A telehealth intervention to promote healthy lifestyles after stroke: The Stroke Coach protocol

Non-pharmacological interventions to treat mood disturbances post-stroke: a systematic review

BACKGROUND

Stroke survivors face high rates of depression, anxiety, and pseudobulbar affect. Clinicians report lack of clarity on effective non-pharmacological interventions due to uncertainty about treatment options as barriers to evidence-based treatment. No systematic review has investigated the effectiveness of non-pharmacological interventions on the conditions of depression, anxiety, and pseudo-bulbar affect.

OBJECTIVES

The aim of this study was to evaluate the effectiveness of non-pharmacological interventions on the outcomes of depression, anxiety, and pseudobulbar affect in post-stroke individuals.

METHODS

Following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched databases Medline, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO for randomized controlled trials in English, within 2012-2023, evaluating the effect of a non-pharmacological intervention on depression, anxiety, and/or pseudobulbar affect. Two researchers screened titles, abstracts, and full texts. One researcher extracted data and assessed risk of bias. Data were synthesized narratively.

RESULTS

Forty-two studies were included. Intervention types included education (n = 9), psychological therapy (n = 8), and physical exercise (n = 8). Intervention types reporting positive outcomes for depression were psychological therapy (n = 6), physical exercise (n = 3) and robot-assisted therapy (n = 3). Intervention types effective in improving anxiety were physical exercise (n = 2), psychological therapy (n = 3) and multi-modal therapy approaches (n = 2). No studies explored the impact on pseudobulbar affect.

CONCLUSION

Non-pharmacological interventions may be effective in improving mood in stroke survivors. Robot-assisted therapy and physical exercise were seen to improve multiple outcome measures. Patient education should be delivered alongside rehabilitation and directed to both stroke-survivor and caregiver.

Acceptability of Telerehabilitation: Experiences and Perceptions by Individuals with Stroke and Caregivers in an Early Supported Discharge Program

INTRODUCTION

Telerehabilitation (TR) is a promising method for facilitating the delivery and access to post-stroke rehabilitation services.

OBJECTIVE

The aim of this study was to explore the acceptability of TR and factors influencing its adoption by individuals with stroke and caregivers.

METHODS

A qualitative descriptive approach was used. Six individuals with stroke and three caregivers participated in individual online interviews. An abductive thematic analysis was employed to analyze the qualitative data, using the Unified Theory of Acceptance and Use of Technology 2 (UTAUT-2) model.

RESULTS

Participants reported positive experiences with TR, resulting in improvements in functional abilities, such as manual dexterity, balance, and positive interactions with therapists. They found the technology easy to learn and use, facilitating engagement in TR. Participants' prior experiences with technology, along with support from caregivers and therapists, facilitated acceptance and the use of TR. The COVID-19 pandemic also motivated participants to accept TR. However, technical issues, unstable internet connections, and lack of feedback were barriers to the use of TR.

CONCLUSION

Despite existing obstacles, TR can be used to provide rehabilitation services for individuals with stroke. Addressing these barriers is necessary to promote the widespread and effective use of TR in the context of stroke recovery.

Addressing Opportunities and Barriers in Telehealth Neurologic Physical Therapy: Strategies to Advance Practice

BACKGROUND AND PURPOSE

Since the COVID-19 pandemic, the use and implementation of telehealth has expanded, with implementation moving ahead of best practice recommendations due to necessity. Telehealth has improved access and care coordination for patients with various neurologic conditions; however, information regarding therapeutic intensity, safety, and appropriateness is lacking. In 2021, the Academy of Neurologic Physical Therapy formed a Telehealth Taskforce to provide clinical and educational resources for its members and the neurologic physical therapy (PT) community. The purpose of this special interest article is to provide consensus-driven best practice resources developed by the Taskforce and describe the process of creating these resources to assist with telehealth implementation in neurologic PT practice, advocate for continued utilization, and shine light on opportunities for future research.

