Moving stroke rehabilitation research evidence into clinical practice: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable

Availability and barriers to access post-stroke rehabilitation in Latin America

OBJECTIVES

To describe the availability and barriers to access post-stroke rehabilitation services in Latin America.

MATERIALS AND METHODS

We conducted a multi-national survey in Latin American countries. The survey consisted of three sections: (1) the national state of post-stroke rehabilitation; (2) the local state of post-stroke rehabilitation; and (3) the coverage and financing of post-stroke services. Stroke leaders from the surveyed countries were involved in developing and disseminating the survey.

RESULTS

261 responses were collected from 17 countries. The mean age of respondents was 42.4 ± 10.1 years, and 139 (54.5 %) of the respondents were male. National clinical guidelines for post-stroke rehabilitation were reported by 67 (25.7 %) of the respondents. However, there were discrepancies between respondents within the same country. Stroke units, physiotherapy, occupational therapy, speech therapy, and neuropsychological therapy services were less common in public than private settings. The main barriers for inpatient and outpatient services included limited rehabilitation facilities, coverage, and rehabilitation personnel. The main source of financing for the inpatient and outpatient services was the national health insurance, followed by out-of-pocket payments. Private and out-of-pocket costs were more frequently reported in outpatient services.

CONCLUSIONS

Post-stroke rehabilitation services in Latin American countries are restricted due to a lack of coverage by the public health system and private insurers, human resources, and financial aid. Public settings offer fewer post-stroke rehabilitation services compared to private settings. Developing consensus guidelines, increasing coverage, and using innovative approaches to deliver post-stroke rehabilitation is paramount to increase access without posing a financial burden.

Post-stroke lateropulsion in Australia and New Zealand: a survey investigating current knowledge, priorities and practice

BACKGROUND

Post-stroke lateropulsion is prevalent and associated with poor rehabilitation outcomes, but evidence to guide rehabilitation of affected stroke survivors is limited. Current post-stroke lateropulsion rehabilitation practice across Australia and New Zealand has not been previously described.

OBJECTIVES

This study aimed to describe lateropulsion rehabilitation practice in Australia and New Zealand, determine clinicians,' educators' and researchers' opinions about the need for educational resources to guide best-practice, and to identify current barriers to, and enablers of, optimal rehabilitation delivery.

METHODS

This cross-sectional survey was distributed to stroke rehabilitation clinicians, educators and researchers across Australia and New Zealand using Qualtrics. Data were described using frequency distributions and Chi-squared tests. Responses to open-ended questions were summarized for reporting.

RESULTS

The final analyses included 127 surveys. Most participants (93%) were physiotherapists. The importance of identifying and assessing post-stroke lateropulsion was noted by 97.6% of participants; however routine lateropulsion assessment was reported by only 60.6% of respondents. About 93.6% of participants indicated that lateropulsion should be targeted as a rehabilitation priority. Limitations in knowledge and skill among clinicians and insufficient evidence to guide rehabilitation were noted as barriers to best-practice rehabilitation delivery. Most respondents (95.2%) indicated that lateropulsion management should be included in stroke rehabilitation guidelines.

CONCLUSIONS

A sample of clinicians, educators, and researchers involved in stroke rehabilitation across Australia and New Zealand have indicated that lateropulsion should be targeted as a rehabilitation priority. Knowledge and skill were identified as barriers to best-practice rehabilitation implementation, which could be improved by addressing lateropulsion in clinical practice guidelines.

Patients experience of cognitive fatigue post-stroke: an exploratory study

PURPOSE

Cognitive fatigue is commonly reported and described as disabling by patients recovering from neurological conditions including stroke. However, cognitive fatigue is usually underdiagnosed among stroke survivors which leads to a lack of specific treatments for this condition. Therefore, the aim of this study was to explore post-stroke cognitive fatigue as it is experienced by stroke survivors.

METHODS

This qualitative research followed the principles of descriptive phenomenology within a constructivist paradigm. Individual semi-structured interviews were conducted with stroke survivors experiencing post-stroke cognitive fatigue recruited through the Heart and Stroke Foundation, the Canadian Partnership for Stroke Recovery, and social media posts. Data were analyzed through inductive content analysis.

RESULTS

Eleven stroke survivors participated. The analysis revealed five themes illustrating the experience and descriptions of post-stroke cognitive fatigue: (1) characteristics, (2) aggravating factors, (3) management, (4) effect of cognitive fatigue on daily life, and (5) social awareness and support.

CONCLUSION

This study highlights the complexity of post-stroke cognitive fatigue. Cognitive fatigue becomes more evident after discharge; therefore, clinicians should consistently screen for it and provide proper education to the patients and their carers.IMPLICATIONS FOR REHABILITATIONCognitive fatigue is a complex phenomenon that can negatively affect the daily life of stroke survivors.Sensory-overloaded environments, emotional distress, poor sleep, and engaging in complex cognitive tasks can trigger post-stroke cognitive fatigue.More education on the concept of cognitive fatigue should be provided to healthcare providers to be able to identify and manage this symptom properly.

