact of support strategies provided by healthcare organizations, however, have not been examined.Objective: Study objectives were to explore fitness coordinators' and fitness instructors' experiences with implementing a task-oriented community-based exercise program for people with balance and mobility limitations within the context of a healthcare-recreation partnership.Methods: A qualitative descriptive study was conducted. Fitness coordinators and instructors involved with delivering a licensed, group, task-oriented community-based exercise program for people with balance and mobility limitations supported by a healthcare-recreation partnership were interviewed by telephone. Interviews were audio-recorded and transcribed verbatim. A thematic analysis was performed.Results: Eight fitness coordinators and 8 fitness instructors from 14 recreation centres were interviewed. Findings showed that healthcare-recreation partnerships help to optimize exercise program quality and safety through multiple strategies. Fitness coordinators and instructors still face challenges with program implementation at start-up and over time. Recommendations to address these challenges included increased training content related to adjusting exercises to accommodate participant abilities, 1-2 visits from a healthcare professional each program after initial program implementation, suggestions to increase exercise variety, and ongoing education.Conclusions: Findings clarify the role of healthcare organizations, ongoing challenges, and directions for improvement in this program delivery model.Implications for rehabilitationCommunity recreation centres can provide task-oriented exercise programs to help people with balance and mobility limitations safely engage in regular exerciseHealthcare organizations should provide specific supports to help increase the safety and quality of task-oriented exercise programs in recreation centresSupports include providing clear exercise guidelines, and a healthcare professional who trains fitness instructors, visits the program, answers questions between visits, promotes collaboration and information exchange between recreation centres, and provides ongoing education.

Economic burden of stroke: a systematic review on post-stroke care

OBJECTIVES

Stroke is a leading cause for disability and morbidity associated with increased economic burden due to treatment and post-stroke care (PSC). The aim of our study is to provide information on resource consumption for PSC, to identify relevant cost drivers, and to discuss potential information gaps.

METHODS

A systematic literature review on economic studies reporting PSC-associated data was performed in PubMed/MEDLINE, Scopus/Elsevier and Cochrane databases, Google Scholar and gray literature ranging from January 2000 to August 2016. Results for post-stroke interventions (treatment and care) were systematically extracted and summarized in evidence tables reporting study characteristics and economic outcomes. Economic results were converted to 2015 US Dollars, and the total cost of PSC per patient month (PM) was calculated.

RESULTS

We included 42 studies. Overall PSC costs (inpatient/outpatient) were highest in the USA ($4850/PM) and lowest in Australia ($752/PM). Studies assessing only outpatient care reported the highest cost in the United Kingdom ($883/PM), and the lowest in Malaysia ($192/PM). Fifteen different segments of specific services utilization were described, in which rehabilitation and nursing care were identified as the major contributors.

CONCLUSION

The highest PSC costs were observed in the USA, with rehabilitation services being the main cost driver. Due to diversity in reporting, it was not possible to conduct a detailed cost analysis addressing different segments of services. Further approaches should benefit from the advantages of administrative and claims data, focusing on inpatient/outpatient PSC cost and its predictors, assuring appropriate resource allocation.

Experiences of people with stroke and multiple sclerosis and caregivers of a community exercise programme involving a healthcare-recreation partnership