SUMMARY OF KEY POINTS

In this special interest article, we describe the process, challenges, and opportunities of developing and disseminating resources to educate, train, and support telehealth implementation in neurologic clinical practice. Four key strategies to facilitate telehealth implementation emerged: (1) increase knowledge of resources related to telehealth and mobile applications; (2) develop and disseminate evidence-based and consensus-based best practice recommendations for telehealth in neurologic PT; (3) provide future recommendations for integrating telehealth in PT, education, research, and clinical practice; and (4) encourage advocacy for inclusion of telehealth within the PT community. We explain the need to continue research and provide recommendations to expand telehealth research in neurologic clinical practice.

RECOMMENDATIONS FOR CLINICAL PRACTICE

This article highlights the potential and future of telehealth in neurologic PT practice. Our recommendations provide current clinical tools and resources for telehealth implementation following a knowledge-to-action framework and suggest areas for future research.Video Abstract available for more insights from the authors (see the Video, the Supplemental Digital Content, available at: http://links.lww.com/JNPT/A447).

Interventions targeting psychosocial adaptation in people with stroke: A scoping review

OBJECTIVE

This scoping review aimed to describe and map interventions targeting psychosocial adaptation in people with stroke.

METHODS

A scoping review was conducted using the Joanna Briggs Institute methodology and reported according to Systematic Review and Meta-Analyses Extension for Scoping Reviews guidelines. We included original studies with interventions targeting psychosocial adaptation (concept) on people with stroke (population) in any setting (context). We searched five online electronic databases (PubMed, Embase, CINAHL, PsycINFO, and Cochrane Central Registry of Controlled Trials). We described interventions in terms of design characteristics, theoretical basis, details of interventions, and quantitative outcomes indicated in psychosocial adaptation.

RESULTS

Forty-three studies were identified. Five intervention categories were identified to describe the interventions targeting psychosocial adaptation. Quantitative outcomes indicated psychosocial adaptation in our review were grouped into four domains: global adaptation, psychological adaptation, social adaptation, and others.

CONCLUSIONS

The mapping and description brought to light the large heterogeneity of interventions targeting psychosocial adaptation in people with stroke.

PRACTICE IMPLICATIONS

Deepening understanding of psychosocial adaptation can help health professionals further develop effective interventions aiming at promoting psychosocial adaptation and reducing negative health sequelae, such as risk of reduced psychosomatic recovery post stroke.

Results of a four-year multi-channel regional program for monitoring stroke survivors in Franche-Comté, France

INTRODUCTION

Clinical monitoring of stroke survivors after hospital discharge was initiated in France in 2012 and funding for its model began in 2016. A regional program in Franche-Comté relying on various assessment methods including telehealth was initiated. The objective of this study was to describe the implementation and quality of the program.

METHODS

A retrospective observational study was conducted from 1^st January 2016 to 31^st December 2019. Patients were included if they were adults, hospitalized for stroke or transient ischemic attack in one of the six public hospitals in the region and discharged alive. There were five types of monitoring methods: physical consultation, day hospital, nurse-led phone consultation, postal mail or medical record analysis. Characteristics, method of monitoring and discharge delay were described.

RESULTS

In total, 7166 patients were identified; male gender predominated (52.9%); mean age was 72.2years. Monitoring coverage increased from 89.2% to 92% within the period. Most patients had ischemic stroke (68.5%, n=4912) and were at home at the time of monitoring (71.6%, n=5130). The main method was nurse-led phone consultations (40.8%, n=2921) followed by physical consultation (16%, n=1143). Day hospital monitoring increased (1.5% to 14.4%) while the postal mail method decreased (18.7% to 8.1%). The average delay decreased from 240.3 to 148.6days. Monitoring period of less than four months was 46.2% in 2019 and 75.3% for thrombolysis. In 2019, 99.3% of patients were being monitored at one year. Mortality decreased from 10% to 6.3%.

DISCUSSION

The program improved over time with an increase in the number of patients and reduction in delays and mortality rate.