Considerations for developing complex post-stroke upper limb behavioural interventions: An international qualitative study

OBJECTIVE

To simultaneously explore the perspectives and opinions of different invested participant groups on the important considerations for development of upper limb behavioural interventions that drive optimal post-stroke upper limb motor recovery.

DESIGN

A qualitative descriptive study in a constructivist epistemology.

PARTICIPANTS

Purposively selected participant groups (preclinical research n = 9, clinical research n = 9, clinical experience n = 9 and lived experience n = 10).

SETTING

Research participants were selected from top internationally published authors. Experiential participants were recruited internationally, through networks.

RESULTS

Four themes were identified with embedded subthemes. Theme 1: 'Clinical relevance should be the core of a "good" research question' with two subthemes: 'Breaking down silos: forging interdisciplinary research teams', and 'Beyond the pipeline: bench to bedside and back'; theme 2: 'Balance restitution and compensation to maximise outcomes' with three subthemes: 'Good outcome: going beyond an outcome measure', 'Recovery is a puzzle: measure all the pieces', and 'Optimising capacity: knowing when and how'; theme 3: 'Stroke demands personalised solutions' with two subthemes: 'Condition-specific considerations', and 'Person-specific considerations'; theme 4: 'Upper limb recovery requires complex interventions' with four subthemes: 'Fuelling engagement', 'Content is crucial', 'Multidimensional dose', and 'Therapist sway'.

CONCLUSIONS

This study suggests that post-stroke upper limb motor interventions are the interactions of multiple intervention elements (e.g. dose and content) shaped by different contextual considerations (e.g. stroke and personal factors). Development of such interventions may need to consider both content and context of the intervention to drive optimal recovery.

Stroke Rehabilitation Clinical Practice Guidelines in Low- and Middle-Income Countries: A Systematic Review of Quality and Unique Features

INTRODUCTION

Efforts toward reducing stroke burden have been an immense challenge. One important reasons could be the scope and quality of clinical practice guidelines (CPGs) developed for stroke rehabilitation in low- and middle-income countries (LMICs), restricting its translation to clinical practice. This systematic review aimed to assess the availability, scope and quality of CPGs for stroke rehabilitation in LMICs.

METHODS

Following PRISMA guidelines, CPGs for stroke rehabilitation in LMICs were searched across four major electronic databases (Medline, Embase, CINAHL, and PEDro). Additional studies were identified from grey literature and a hand search of key bibliographies and search engines. The availability and content of the CPGs were narratively summarized and quality of de novo CPGs was analyzed using "Appraisal of Guidelines REsearch and Evaluation" (AGREE) tools: version II & Recommendations Excellence (REX) version. Features of contextualizations/adaptations of non-de novo CPGs were narratively summarized.

RESULTS

Twelve CPGs from 10 countries were included. CPGs from Pakistan, Sri Lanka, India, and China were developed de novo. CPGs from Kenya, Philippines, South Africa, Cameroon, Mongolia, and Ukraine were contextualized/adapted based on existing guidelines from high-income countries. Most contextualized CPGs had limited stakeholder involvement, local health systems/patient pathway analyses. All ten countries included recommendations for physiotherapy, seven for communication, swallowing, and five for occupational therapy services poststroke. Quality assessment using AGREE-REX and AGREE-II for de novo guidelines was poor, especially scoring low in development and applicability.

CONCLUSION

Contextualized CPGs for stroke rehabilitation in LMICs were scarcely available and not meeting required quality. There is a need for development of context-specific, culturally relevant CPGs for stroke rehabilitation in LMICs to improve implementation/translation into clinical practice.

Implementation of evidence-based interventions according to the Swedish National Guidelines for Strokecare: a nationwide survey among physiotherapists

OBJECTIVE

To investigate (i) to what extent physiotherapists (PTs) working in stroke rehabilitation in various parts of the stroke care chain have implemented interventions according to the national guidelines for stroke (NGS), (ii) facilitating and hindering factors for the implementation, and (iii) differences between various care settings.

DESIGN

A cross-sectional study.

SUBJECTS

148 PTs working in stroke rehabilitation in various parts of the care chain in Sweden.

METHODS

Data were collected by a web-based survey.

RESULTS

Task-specific training for walking (80-98%), impaired motor function (64-100%) and fall prevention (73-92%) were most implemented. Factors that facilitated implementation were: important to comply with the NGS, that PTs had confidence to perform the interventions, and that interventions were clearly described. Limited time, lack of resources, no clear goals or routines at the workplace hindered the implementation. Significant differences (p < 0.05) between the settings existed. Municipal and primary care reported most challenges in implementing the NGS and providing evidence-based interventions.

CONCLUSION

Most interventions, with high priority according to NGS, are provided by PTs working in stroke rehabilitation, although differences in various parts of the care chain exist. Knowledge, time, education and supportive management are important factors when implementing evidence-based interventions.