Purpose: To explore perceptions of people with neurological conditions and their caregivers of the health benefits of a group, task-oriented community-based exercise programme incorporating a healthcare-recreation partnership.Materials and methods: Descriptive qualitative study. Individuals with balance and mobility deficits from a neurological condition, and their caregivers, were interviewed on completion of a group, task-oriented community-based exercise programme incorporating a healthcare-recreation partnership. A thematic analysis was performed.Results: Nine people post-stroke, and four people with multiple sclerosis (MS) (n = 13; 54% male) and 12 caregivers (83% spouses) participated. Two themes emerged. One theme indicated that the programme fosters diverse, interrelated health benefits. Participants described experiences of improved balance, strength, and confidence that translated to improved everyday functioning and social participation. Benefits were reinforced through repeated programme registration. A second theme indicated that caregivers experience challenges and diverse benefits related to the programme. Transportation and programme cost were primary challenges. Caregivers described emotional health benefits from assisting participants during classes and observing participants improvement over time.Conclusions: Group, task-oriented community-based exercise programmes incorporating a healthcare-recreation partnership may yield health benefits for exercise participants and caregivers. Results can guide programme evaluation, the nature and timing of education about such programmes, and efforts to address cost and transportation issues.Implications of rehabilitationStroke and multiple sclerosis commonly cause balance and mobility limitations that can result in physical inactivity and further deterioration in health.Group, task-oriented community-based exercise programmes in which rehabilitation professionals train and support fitness instructors to deliver the exercise programme in community centres may increase access to exercise participation for this group.Study results suggest by improving balance and mobility, these programmes help increase independence in activities of daily living and social and leisure participation, while improving caregiver mental health and decreasing the need for caregiver assistance.Rehabilitation professionals can use findings to inform patient education, and support programme implementation and referral.

The effectiveness of group exercise for improving activity and participation in adult stroke survivors: a systematic review

BACKGROUND

Following post stroke rehabilitation, group exercise interventions can be used to continue improving cardiovascular fitness, activity levels, balance, gait, movement efficiency, and strengthening. However, little is known of the effectiveness of group exercise for improving activity and participation in stroke survivors.

OBJECTIVES

This review aims to assess the effectiveness of group exercise for improving activity and participation in adult stroke survivors.

DATA SOURCES

Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) of group exercise using validated outcome measures of activity and participation for post stroke rehabilitation. Two independent reviewers assessed all abstracts, extracted data, conducted a narrative synthesis and assessed the quality of all included articles. The Cochrane Risk of Bias Tool assessed methodological quality and included outcome measure quality was assessed.

RESULTS

14 RCTs were included (n=624 chronic stroke survivors collectively). Studies ranged between 12 and 243 stroke participants with an average of left:right hemisphere lesions of 32:39 and average age was 66.7 years. Although intervention and control groups improved, no significant difference between group differences were evident.

CONCLUSION

and implications of key findings: The review found improvements are short-term and less evident at long-term follow up with little improvements in participation after 6months. However, this review was limited to the standard of intervention reporting. Further research should consider consistency in measuring underpinning mechanisms of group exercise interventions, which may explain the lack of activity changes in long-term follow-up.

SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO

CRD42017078917.

Acceptability and experience of a functional training programme (ReTrain) in community-dwelling stroke survivors in South West England: a qualitative study

Rehabilitation Training (ReTrain) is a group-based approach to functional training post stroke. ReTrain has recently been evaluated through a pilot randomised controlled trial.

OBJECTIVE

This article reports on the acceptability of the intervention as described by trial participants.

DESIGN

A qualitative approach was undertaken. Of the 45 participants recruited into the trial, 23 were randomised to receive ReTrain. Following a sampling strategy, 10 participants undertook 1:1 semistructured audio-recorded interviews. Transcripts were analysed following a modified Framework Approach.

RESULTS

Six themes were developed including exploration of: the physical and psychological impacts of training,the perceived mechanisms of change, the interaction of the group and approach of the trainer. A further theme considered the reported longer term impact of participation. Overall, the results indicated the acceptability of the intervention, but also key areas for potential modification in the definitive trial. These include a need to consider potential impact on both physical and psychological function, careful consideration of dosing and fatigue and the interpersonal factors that facilitate appropriate level of delivery, the trainer to participant ratio, and enhancing features that support continuation of activity postintervention.

CONCLUSION

Overall, this study supports the acceptability of ReTrain and the development of a definitive trial evaluation of this intervention to full.

TRIAL REGISTRATION NUMBER

NCT02429180.

Health economic evaluations of patient education interventions a scoping review of the literature

OBJECTIVES

To provide a comprehensive overview of health economic evaluations of patient education interventions for people living with chronic illness.