Specific health-related quality of life in Cerebrovascular accident survivors: associated factors

OBJECTIVES

to identify factors associated with specific health-related quality of life in cerebrovascular accident, or stroke, survivors.

METHODS

cross-sectional study, carried out with 160 cerebrovascular accident survivors. Data were collected using the Barthel Index, Cerebrovascular Accident Specific Quality of Life Scale, and semi-structured instruments for sociodemographic and clinical data, analyzed by descriptive and inferential statistics.

RESULTS

health-related quality of life was associated with work activity (p=0.027), physical activity (p=0.007), functional capacity (p=0.001), presence of caregiver (<0.001), motor alteration (p = 0.001) and rehabilitation (p=0.003). The functionally dependent people were 14.61 times more likely to present low health-related quality of life, and those with motor impairment were 3.07 times more likely.

CONCLUSIONS

it was evidenced that functional dependence and motor impairment increase the chance of low health-related quality of life in cerebrovascular accident survivors.

"Lessons Learned" Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review

Recurrent ischemic strokes are a cause of significant healthcare burdens globally. Patients with uncontrolled vascular risk factors are more likely to develop recurrent ischemic strokes. This study aims to compile information gained from current secondary prevention programs. A pre-defined literature search strategy was applied to PubMed, SCOPUS, CINAHL, and Google Scholar databases, and studies from 1997 to 2020 were evaluated for quality, study aims, and outcomes. The search produced 1175 articles (1092 after duplicates were removed) and titles were screened; 55 titles were retained for the full-text analysis. Of the remaining studies, 31 were retained for assessment, five demonstrated long-term effectiveness, eight demonstrated short-term effectiveness, and 18 demonstrated no effectiveness. The successful studies utilized a variety of different techniques in the categories of physical fitness, education, and adherence to care plans to reduce the risk of recurrent strokes. The lessons we learned from the current prevention programs included (1) offer tailored care for underserved groups, (2) control blood pressure, (3) provide opportunities for medication dosage titration, (4) establish the care plan prior to discharge, (5) invest in supervised exercise programs, (6) remove barriers to accessing care in low resource settings, and (7) improve the transition of care.

Telehealth coaching to improve self-management for secondary prevention after stroke: A randomized controlled trial of Stroke Coach

BACKGROUND

Stroke Coach is a lifestyle coaching telehealth program to improve self-management of stroke risk factors.

AIMS

To examine the efficacy of Stroke Coach on lifestyle behavior and risk factor control among community-living stroke survivors within one-year post stroke.

METHODS

Participants were randomized to Stroke Coach or an attention control Memory Training group. Lifestyle behavior was measured using the Health Promoting Lifestyle Profile II. Secondary outcomes included specific behavioral and cardiometabolic risk factors, health-related quality of life (HRQoL), cognitive status, and depressive symptoms. Measurements were taken at baseline, post-intervention (6 months), and retention (12 month). Linear mixed-effects models were used to test the study hypotheses (p < 0.05). All analyses were intention-to-treat.

RESULTS

The mean age of the Stroke Coach (n = 64) and Memory Training (n = 62) groups was 67.2 and 69.1 years, respectively. The majority of participants (n = 100) had mild stroke (modified Rankin Scale = 1 or 2), were active, with controlled blood pressure (mean = 129/79 mmHg) at baseline. At post-intervention, there were no significant differences in lifestyle (b = -2.87; 95%CI - 8.03 to 2.29; p = 0.28). Glucose control, as measured by HbA1c (b = 0.17; 95%CI 0.17 to 0.32; p = 0.03), and HRQoL, measured using SF-36 Physical Component Summary (b = -3.05; 95%CI -5.88 to -0.21; p = 0.04), were significantly improved in Stroke Coach compared to Memory Training, and the improvements were maintained at retention.

CONCLUSION

Stroke Coach did not improve lifestyle behavior; however, there were improvements to HbA1c and HRQoL among community-living stroke survivors with mild stroke-related disability. (ClinicalTrials.gov identifier: NCT02207023).