Unlocking the restraint-Development of a behaviour change intervention to increase the provision of modified constraint-induced movement therapy in stroke rehabilitation

BACKGROUND

Strong evidence supports the provision of modified constraint-induced movement therapy (mCIMT) to improve upper limb function after stroke. A service audit identified that very few patients received mCIMT in a large subacute, early-supported discharge rehabilitation service. A behaviour change intervention was developed to increase the provision of mCIMT following an unsuccessful 'education only' attempt. This paper aims to systematically document the steps undertaken and to provide practical guidance to clinicians and rehabilitation services to implement this complex, yet effective, rehabilitation intervention.

METHODS

This clinician behaviour change intervention was developed over five stages and led by a working group of neurological experts (n = 3). Data collection methods included informal discussions with clinicians and an online survey (n = 35). The staged process included reflection on why the first attempt did not improve the provision of mCIMT (stage 1), mapping barriers and enablers to the Theoretical Domains Framework (TDF) and behaviour change wheel (BCW) to guide the behaviour change techniques (stages 2 and 3), developing a suitable mCIMT protocol (stage 4), and delivering the behaviour change intervention (stage 5).

RESULTS

Reflection among the working group identified the need for upskilling in mCIMT delivery and the use of a behaviour change framework to guide the implementation program. Key determinants of behaviour change operated within the TDF domains of knowledge, skills, environmental context and resources, social role and identity, and social influences. Following the development of a context-specific mCIMT protocol, the BCW guided the behaviour change intervention, which included education, training, persuasion, environmental restructuring, and modelling.

CONCLUSION

This paper provides an example of using the TDF and BCW to support the implementation of mCIMT in a large early-supported discharge service. It outlines the suite of behaviour change techniques used to influence clinician behaviour. The success of this behaviour change intervention will be explored in future research.

Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs): Protocol for systematic review

INTRODUCTION

Stroke rehabilitation guidelines promoteclinical decision making, enhance quality of healthcare delivery, minimize healthcare costs, and identify gaps in current knowledge to guide future research. However, there are no published reviews that have exclusively evaluated the quality of existing Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs) or provided any insights into the cultural variation, adaptations, or gaps in implementation specific to LMICs.

OBJECTIVES

To identify CPGs developed by LMICs for stroke rehabilitation and evaluate their quality using AGREE-II and AGREE-REX tool.

METHODS

The review protocol is prepared in accordance with the PRISMA-P guidelines and the review was registered in PROSPERO (CRD42022382486). The search was run in Medline, EMBASE, CINHAL, PEDro for guidelines published between 2000 till July 2022. Additionally, SUMSearch, Google, and other guideline portals and gray literature were searched. The included studies were then subjected to data extraction for the following details: Study ID, title of the CPG, country of origin, characteristics of CPG (Scope-national/regional, level of care, multidisciplinary/uni-disciplinary), and information on stroke rehabilitation relevant recommendations. The quality of the included CPGs will be subsequently evaluated using AGREE-II and AGREE-REX tool.

RESULTS & CONCLUSION

This systematic review aims to explore the gaps in existing CPGs specific to LMICs and will aid in development/adaptation/contextualization of CPGs for implementation in LMICs.

Stroke systems of care in South-East Asia Region (SEAR): commonalities and diversities

The Southeast Asia Region (SEAR) accounts for nearly 50% of the developing world's stroke burden. With various commonalities across its countries concerning health services, user awareness, and healthcare-seeking behavior, SEAR still presents profound diversities in stroke-related services across the continuum of care. This review highlights the numerous systems and challenges in access to stroke care, acute stroke care services, and health care systems, including rehabilitation. The paper has also attempted to compile information on the availability of stroke specialized centers, Intravenous thrombolysis (IVT) ready centers, Endovascular therapy (EVT) ready centers, rehabilitation centers, and workforce against a backdrop of each country's population. Lastly, the efforts of WHO (SEARO)-CMCL (World Health Organization-South East Asia region, Christian Medical College & Hospital Ludhiana) collaboration towards improving stroke services and capacity among the SEAR have been described.

From healthcare system to individuals through stroke rehabilitation pathways.Outcomes, information, and satisfaction along 12 months prospective cohort in Portugal

BACKGROUND

The nature and quality of stroke survivor rehabilitation varies throughout Europe, including in Portugal, having not been widely monitored or benchmarked.

OBJECTIVES

This study analyses the stroke care pathway from three perspectives: healthcare system, process, and patient.

METHODS

The study uses data from a one-year single-center prospective cohort of first stroke patients, assessed at baseline, 3, 6, and 12 months. Care pathways and settings were described in terms of organizational model, funding, patient involvement, frequency and intensity and multidisciplinary team. Patient-level information and satisfaction were evaluated using a 10-point numeric rating scale. Kruskal - Wallis and post-hoc tests were used to compare EQ-5D-3 L, National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Barthel Index, Mini-Mental State Examination scores between pathways and settings.

RESULTS

A total of 391 acute stroke patients, with a mean disability of 3.7 (mRS) and severity of 11.7 (NIHSS) participated. Six pathways and eight settings were described. A lack of compliance between guidelines and care was identified. There were significant differences in the four outcomes between the six pathways (p-values 0.007 to 0.020) suggesting inefficiency and inequalities, with an inadequate level of information and patient satisfaction. After post-hoc analysis, pathways 1 and 2 showed highest outcomes (p-values 0.001 to 0.002). Within settings, short-term units showed high scores, followed by rehabilitation center, outpatient hospital, and community clinic (p-values 0.001 to 0.040).