METHODS

Relevant literature published between 2000 and 2016 has been comprehensively reviewed, with attention paid to variations in study, intervention, and patient characteristics.

RESULTS

Of the 4693 titles identified, 56 articles met the inclusion criteria and were included in this scoping review. Of the studies reviewed, 46 concluded that patient education interventions were beneficial in terms of decreased hospitalization, visits to Emergency Departments or General Practitioners, provide benefits in terms of quality-adjusted life years, and reduce loss of production. Eight studies found no health economic impact of the interventions.

CONCLUSIONS

The results of this review strongly suggest that patient education interventions, regardless of study design and time horizon, are an effective tool to cut costs. This is a relatively new area of research, and there is a great need of more research within this field.

PRACTICE IMPLICATIONS

In bringing this evidence together, our hope is that healthcare providers and managers can use this information within a broad decision-making process, as guidance in discussions of care quality and of how to provide appropriate, cost-effective patient education interventions.

Effectiveness of Client-Centered "Tune-Ups" on Community Reintegration, Mobility, and Quality of Life After Stroke: A Randomized Controlled Trial

OBJECTIVE

To explore the effectiveness of a 2-week client-centered rehabilitation intervention (tune-up) delivered 6 months after inpatient discharge on community reintegration at 1 year in people with stroke.

DESIGN

A multicenter randomized controlled trial with 2 groups: an intervention ("tune-up") group and a control group having the same exposure to assessment.

SETTING

Three research laboratories.

PARTICIPANTS

Participants (N=103) with hemiparetic stroke recruited from inpatient rehabilitation units at the time of discharge.

INTERVENTIONS

Participants randomized to the tune-up group received 1-hour therapy sessions in their home 3times/wk for 2 weeks at 6 months postdischarge focusing on identified mobility-related goals. A second tune-up was provided at 12 months.

MAIN OUTCOME MEASURES

Community reintegration measured by the Subjective Index of Physical and Social Outcome at 12 months and secondary outcomes included the Berg Balance Scale and measures of mobility and health-related quality of life up to 15 months.

RESULTS

At 12 months, both groups showed significant improvement in community reintegration (P<.05), a trend evident at all time points, with no difference between groups (mean difference, -0.5; 95% confidence interval, -1.8 to 2.7; P=.68). Similarly, a main effect of time reflected improvement in mobility-related and quality of life outcomes for both groups (P≤.0.5), but no group differences (P≥.30).

CONCLUSIONS

All participants in the tune-up group met or exceeded at least 1 mobility-related goal; however, the intervention did not differentially improve community reintegration. The improvements in mobility and quality of life over the 15-month postdischarge period may be secondary to high activity levels in both study groups and exposure to regular assessment.

Considerations for expanding community exercise programs incorporating a healthcare-recreation partnership for people with balance and mobility limitations: a mixed methods evaluation

OBJECTIVE

To increase access to safe and appropriate exercise for people with balance and mobility limitations, community organizations have partnered with healthcare providers to deliver an evidence-based, task-oriented group exercise program in community centers in Canada. We aimed to understand challenges and solutions to implementing this program model to inform plans for expansion.

RESULTS

At a 1-day meeting, 53 stakeholders (healthcare/recreation personnel, program participants/caregivers, researchers) identified challenges to program implementation that were captured by seven themes: Resources to deliver the exercise class (e.g., difficulty finding instructors with the skills to work with people with mobility limitations); Program marketing (e.g., to foster healthcare referrals); Transportation (e.g., particularly from rural areas); Program access (e.g., program full); Maintaining program integrity; Sustaining partnerships (i.e., with healthcare partners); and Funding (e.g., to deliver program or register). Stakeholders prioritized solutions to form an action plan. A survey of individuals supervising 28 programs revealed that people with stroke, acquired brain injury, multiple sclerosis, and Parkinson's disease register at 95-100% of centers. The most prevalent issues with program fidelity across centers were not requiring a minimum level of walking ability (32%), class sizes exceeding 12 (21%), and instructor-to-participant ratios exceeding 1:4 (19%). Findings provide considerations for program expansion.