Activity monitors for increasing physical activity in adult stroke survivors

BACKGROUND

Stroke is the third leading cause of disability worldwide. Physical activity is important for secondary stroke prevention and for promoting functional recovery. However, people with stroke are more inactive than healthy age-matched controls. Therefore, interventions to increase activity after stroke are vital to reduce stroke-related disability.

OBJECTIVES

To summarise the available evidence regarding the effectiveness of commercially available, wearable activity monitors and smartphone applications for increasing physical activity levels in people with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, and the following clinical trial registers: WHO International Clinical Trials Registry Platform, Clinical Trials, EU Clinical Trial Register, ISRCTN Registry, Australian and New Zealand Clinical Trial Registry, and Stroke Trials Registry to 3 March 2018. We also searched reference lists, Web of Science forward tracking, and Google Scholar, and contacted trial authors to obtain further data if required. We did not restrict the search on language or publication status.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and randomised cross-over trials that included use of activity monitors versus no intervention, another type of intervention, or other activity monitor. Participants were aged 18 years or older with a diagnosis of stroke, in hospital or living in the community. Primary outcome measures were steps per day and time in moderate-to-vigorous intensity activity. Secondary outcomes were sedentary time, time spent in light intensity physical activity, walking duration, fatigue, mood, quality of life, community participation and adverse events. We excluded upper limb monitors that only measured upper limb activity.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology to analyse and interpret the data. At least two authors independently screened titles and abstracts for inclusion. We resolved disagreements by consulting a third review author. We extracted the following data from included studies into a standardised template: type of study, participant population, study setting, intervention and co-interventions, time-frame, and outcomes. We graded levels of bias as high, low, or unclear, and assessed the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We retrieved 28,098 references, from which we identified 29 potential articles. Four RCTs (in 11 reports) met the inclusion criteria.The sample sizes ranged from 27 to 135 (total 245 participants). Time poststroke varied from less than one week (n = 1), to one to three months (n = 2), or a median of 51 months (n = 1). Stroke severity ranged from a median of one to six on the National Institutes of Health Stroke Scale (NIHSS). Three studies were conducted in inpatient rehabilitation, and one was in a university laboratory. All studies compared use of activity monitor plus another intervention (e.g. a walking retraining programme or an inpatient rehabilitation programme) versus the other intervention alone. Three studies reported on the primary outcome of daily step counts.There was no clear effect for the use of activity monitors in conjunction with other interventions on step count in a community setting (mean difference (MD) -1930 steps, 95% confidence interval (CI) -4410 to 550; 1 RCT, 27 participants; very low-quality evidence), or in an inpatient rehabilitation setting (MD 1400 steps, 95% CI -40 to 2840; 2 RCTs, 83 participants; very low-quality evidence). No studies reported the primary outcome moderate-to-vigorous physical activity, but one did report time spent in moderate and vigorous intensity activity separately: this study reported that an activity monitor in addition to usual inpatient rehabilitation increased the time spent on moderate intensity physical activity by 4.4 minutes per day (95% CI 0.28 to 8.52; 1 RCT, 48 participants; low-quality evidence) compared with usual rehabilitation alone, but there was no clear effect for the use of an activity monitor plus usual rehabilitation for increasing time spent in vigorous intensity physical activity compared to usual rehabilitation (MD 2.6 minutes per day, 95% CI -0.8 to 6; 1 RCT, 48 participants; low-quality evidence). The overall risk of bias was low, apart from high-risk for blinding of participants and study personnel. None of the included studies reported any information relating to adverse effects.

AUTHORS' CONCLUSIONS

Only four small RCTs with 274 participants (three in inpatient rehabilitation and one in the community) have examined the efficacy of activity monitors for increasing physical activity after stroke. Although these studies showed activity monitors could be incorporated into practice, there is currently not enough evidence to support the use of activity monitors to increase physical activity after stroke.