CONCLUSION

A multilevel characterization of the post-stroke rehabilitation pathway showed a more complete perspective on stroke management which may contribute to future rehabilitation and stroke policies.

Perspectives of users for a future interactive wearable system for upper extremity rehabilitation following stroke: a qualitative study

BACKGROUND

Wearable sensor technology can facilitate diagnostics and monitoring of people with upper extremity (UE) paresis after stroke. The purpose of this study is to investigate the perspectives of clinicians, people living with stroke, and their caregivers on an interactive wearable system that detects UE movements and provides feedback.

METHODS

This qualitative study used semi-structured interviews relating to the perspectives of a future interactive wearable system including a wearable sensor to capture UE movement and a user interface to provide feedback as the means of data collection. Ten rehabilitation therapists, 9 people with stroke, and 2 caregivers participated in this study.

RESULTS

Four themes were identified (1) "Everyone is different" highlighted the need for addressing individual user's rehabilitation goal and personal preference; (2) "The wearable system should identify UE and trunk movements" emphasized that in addition to arm, hand, and finger movements, detecting compensatory trunk movements during UE movements is also of interest; (3) "Both quality and amount of movements are necessary to measure" described the parameters related to how well and how much the user is using their affected UE that participants envisioned the system to monitor; (4) "Functional activities should be practiced by the users" outlined UE movements and activities that are of priority in designing the system.

CONCLUSIONS

Narratives from clinicians, people with stroke, and their caregivers offer insight into the design of interactive wearable systems. Future studies examining the experience and acceptability of existing wearable systems from end-users are warranted to guide the adoption of this technology.

Scoping review protocol of the use of codesign methods in stroke intervention development

INTRODUCTION

Codesign is an emerging research method to enhance intervention development by actively engaging non-researchers (eg, people who have had a stroke, caregivers and clinicians) in research. The involvement of non-researchers in research is becoming increasingly popular within health studies as it may produce more relevant and effective findings. The stroke population commonly exhibits challenges such as aphasia and cognitive changes that may limit their participation in codesign. However, the use of codesign within the stroke literature has not been comprehensively reviewed. This scoping review will determine: (1) what is the extent, range and nature of stroke research that has used codesign methods? (2) What codesign methods have been used to develop stroke interventions? (3) What considerations for codesigning interventions with people who have stroke are not captured in the findings?

METHODS AND ANALYSIS

This is a protocol for a scoping review to identify the literature relating to stroke, and codesign will be conducted on OVID Medline, OVID Embase, OVID PsychINFO, EBSCO CINAHL, the Cochrane Library, Scopus, PEDro-Physiotherapy Evidence Database and Global Index Medicus. Studies of any design and publication date will be included. Title and abstract and full-text review will be conducted independently by two reviewers. Data will be extracted, collated and then summarised descriptively using quantitative (eg, numerical descriptions) and qualitative (eg, textual descriptions) methods. Numerical summaries will map the extent (eg, number of studies), range (eg, types of studies) and nature (eg, types of interventions developed) of the literature on this topic. A thematic analysis will provide insights into the codesign methods (eg, activities, non-researchers), including heterogeneity across and within studies.

ETHICS AND DISSEMINATION

This review protocol does not require ethics approval as data has not been collected/analysed. The findings will highlight opportunities and recommendations to inform future codesign research in stroke and other populations who exhibit similar challenges/disabilities, and they will be disseminated via publications, presentations and stakeholder meetings.

TRIAL REGISTRATION NUMBERREGISTRATION

Open Science Framework: 10.17605/OSF.IO/NSD2W.

A qualitative study exploring the experiences of individuals living with stroke and their caregivers with community-based poststroke services: A critical need for action

BACKGROUND

Unmet poststroke service needs are common among people living in the community. Community-Based Stroke Services (CBSS) have the potential to address these unmet needs, yet there are no comprehensive guidelines to inform the design of CBSS, and they remain an understudied aspect of stroke care. This study aimed to describe the perceived barriers to accessing community-based stroke services, benefits from these programs and opportunities to address unmet needs.

METHODS

This was a qualitative descriptive study with interviews and focus groups conducted with people living with stroke and caregivers. Data were transcribed and analyzed thematically.

RESULTS

Eighty-five individuals with stroke and caregivers participated. Four key overarching themes were identified: facilitators and barriers to accessing and participating in community-based stroke services; components of helpful and unhelpful stroke services; perceived benefits of community-based stroke services; and opportunities to address unmet stroke service needs.

INTERPRETATIONS

The findings resonate with and extend prior literature, suggesting a critical need for personalized and tailored stroke services to address persistent unmet needs. We call on relevant stakeholders, such as policymakers, providers, and researchers, to move these insights into action through comprehensive guidelines, practice standards and interventions to personalize and tailor CBSS.