A survey of exercise professionals' barriers and facilitators to working with stroke survivors

Stroke survivors (SSs) are largely inactive despite the benefits of exercise. Exercise professionals (EPs), skilled in exercise prescription and motivation, may have a role in promoting exercise among SSs. However, the number of EPs working with SSs is estimated to be low. This study aimed to investigate EPs' opinions on working with SSs by rating their agreement of barriers and facilitators to working with SSs. The study also investigated EPs skills, interest and experience working with SSs and the relationship between EPs' barriers and facilitators with their training on stroke. A descriptive cross-sectional study was conducted using a researcher-designed online survey between October and December 2015. Purposive sampling was used to survey EPs on the Register of Exercise Professionals in Ireland (n = 277). The response rate was 31% (87/277). Only 22% (19/86) of EPs had experience working with SSs. The primary barriers rated by EPs included insufficient training on psychological problems post-stroke (84%; 61/73), unsuitable equipment for SSs (69%; 50/73) and the level of supervision SSs require (56%; 41/73). The primary facilitators rated included access to suitable equipment (97%; 69/71), practical (100%; 71/71) and theoretical training (93%; 66/71) on stroke. Respondents with no training on stroke were significantly more likely to agree that insufficient training on psychological problems post-stroke and lack of experience were barriers. Seventy-six per cent of EPs (58/76) were interested in one-to-one exercise sessions with SSs but only 53% (40/76) were interested in group sessions. Eighty-two per cent of EPs (62/76) rated their motivational skills as good or very good but 42% (32/76) indicated having only acceptable skills dealing with psychological problems. Results indicate that EPs are interested in working with SSs despite limited experience and practical barriers. Training opportunities on stroke need to be developed; taking into account EPs' barriers, facilitators and skills along with access to suitable equipment.

Community-based rehabilitation training after stroke: results of a pilot randomised controlled trial (ReTrain) investigating acceptability and feasibility

OBJECTIVES

To assess acceptability and feasibility of trial processes and the Rehabilitation Training (ReTrain) intervention including an assessment of intervention fidelity.

DESIGN

A two-group, assessor-blinded, randomised controlled trial with parallel mixed methods process and economic evaluations.

SETTING

Community settings across two sites in Devon.

PARTICIPANTS

Eligible participants were: 18 years old or over, with a diagnosis of stroke and with self-reported mobility issues, no contraindications to physical activity, discharged from National Health Service or any other formal rehabilitation programme at least 1 month before, willing to be randomised to either control or ReTrain and attend the training venue, possessing cognitive capacity and communication ability sufficient to participate. Participants were individually randomised (1:1) via a computer-generated randomisation sequence minimised for time since stroke and level of functional disability. Only outcome assessors independent of the research team were blinded to group allocation.

INTERVENTIONS

ReTrain comprised (1) an introductory one-to-one session; (2) ten, twice-weekly group classes with up to two trainers and eight clients; (3) a closing one-to-one session, followed by three drop-in sessions over the subsequent 3 months. Participants received a bespoke home-based training programme. All participants received treatment as usual. The control group received an exercise after stroke advice booklet.

OUTCOME MEASURES

Candidate primary outcomes included functional mobility and physical activity.

RESULTS

Forty-five participants were randomised (ReTrain=23; Control=22); data were available from 40 participants at 6 months of follow-up (ReTrain=21; Control=19) and 41 at 9 months of follow-up (ReTrain=21; Control=20). We demonstrated ability to recruit and retain participants. Participants were not burdened by the requirements of the study. We were able to calculate sample estimates for candidate primary outcomes and test procedures for process and health economic evaluations.

CONCLUSIONS

All objectives were fulfilled and indicated that a definitive trial of ReTrain is feasible and acceptable.

TRIAL REGISTRATION NUMBER

NCT02429180; Results.