Interventions for improving modifiable risk factor control in the secondary prevention of stroke

BACKGROUND

People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Stroke services need to be configured to maximise the adoption of evidence-based strategies for secondary stroke prevention. Smoking-related interventions were examined in a separate review so were not considered in this review. This is an update of our 2014 review.

OBJECTIVES

To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2017), CENTRAL (the Cochrane Library 2017, issue 3), MEDLINE (1950 to April 2017), Embase (1981 to April 2017) and 10 additional databases including clinical trials registers. We located further studies by searching reference lists of articles and contacting authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention.

DATA COLLECTION AND ANALYSIS

Four review authors selected studies for inclusion and independently extracted data. The quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach (GRADEpro GDT).Three review authors assessed the risk of bias for the included studies. We sought missing data from trialists.The results are presented in 'Summary of findings' tables.

MAIN RESULTS

The updated review included 16 new studies involving 25,819 participants, resulting in a total of 42 studies including 33,840 participants. We used the Cochrane risk of bias tool and assessed three studies at high risk of bias; the remainder were considered to have a low risk of bias. We included 26 studies that predominantly evaluated organisational interventions and 16 that evaluated educational and behavioural interventions for participants. We pooled results where appropriate, although some clinical and methodological heterogeneity was present.Educational and behavioural interventions showed no clear differences on any of the review outcomes, which include mean systolic and diastolic blood pressure, mean body mass index, achievement of HbA1c target, lipid profile, mean HbA1c level, medication adherence, or recurrent cardiovascular events. There was moderate-quality evidence that organisational interventions resulted in improved blood pressure control, in particular an improvement in achieving target blood pressure (odds ratio (OR) 1.44, 95% confidence interval (CI) 1.09 to1.90; 13 studies; 23,631 participants). However, there were no significant changes in mean systolic blood pressure (mean difference (MD), -1.58 mmHg 95% CI -4.66 to 1.51; 16 studies; 17,490 participants) and mean diastolic blood pressure (MD -0.91 mmHg 95% CI -2.75 to 0.93; 14 studies; 17,178 participants). There were no significant changes in the remaining review outcomes.

AUTHORS' CONCLUSIONS

We found that organisational interventions may be associated with an improvement in achieving blood pressure target but we did not find any clear evidence that these interventions improve other modifiable risk factors (lipid profile, HbA1c, medication adherence) or reduce the incidence of recurrent cardiovascular events. Interventions, including patient education alone, did not lead to improvements in modifiable risk factor control or the prevention of recurrent cardiovascular events.

Development of a Chronic Disease Management Program for Stroke Survivors Using Intervention Mapping: The Stroke Coach

OBJECTIVE

To describe the systematic development of the Stroke Coach, a theory- and evidence-based intervention to improve control of lifestyle behavior risk factors in patients with stroke.

DESIGN

Intervention development.

SETTING

Community.

PARTICIPANTS

Individuals who have had a stroke.

INTERVENTIONS

We used intervention mapping to guide the development of the Stroke Coach. Intervention mapping is a systematic process used for intervention development and composed of steps that progress from the integration of theory and evidence to the organization of realistic strategies to facilitate the development of a practical intervention supported by empirical evidence. Social cognitive theory was the underlying premise for behavior change, whereas control theory methods were directed toward sustaining the changes to ensure long-term health benefits. Practical evidence-based strategies were linked to behavioral determinants to improve stroke risk factor control.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

The Stroke Coach is a patient-centered, community-based, telehealth intervention to promote healthy lifestyles after stroke. Over 6 months, participants receive seven 30- to 60-minute telephone sessions with a lifestyle coach who provides education, facilitates motivation for lifestyle modification, and empowers participants to self-management their stroke risk factors. Participants also receive a self-management manual and a self-monitoring kit.

CONCLUSIONS

Through the use of intervention mapping, we developed a theoretically sound and evidence-grounded intervention to improve risk factor control in patients with stroke. If empirical evaluation of the Stroke Coach produces positive results, the next step will be to develop an implementation intervention to ensure successful uptake and delivery of the program in community and outpatient settings.

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.