A Stroke Rehabilitation Educational Program for Occupational Therapy Students and Practitioners: Usability Study

BACKGROUND

There are gaps in knowledge translation (KT) of current evidence-based practices regarding stroke assessment and rehabilitation delivered through teletherapy. A lack of this knowledge can prevent occupational therapy (OT) students and practitioners from implementing current research findings.

OBJECTIVE

The aim of this pilot study was to create an educational program to translate knowledge into practice regarding the remote delivery of stroke assessment and rehabilitation to OT students and practitioners. Four areas of focus were addressed in the educational program, including KT, task-oriented training, stroke assessments, and telerehabilitation.

METHODS

Two pilot studies were conducted to assess the knowledge gained via pretests and posttests of knowledge, followed by a System Usability Scale and general feedback questionnaire. Participants in study 1 were 5 OT practitioners and 1 OT assistant. Participants in study 2 were 9 current OT students. Four 1-hour modules were emailed weekly to participants over the course of 4 weeks, with each module covering a different topic (KT, task-oriented training, stroke assessments, and telerehabilitation). Preliminary results were reviewed using descriptive statistics.

RESULTS

Statistically significant results were found with increased scores of knowledge for both students and practitioners. Most of the educational modules had an above-average score regarding value and positive feedback for the educational program as a whole from the participants.

CONCLUSIONS

Overall, the results of this pilot study indicate that a web-based educational program is a valuable, informational method of increasing the translation of knowledge in the remote delivery of stroke assessment and rehabilitation. OT students and practitioners found the information presented to be valuable and relevant to their future profession and current practice.

The Stroke Recovery in Motion Implementation Planner: Mixed Methods User Evaluation

Background

As more people are surviving stroke, there is a growing need for services and programs that support the long-term needs of people living with the effects of stroke. Exercise has many benefits; however, most people with stroke do not have access to specialized exercise programs that meet their needs in their communities. To catalyze the implementation of these programs, our team developed the Stroke Recovery in Motion Implementation Planner, an evidence-informed implementation guide for teams planning a community-based exercise program for people with stroke.

Objective

This study aimed to conduct a user evaluation to elicit user perceptions of the usefulness and acceptability of the Planner to inform revisions.

Methods

This mixed methods study used a concurrent triangulation design. We used purposive sampling to enroll a diverse sample of end users (program managers and coordinators, rehabilitation health partners, and fitness professionals) from three main groups: those who are currently planning a program, those who intend to plan a program in the future, and those who had previously planned a program. Participants reviewed the Planner and completed a questionnaire and interviews to identify positive features, areas of improvement, value, and feasibility. We used descriptive statistics for quantitative data and content analysis for qualitative data. We triangulated the data sources to identify Planner modifications.

Results

A total of 39 people participated in this study. Overall, the feedback was positive, highlighting the value of the Planner’s comprehensiveness, tools and templates, and real-world examples. The identified areas for improvement included clarifying the need for specific steps, refining navigation, and creating more action-oriented content. Most participants reported an increase in knowledge and confidence after reading the Planner and reported that using the resource would improve their planning approach.

Conclusions

We used a rigorous and user-centered process to develop and evaluate the Planner. End users indicated that it is a valuable resource and identified specific changes for improvement. The Planner was subsequently updated and is now publicly available for community planning teams to use in the planning and delivery of evidence-informed, sustainable, community-based exercise programs for people with stroke.

Tailored GuideLine Implementation in STrokE Rehabilitation (GLISTER) in Germany. Protocol of a Mixed Methods Study Using the Behavior Change Wheel and the Theoretical Domains Framework

Objective

Evidence-based guidelines are important for informing clinical decision-making and improving patient outcomes. There is inconsistent usage of guidelines among physical therapists involved in stroke rehabilitation, suggesting the existence of a gap between theory and practice. Addressing the German guideline "evidence-based rehabilitation of mobility after stroke (ReMoS)," the aims of this project are (1) to describe the current physical therapy practice within the context of stroke rehabilitation in Germany, (2) to evaluate barriers and facilitators of guideline usage, (3) to develop, and (4) to pilot test a theory-based, tailored implementation intervention for the benefit of guideline recommendations.

Materials and Methods

This study uses a stepwise mixed methods approach for implementing a local guideline. A self-reported online questionnaire will be used to survey the current physical therapy practice in stroke rehabilitation. The same survey and systematic-mixed methods review will be used to evaluate the barriers and facilitators of guideline usage quantitatively. Semi-structured interviews will add a qualitative perspective on factors that influence ReMoS guideline implementation. The Behavior Change Wheel and Theoretical Domains Framework will be used to support the development of a tailored implementation intervention which will be pilot tested in a controlled study. Patient and physical therapy-related outcomes, as well as the appropriateness, such as acceptance and feasibility of the tailored implementation intervention, will be analyzed.

Conclusion

This will be the first endeavor to implement a guideline in German stroke rehabilitation with a focus on changing care provider behavior based on the knowledge of current practice and determining factors using a tailored and theory-based intervention.