Do Exercise Interventions Improve Participation in Life Roles in Older Adults? A Systematic Review and Meta-Analysis

Background

The World Health Organization recognizes participation in meaningful life roles as a key component of health. However, the evidence base for interventions to improve participation remains inconclusive. In particular, whether exercise interventions improve participation in life roles is unclear.

Purpose

The aim of this review was to evaluate the effect of physical exercise interventions on participation in life roles in older adults residing in the community.

Data sources

The PubMed, Embase, CINAHL, Cochrane, and PEDro databases were searched from inception through March 2015.

Study selection

Randomized controlled trials comparing the effects of an exercise intervention to usual care on participation in life roles in adults who were 60 years of age or older were included in this review.

Data extraction

Teams of 2 investigators independently extracted data on participation. Methodological quality was appraised using the Cochrane tool for assessing the risk of bias. The protocol was registered with Prospero (CRD42014014880).

Data synthesis

Eighteen randomized controlled trials with a total of 2,315 participants met the inclusion criteria. Standardized mean differences (SMDs) with 95% CIs were calculated using a random-effects model. A meta-analysis of 16 studies showed no overall effect of the exercise interventions on participation (SMD = 0.03; 95% CI = -0.10 to 0.16). Subgroup analysis showed that exercise interventions lasting 12 months or more had a small positive effect on participation (SMD = 0.15; 95% CI = 0.02 to 0.28).

Limitations

Limitations included variability in definitions and measures of participation.

Conclusions

In general, exercise interventions do not improve participation in life roles in older adults. The results do not support the implicit assumption that exercise-based interventions associated with improved function/activity also result in improved participation. Investigation of complex interventions that go beyond exercise to address participation in life roles for older adults is warranted.

A Pilot Trial of a Lifestyle Intervention for Stroke Survivors: Design of Healthy Eating and Lifestyle after Stroke (HEALS)

BACKGROUND

Stroke survivors have high rates of subsequent cardiovascular and recurrent cerebrovascular events, and mortality. While healthy lifestyle practices - including a diet rich in fruits and vegetables, limited alcohol intake, and regular physical activity - can mitigate these outcomes, few stroke survivors adhere to them. Minorities from socioeconomically disadvantaged communities who obtain care in safety-net health systems experience the most barriers to implementing healthy lifestyle changes after stroke.

PURPOSE

To report the design of Healthy Eating and Lifestyle After Stroke (HEALS), a randomized controlled trial (RCT) was designed to test the feasibility of using a manualized, lifestyle management intervention in a safety-net setting to improve lifestyle practices among ethnically diverse individuals with stroke or transient ischemic attack (TIA).

METHODS

Design: Pilot RCT.

PARTICIPANTS

Inclusion criteria: 1) Adults (≥40 years) with ischemic stroke or TIA (≥ 90 days prior); 2) English- or Spanish-speaking.

SETTING

Outpatient clinic, safety-net setting.

INTERVENTION

Weekly two-hour small group sessions led by an occupational therapist for six weeks. The sessions focused on implementing nutrition, physical activity, and self-management strategies tailored to each participant's goals.

MAIN OUTCOME MEASURES

Body mass index, diet, and physical activity.

CONCLUSIONS

Recruitment for this study is complete. If the HEALS intervention study is feasible and effective, it will serve as a platform for a large-scale RCT that will investigate the efficacy and cost-effectiveness of life management interventions for racially and ethnically diverse, low-income individuals with a history of stroke or TIA who seek healthcare in the safety-net system.

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'.

Circuit class therapy for improving mobility after stroke

BACKGROUND

Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practice time without increasing staffing. This is an update of the original review published in 2010.

OBJECTIVES

To examine the effectiveness and safety of CCT on mobility in adults with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched January 2017), CENTRAL (the Cochrane Library, Issue 12, 2016), MEDLINE (1950 to January 2017), Embase (1980 to January 2017), CINAHL (1982 to January 2017), and 14 other electronic databases (to January 2017). We also searched proceedings from relevant conferences, reference lists, and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including people over 18 years old, diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT.