A Large-Scale Prospective Study on Functional Ability and Mortality Following Stroke Based on HRS Data Set: Implications for Rehabilitation

According to the WHO, 15 million people worldwide suffer a stroke annually. Of these, 5 million die and another 5 million are left permanently disabled. Patients endure the impacts of strokes during their rehabilitation and afterward, placing economical and emotional burdens on family and community. Using data from the Health and Retirement Study (HRS) of the USA, the research performed a large-scale prospective analysis to examine how demographics, socioeconomic factors, cognition, emotion, and physical activity predict functional impairment and mortality. Multiple regression was employed to identify statistically significant variables that predict longitudinal Activities of Daily Life (ADLs). The least absolute shrinkage and selection operator (LASSO) logistic regression, a supervised machine learning approach, was deliberately chosen to obtain the subset of predictors that provide the best possible classification for the dependent variable. The LASSO regression produced a model with a fair mean Area Under the Curve (AUC) of 0.75 in predicting the risk of the patient's mortality. My findings also uncovered the important roles of BMI, mobility, muscle strength, memory, mental status, and socioeconomic status play in the long-term ADLs and survival of patients with stroke.

“I Give It Everything for an Hour Then I Sleep for Four.” The Experience of Post-stroke Fatigue During Outpatient Rehabilitation Including the Perspectives of Carers: A Qualitative Study

Background

Fatigue is a debilitating post-stroke symptom negatively impacting rehabilitation. Lack of acknowledgment from carers can be additionally distressing. The purpose of this study was to describe the experience of post-stroke fatigue during outpatient rehabilitation, including the perspectives of carers.

Methods

This qualitative study was guided by descriptive phenomenology within a constructivist paradigm. Semi-structured interviews were conducted with stroke survivors experiencing fatigue (Fatigue Assessment Scale >23) and attending outpatient rehabilitation. Carers were also interviewed where identified, providing insight into their own and stroke survivor experiences. Data were analyzed according to Colaizzi's analytic method.

Results

Fourteen stroke survivors (50% culturally and linguistically diverse), and nine carers participated. Six themes were identified: 1. The unpredictable and unprepared uncovering of fatigue; 2. Experience and adjustment are personal 3. Being responsible for self-managing fatigue; 4. The complex juggle of outpatient stroke rehabilitation with fatigue; 5. Learning about fatigue is a self-directed problem-solving experience; 6. Family and carers can support or constrain managing fatigue.

Conclusion

Despite engaging in outpatient rehabilitation, stroke survivors largely learnt to manage fatigue independent of healthcare professionals. Carers often facilitated learning, monitoring rehabilitation, daily routines and fatigue exacerbation. Conversely, family could be dismissive of fatigue and possess unrealistic expectations. Post-stroke fatigue must be considered by clinicians when delivering outpatient rehabilitation to stroke survivors. Clinicians should consistently screen for fatigue, provide flexible session scheduling, and educate about individual indicators and strategies for management. Clinicians should also explicitly engage carers who play a critical role in the management of fatigue.

Self-Management in Stroke Survivors: Development and Implementation of the Look after Yourself (LAY) Intervention

Objective: Self-management is recommended in stroke rehabilitation. This report aims to describe timing, contents, and setting of delivery of a patient-centered, self-management program for stroke survivors in their early hospital rehabilitation phase: the Look After Yourself (LAY) intervention. Methods: After extensive literature search, the LAY intervention was developed by integrating the Chronic Disease Self-Management Program, based on the self-efficacy construct of social cognitive theory, with evidence-based key elements and input from stroke survivors. Results: the LAY intervention aims to implement self-management skills in stroke survivors, enabling them to be active in goal setting and problem solving using action plans and to facilitate the critical transition from hospital to community. It includes both group sessions to facilitate sharing of experiences, social comparison, vicarious learning, and increase motivation and one-to-one sessions focused on setting feasible action plans and on teaching personalized strategies to prevent falls. Standardization is ensured by manuals for facilitators and patients. Conclusion: The LAY intervention is the first Italian program to support early self-management in stroke rehabilitation; it has been experimented and its efficacy proven in improving self-efficacy, mental health, and activities of daily living, and detailed results have been published. The LAY intervention is described according to the TIDieR checklist.

Development of a short-form Swedish version of the Montreal Cognitive Assessment (s-MoCA-SWE): protocol for a cross-sectional study

INTRODUCTION

Short forms of the Montreal Cognitive Assessment (MoCA) have allowed quick cognitive screening. However, none of the available short forms has been created or validated in a Swedish sample of patients with stroke.The aim is to develop a short-form Swedish version of the MoCA (s-MoCA-SWE) in a sample of patients with acute and subacute stroke. The specific objectives are: (1) to identify a subgroup of MoCA items that have the potential to form the s-MoCA-SWE; (2) to determine the optimal cut-off value of s-MoCA-SWE for predicting cognitive impairment and (3) and to compare the psychometric properties of s-MoCA-SWE with those of previously developed MoCA short forms.

METHODS AND ANALYSIS

This is a statistical analysis protocol for a cross-sectional study. The study sample will comprise patients from Väststroke, a local stroke registry from Gothenburg, Sweden and Efficacy oF Fluoxetine-a randomisEd Controlled Trial in Stroke (EFFECTS), a randomised controlled trial in Sweden. The s-MoCA-SWE will be developed by using exploratory factor analysis and the boosted regression tree algorithm. The cut-off value of s-MoCA-SWE for impaired cognition will be determined based on binary logistic regression analysis. The psychometric properties of s-MoCA-SWE will be compared with those of other MoCA short forms by using cross-tabulation and area under the receiving operating characteristic curve analyses.

ETHICS AND DISSEMINATION

The Väststroke study has received ethical approval from the Regional Ethical Review Board in Gothenburg (346-16) and the Swedish Ethical Review Authority (amendment 2019-04299). The handling of data generated within the framework of quality registers does not require written informed consent from patients. The EFFECTS study has received ethical approval from the Stockholm Ethics Committee (2013/1265-31/2 on 30 September 2013). All participants provided written consent. Results will be published in an international, peer-reviewed journal, presented at conferences and communicated to clinical practitioners in local meetings and seminars.

Evidence-based stroke rehabilitation: do priorities for practice change and feasibility of implementation vary across high income, upper and lower-middle income countries?

PURPOSE

The context of implementation plays an important role in the delivery of optimal treatments in stroke recovery and rehabilitation. Considering that stroke systems of care vary widely across the globe, the goal of the present paper is to compare healthcare providers' priority of key areas in translating stroke research to clinical practice among High Income Countries, Upper Middle- and Lower Middle-Income Countries (HICs, UMICs, LMICs). We also aimed to compare perceptions regarding the key areas' feasibility of implementation, and formulate recommendations specific to each socioeconomic region.

METHODS

Data related to recommendations for knowledge translation in stroke, from a primary survey from the second Stroke Recovery and Rehabilitation Roundtable were segregated based on socioeconomic region. Frequency distribution was used to compare the key areas for practice change and examine the perceived feasibility of implementation of the same across HIC, UMIC and LMICs.

RESULTS

A total of 632 responses from healthcare providers across 28 countries were received. Interdisciplinary care and access to services were high priorities across the three groups. Transitions in Care and Intensity of Practice were high priority areas in HICs, whereas Clinical Practice Guidelines were a high priority in LMICs. Interventions specific to clinical discipline, screening and assessment were among the most feasible areas in HICs, whereas Intensity of practice and Clinical Practice Guidelines were perceived as most feasible to implement in LMICs.

CONCLUSION

We have identified healthcare providers' priorities for addressing international practice change across socioeconomic regions. By focusing on the most feasible key areas, we can aid the channeling of appropriate resources to bridge the disparities in stroke outcomes across HICs, UMICs and LMICs.IMPLICATIONS FOR REHABILITATIONIt is pertinent to examine the differences in priorities of stroke rehabilitation professionals and the feasibility of implementing evidence-based practice across socioeconomic regions.There is an urgent necessity for the development of clinical practice guidelines for stroke rehabilitation in Low-Middle Income Countries, taking into consideration the cultural, economic and geographical constraints.In upper-middle income countries, encouraging family support and timely screening and assessment for aphasia, cognition and depression appear to be the low hanging fruits to enhance quality of life after stroke.Innovative ways to increase intensity of practice and channelling of resources to improve transitions in care may prove to be the most beneficial in advancing stroke rehabilitation in high income countries.

Do clinical guidelines guide clinical practice in stroke rehabilitation? An international survey of health professionals

PURPOSE

To identify health professionals awareness of stroke rehabilitation guidelines, and factors perceived to influence guideline use internationally.

METHODS

Online survey study. Open-ended responses were thematically analysed, guided by the Consolidated Framework for Implementation Research.

RESULTS

Data from 833 respondents from 30 countries were included. Locally developed guidelines were available in 22 countries represented in the sample. Respondents from high-income countries were more aware of local guidelines compared with respondents from low- and middle-income countries.Local contextual factors such as management support and a culture of valuing evidence-based practice were reported to positively influence guideline use, whereas inadequate time and shortages of skilled staff inhibited the delivery of guideline-recommended care. Processes reported to improve guideline use included education, training, formation of workgroups, and audit-feedback cycles. Broader contextual factors included accountability (or lack thereof) of health professionals to deliver rehabilitation consistent with guideline recommendations.

CONCLUSION

While many health professionals were aware of clinical guidelines, they identified multiple barriers to their implementation. Efforts should be made to raise awareness of local guidelines in low- and middle-income countries. More attention should be paid to addressing local contextual factors to improve guideline use internationally, going beyond traditional strategies focused on individual health professionals.IMPLICATIONS FOR REHABILITATIONSystems are required so people and organisations are held accountable to deliver evidence-based care in stroke rehabilitation.Locally developed stroke rehabilitation guidelines should be promoted to boost awareness of these guidelines in low- and middle-income countries.In all regions, strategies to influence or adapt to the local setting, are required to optimise guideline use.