DATA COLLECTION AND ANALYSIS

Review authors independently selected trials for inclusion, assessed risk of bias in all included studies, and extracted data.

MAIN RESULTS

We included 17 RCTs involving 1297 participants. Participants were stroke survivors living in the community or receiving inpatient rehabilitation. Most could walk 10 metres without assistance. Ten studies (835 participants) measured walking capacity (measuring how far the participant could walk in six minutes) demonstrating that CCT was superior to the comparison intervention (Six-Minute Walk Test: mean difference (MD), fixed-effect, 60.86 m, 95% confidence interval (CI) 44.55 to 77.17, GRADE: moderate). Eight studies (744 participants) measured gait speed, again finding in favour of CCT compared with other interventions (MD 0.15 m/s, 95% CI 0.10 to 0.19, GRADE: moderate). Both of these effects are considered clinically meaningful. We were able to pool other measures to demonstrate the superior effects of CCT for aspects of walking and balance (Timed Up and Go: five studies, 488 participants, MD -3.62 seconds, 95% CI -6.09 to -1.16; Activities of Balance Confidence scale: two studies, 103 participants, MD 7.76, 95% CI 0.66 to 14.87). Two other pooled balance measures failed to demonstrate superior effects (Berg Blance Scale and Step Test). Independent mobility, as measured by the Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index, also improved more in CCT interventions compared with others. Length of stay showed a non-significant effect in favour of CCT (two trials, 217 participants, MD -16.35, 95% CI -37.69 to 4.99). Eight trials (815 participants) measured adverse events (falls during therapy): there was a non-significant effect of greater risk of falls in the CCT groups (RD 0.03, 95% CI -0.02 to 0.08, GRADE: very low). Time after stroke did not make a difference to the positive outcomes, nor did the quality or size of the trials. Heterogeneity was generally low; risk of bias was variable across the studies with poor reporting of study conduct in several of the trials.

AUTHORS' CONCLUSIONS

There is moderate evidence that CCT is effective in improving mobility for people after stroke - they may be able to walk further, faster, with more independence and confidence in their balance. The effects may be greater later after the stroke, and are of clinical significance. Further high-quality research is required, investigating quality of life, participation and cost-benefits, that compares CCT with standard care and that also investigates the influence of factors such as stroke severity and age. The potential risk of increased falls during CCT needs to be monitored.

An investigation of the psychometric properties of the Chinese (Cantonese) version of Subjective Index of Physical and Social Outcome (SIPSO)

OBJECTIVE

The objectives of this study were 1) to translate and make cultural adaptations to the English version of the SIPSO questionnaire to create a Chinese (Cantonese) version, 2) evaluate the internal consistency, test-retest reliability the C-SIPSO questionnaire, and 3) compare the SIPSO-C scores of stroke survivors with different demographic characteristics to establish the discriminant validity of the questionnaire Design: Translation of questionnaire, cross sectional study.

SETTING

University-based clinical research laboratory. Subjects Community-dwelling chronic stroke survivors.

INTERVENTIONS

Not applicable.

MAIN MEASURES

Subjective Index of Physical and Social Outcome, Geriatric Depression Scale, 10-metre Walk test.

RESULTS

Two bilingual professional translators translated the SIPSO questionnaire independently. An expert panel comprising five registered physiotherapists verified the content validity of the final version (C-SIPSO). C-SIPSO demonstrated good internal consistency (Cronbach's α = 0.83) and excellent test-retest reliability (ICC_3,1 = 0.866) in ninety-two community dwelling chronic stroke survivors. Stroke survivors scored higher than 10 in the Geriatric Depression Scale ( U = 555.0, P < 0.001) and with the comfortable walking speed lower than 0.8ms^-1 ( U = 726.5; P = 0.012) scored significantly lower on SIPSO-C.

CONCLUSION

SIPSO-C is a reliable instrument that can be used to measure the level of community integration in community-dwelling stroke survivors in Hong Kong and southern China. Stroke survivors who were at high risk of minor depression and with limited community ambulation ability demonstrated a lower level of community integration as measured with SIPSO-C.

Caregiver-mediated exercises for improving outcomes after stroke

BACKGROUND

Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

OBJECTIVES

To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, Issue 10), MEDLINE (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

MAIN RESULTS

We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention.We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; P = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; P = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; P = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; P = 0.45; low-quality evidence).Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; P = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; P = 0.37; very low-quality evidence).At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; P = 0.002; low-quality evidence) and quality of life (1 study; physical functioning: MD 12.40, 95% CI 1.67 to 23.13; P = 0.02; mobility: MD 18.20, 95% CI 7.54 to 28.86; P = 0.0008; general recovery: MD 15.10, 95% CI 8.44 to 21.76; P < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; P = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; P < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (i.e.

PATIENT

motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life).In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; P = 0.01; moderate-quality evidence).The methodological quality of the included trials and variability in interventions (e.g. content, timing, and duration), affected the validity and generalisability of these observed results.

AUTHORS' CONCLUSIONS

There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.

Characterising community exercise programmes delivered by fitness instructors for people with neurological conditions: a scoping review

A scoping review was conducted to characterise evaluations of community-based exercise programmes (CBEPs) delivered by fitness instructors to people with neurological conditions. Literature published from 1946 to April 2014 in MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and the grey literature were searched. Search terms included community, programme, exercise, adult, brain disease and spinal cord disease. Two reviewers independently screened titles and abstracts for inclusion. One author reviewed full-text articles to evaluate eligibility. Studies were included if the study objective was to evaluate an exercise programme, the programme was community-based and delivered by fitness instructors, exercise participants were ≥18 years of age and had a neurological condition, and a full-text article was available and written in English. After reviewing 1785 titles and abstracts, 18 (1.01%) articles describing 15 studies were included in the review. One author completed data abstraction from the included studies. A second reviewer independently verified the extracted data for accuracy. Exercise programmes most commonly included people with stroke (47%) and Parkinson's disease (40%), incorporated a stand-alone (80%), multi-component (20%), group (67%), individual (20%) and combined format (13%), strength training (40%) and functional/task-oriented training (40%), reported a minimum walking requirement (67%), and involved a healthcare professional (HCP) with various roles (53%), including training (27%), advising and supporting (33%). The most commonly examined participant outcomes were health-related quality of life (60%) and functional balance (47%). More research is needed to develop CBEPs targeting individuals with low ambulatory function and multiple neurological conditions, to develop recommendations for the involvement of HCPs in CBEPs and document their involvement, and to evaluate system-level outcomes such as cost, healthcare utilisation and impact on caregivers. The findings support a number of considerations to guide future research into CBEPs delivered by fitness instructors for individuals with neurological conditions.

Community-based Rehabilitation Training after stroke: protocol of a pilot randomised controlled trial (ReTrain)

INTRODUCTION

The Rehabilitation Training (ReTrain) intervention aims to improve functional mobility, adherence to poststroke exercise guidelines and quality of life for people after stroke. A definitive randomised controlled trial (RCT) is required to assess the clinical and cost-effectiveness of ReTrain, which is based on Action for Rehabilitation from Neurological Injury (ARNI). The purpose of this pilot study is to assess the feasibility of such a definitive trial and inform its design.

METHODS AND ANALYSIS

A 2-group, assessor-blinded, randomised controlled external pilot trial with parallel mixed-methods process evaluation and economic evaluation. 48 participants discharged from clinical rehabilitation despite residual physical disability will be individually randomised 1:1 to ReTrain (25 sessions) or control (exercise advice booklet). Outcome assessment at baseline, 6 and 9 months include Rivermead Mobility Index; Timed Up and Go Test; modified Patient-Specific Functional Scale; 7-day accelerometry; Stroke Self-efficacy Questionnaire, exercise diary, Fatigue Assessment Scale, exercise beliefs and self-efficacy questionnaires, SF-12, EQ-5D-5L, Stroke Quality of Life, Carer Burden Index and Service Receipt Inventory. Feasibility, acceptability and process outcomes include recruitment and retention rates; with measurement burden and trial experiences being explored in qualitative interviews (20 participants, 3 intervention providers). Analyses include descriptive statistics, with 95% CI where appropriate; qualitative themes; intervention fidelity from videos and session checklists; rehearsal of health economic analysis.