Stroke rehabilitation in low-income and middle-income countries: a call to action

The WHO Rehabilitation 2030 agenda recognises the importance of rehabilitation in the value chain of quality health care. Developing and delivering cost-effective, equitable-access rehabilitation services to the right people at the right time is a challenge for health services globally. These challenges are amplified in low-income and middle-income countries (LMICs), in which the unmet need for rehabilitation and recovery treatments is high. In this Series paper, we outline what is happening more broadly as part of the WHO Rehabilitation 2030 agenda, then focus on the specific challenges to development and implementation of effective stroke rehabilitation services in LMICs. We use stroke rehabilitation clinical practice guidelines from both high-income countries and LMICs to highlight opportunities for rapid uptake of evidence-based practice. Finally, we call on educators and the stroke rehabilitation clinical, research, and not-for-profit communities to work in partnership for greater effect and to accelerate progress.

Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives

Stroke is the second leading cause of death and a major contributor to disability worldwide. The prevalence of stroke is highest in developing countries, with ischemic stroke being the most common type. Considerable progress has been made in our understanding of the pathophysiology of stroke and the underlying mechanisms leading to ischemic insult. Stroke therapy primarily focuses on restoring blood flow to the brain and treating stroke-induced neurological damage. Lack of success in recent clinical trials has led to significant refinement of animal models, focus-driven study design and use of new technologies in stroke research. Simultaneously, despite progress in stroke management, post-stroke care exerts a substantial impact on families, the healthcare system and the economy. Improvements in pre-clinical and clinical care are likely to underpin successful stroke treatment, recovery, rehabilitation and prevention. In this review, we focus on the pathophysiology of stroke, major advances in the identification of therapeutic targets and recent trends in stroke research.

Validation of the Simplified Modified Rankin Scale Questionnaire

INTRODUCTION

The modified Rankin scale (mRS) is the most common assessment tool for measuring overall functional outcome in stroke studies. The traditional way of using mRS face-to-face is time- and cost-consuming. The aim of this study was to test the validity of the Swedish translation of the simplified modified Rankin scale questionnaire (smRSq) as compared with the mRS assessed face-to-face 6 months after a stroke.

METHODS

Within the ongoing EFFECTS trial, smRSq was sent out to 108 consecutive stroke patients 6 months after a stroke. The majority, 90% (97/108), of the patients answered the questionnaire; for the remaining 10%, it was answered by the next of kin. The patients were assessed by face-to-face mRS by 7 certified healthcare professionals at 4 Swedish stroke centres. The primary outcome was assessed by Cohen's kappa and weighted kappa.

RESULTS

There was good agreement between postal smRSq, answered by the patients, and the mRS face-to-face; Cohen's kappa was 0.43 (CI 95% 0.31-0.55), weighted kappa was 0.64 (CI 95% 0.55-0.73), and Spearman rank correlation was 0.82 (p < 0.0001). In 55% (59/108), there was full agreement, and of the 49 patients not showing exact agreement, 44 patients differed by 1 grade and 5 patients had a difference of 2 grades.

DISCUSSION/CONCLUSION

Our results show good validity of the postal smRSq, answered by the patients, compared with the mRS carried out face-to-face at 6 months after a stroke. This result could help trialists in the future simplify study design and make multicentre trials and quality registers with a large number of patients more feasible and time-saving.

Facilitators and "deal breakers": a mixed methods study investigating implementation of the Goal setting and action planning (G-AP) framework in community rehabilitation teams

BACKGROUND

High quality goal setting in stroke rehabilitation is vital, but challenging to deliver. The G-AP framework (including staff training and a stroke survivor held G-AP record) guides patient centred goal setting with stroke survivors in community rehabilitation teams. We found G-AP was acceptable, feasible to deliver and clinically useful in one team. The aim of this study was to conduct a mixed methods investigation of G-AP implementation in diverse community teams prior to a large-scale evaluation.

METHODS

We approached Scottish community rehabilitation teams to take part. Following training, G-AP was delivered to stroke survivors within participating teams for 6 months. We investigated staff experiences of G-AP training and its implementation using focus groups and a training questionnaire. We investigated fidelity of G-AP delivery through case note review. Focus group data were analysed using a Framework approach; identified themes were mapped into Normalisation Process Theory constructs. Questionnaire and case note data were analysed descriptively.

RESULTS

We recruited three teams comprising 55 rehabilitation staff. Almost all staff (93%, 51/55) participated in G-AP training; of those, 80% (n = 41/51) completed the training questionnaire. Training was rated as 'good' or 'very good' by almost all staff (92%, n = 37/41). G-AP was broadly implemented as intended in two teams. Implementation facilitators included - G-AP 'made sense'; repetitive use of G-AP in practice; flexible G-AP delivery and positive staff appraisals of G-AP impact. G-AP failed to gain traction in the third team. Implementation barriers included - delays between G-AP training and implementation; limited leadership engagement; a poor 'fit' between G-AP and the team organisational structure and simultaneous delivery of other goal setting methods. Staff recommended (i) development of training to include implementation planning; (ii) ongoing local implementation review and tailoring, and (iii) development of electronic and aphasia friendly G-AP records.

CONCLUSIONS

The interaction between G-AP and the practice setting is critical to implementation success or failure. Whilst facilitators support implementation success, barriers can collectively act as implementation "deal breakers". Local G-AP implementation efforts should be planned, monitored and tailored. These insights can inform implementation of other complex interventions in community rehabilitation settings.