ETHICS AND DISSEMINATION

National Health Service (NHS) National Research Ethics Service approval granted in April 2015; recruitment started in June. Preliminary studies suggested low risk of serious adverse events; however (minor) falls, transitory muscle soreness and high levels of postexercise fatigue are expected. Outputs include pilot data to inform whether to proceed to a definitive RCT and support a funding application; finalised Trainer and Intervention Delivery manuals for multicentre replication of ReTrain; presentations at conferences, public involvement events; internationally recognised peer-reviewed journal publications, open access sources and media releases.

TRIAL REGISTRATION NUMBER

NCT02429180; Pre-results.

Self management programmes for quality of life in people with stroke

BACKGROUND

Stroke results from an acute lack of blood supply to the brain and becomes a chronic health condition for millions of survivors around the world. Self management can offer stroke survivors a pathway to promote their recovery. Self management programmes for people with stroke can include specific education about the stroke and likely effects but essentially, also focusses on skills training to encourage people to take an active part in their management. Such skills training can include problem-solving, goal-setting, decision-making, and coping skills.

OBJECTIVES

To assess the effects of self management interventions on the quality of life of adults with stroke who are living in the community, compared with inactive or active (usual care) control interventions.

SEARCH METHODS

We searched the following databases from inception to April 2016: the Cochrane Stroke Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, Web of Science, OTSeeker, OT Search, PEDro, REHABDATA, and DARE. We also searched the following trial registries: ClinicalTrials.gov, Stroke Trials Registry, Current Controlled Trials, World Health Organization, and Australian New Zealand Clinical Trials Registry.

SELECTION CRITERIA

We included randomised controlled trials of adults with stroke living in the community who received self management interventions. These interventions included more than one component of self management or targeted more than a single domain of change, or both. Interventions were compared with either an inactive control (waiting list or usual care) or active control (alternate intervention such as education only). Measured outcomes included changes in quality of life, self efficacy, activity or participation levels, impairments, health service usage, health behaviours (such as medication adherence or lifestyle behaviours), cost, participant satisfaction, or adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted prespecified data from all included studies and assessed trial quality and risk of bias. We performed meta-analyses where possible to pool results.

MAIN RESULTS

We included 14 trials with 1863 participants. Evidence from six studies showed that self management programmes improved quality of life in people with stroke (standardised mean difference (SMD) random effects 0.34, 95% confidence interval (CI) 0.05 to 0.62, P = 0.02; moderate quality evidence) and improved self efficacy (SMD, random effects 0.33, 95% CI 0.04 to 0.61, P = 0.03; low quality evidence) compared with usual care. Individual studies reported benefits for health-related behaviours such as reduced use of health services, smoking, and alcohol intake, as well as improved diet and attitude. However, there was no superior effect for such programmes in the domains of locus of control, activities of daily living, medication adherence, participation, or mood. Statistical heterogeneity was mostly low; however, there was much variation in the types and delivery of programmes. Risk of bias was relatively low for complex intervention clinical trials where participants and personnel could not be blinded.

AUTHORS' CONCLUSIONS

The current evidence indicates that self management programmes may benefit people with stroke who are living in the community. The benefits of such programmes lie in improved quality of life and self efficacy. These are all well-recognised goals for people after stroke. There is evidence for many modes of delivery and examples of tailoring content to the target group. Leaders were usually professionals but peers (stroke survivors and carers) were also reported - the commonality is being trained and expert in stroke and its consequences. It would be beneficial for further research to be focused on identifying key features of effective self management programmes and assessing their cost-effectiveness.