Exploring views on long term rehabilitation for people with stroke in a developing country: findings from focus group discussions

Outcomes of importance to people with multiple sclerosis, Parkinson's disease and stroke following a falls prevention intervention: a qualitative study to inform a core outcome set

Purpose: Falls are a major issue for people with neurological conditions, and the evaluation of falls prevention interventions is of high priority. To date, the views of patient groups regarding outcomes of importance have been largely overlooked. The purpose of this study was to explore outcomes of interest among people with Multiple Sclerosis (MS), Parkinson's disease (PD) and stroke upon completion of falls prevention interventions to inform the development of a core outcome set (COS).Materials and methods: Five online focus groups and one semi-structured interview were conducted among people with PD (n = 10), MS (n = 7), and post-stroke (n = 3), one of whom also had PD. Transcripts were analysed using reflexive thematic analysis.Results: Four themes were developed; (1) Fall events are not homogeneous, (2) Exercise-based programmes are beneficial but falls services are not meeting user needs, (3) Programme success beyond the reduction in falls, and (4) Acquisition of skills to self-manage falls beyond the life of the programme.Conclusions: This study presents new perspectives across patient groups regarding important outcomes upon completion of falls prevention interventions. Taken together with the findings of a literature review, this data will inform the development of a COS.Implications for rehabilitationPeople with multiple sclerosis, Parkinson's disease and stroke consider the success of a falls prevention intervention to be dependent on improvements across a wide range of outcomes.The design and implementation of falls prevention interventions should align with patient preferences.Clinicians and researchers should consider the use of multidomain interventions to facilitate improvements in the desired outcomes of patients.

The Effect of ICF-Core Set-Based Occupational Therapy Interventions on the Function and Satisfaction of Individuals with Chronic Stroke: A Randomized Clinical Trial

Stroke can affect all aspects of a person's health and functioning. Therefore, it is important occupational therapists, have a comprehensive understanding of various levels of function and the factors affecting function. The ICF (International Classification of Functioning, Disability, and Health) and the selections of ICF categories or Core Sets relevant for people with a specific health condition, offer a model for intervention. This study aimed to investigate the effect of ICF-CS-based occupational therapy interventions on the function and satisfaction of individuals with chronic stroke. This study was designed as a randomized, single-blind, parallel-group clinical trial. Twenty-five patients with stroke were randomly assigned to the control group (which received traditional occupational therapy) or the treatment group (Stroke ICF-CS based occupational therapy). Patients were evaluated before and after the intervention (two months, three sessions per week, 45 minutes each session), as well as two weeks after the end of the intervention, using Fugl-Meyer and COPM (Canadian Occupational Performance Measure) tools. The independent T-test, Chi-square, and ANOVA with repeated measures were used to analyze the data. The results showed that the interaction effect of time and group was not significant in none of the Fugl-Meyer test sections (p > 0. 05), but it was significant in the performance and satisfaction of COPM (p < 0.05). The results suggest that ICF-CS-based occupational therapy interventions may assist persons with chronic stroke improve their functional level and satisfaction.

Exercise preference in stroke survivors: a concept analysis

Background

Exercise preference in stroke survivors is related to their adherence to long-term rehabilitation regimen and functional recovery. Although explored recently, the term exercise preference still lacks a clear definition.

Objective

The aim of this study is to conceptualize exercise preference in stroke survivors.

Methods

The Walker and Avant method was applied as a framework for the conceptual analysis of exercise preference. Data from 34 publications were collected using seven databases (PubMed, Web of Science, Embase, CINAHL, CNKI, Wanfang Data, and CBM) and applied in the analysis. The search period was from the inception of the database to April 30, 2023.

Results

Exercise preference in stroke survivors was defined according to four attributes: priority of choice, behavioral tendency, affective priming, and patience in adherence. The common antecedents of the concept of exercise preference in stroke survivors were classified into patient-related, therapy-related, and environmental-related categories and the consequences were classified into three categories: patient-related, rehabilitation provider-related, and rehabilitation service system-related.

Conclusion

Exercise preference in stroke survivors refers to the patient's choice, tendency, affective response, and attitude toward engagement in the recommended rehabilitation regimen. It is beneficial for understanding the essential attributes of exercise preference in stroke survivors by clarifying the concept. In addition, it will facilitate the development of instruments for assessing exercise preference in stroke survivors and the construction of theory-based intervention programs that can improve adherence to exercise rehabilitation.

Effectiveness of mobile application interventions for stroke survivors: systematic review and meta-analysis

BACKGROUND

Although smartphone usage is ubiquitous, and a vast amount of mobile applications have been developed for chronic diseases, mobile applications amongst stroke survivors remain unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to determine the effectiveness of mobile applications on medication adherence, functional outcomes, cardiovascular risk factors, quality of life and knowledge on stroke in stroke survivors.

METHODS

A review of the literature was conducted using key search terms in PubMed, EMBASE, Cochrane and Web of Science databases until 16 March 2023 to identify eligible randomized controlled trials (RCTs) or controlled clinical trial (CCTs) of mobile application interventions among stroke survivors. Two reviewers independently screened the literature in accordance with the eligibility criteria and collected data from the articles included. Outcomes included medication adherence,functional outcomes,cardiovascular risk factors, quality of life,and knowledge of stroke.

RESULTS

Twenty-three studies involving 2983 participants across nine countries were included in this review. Sixteen trials involved health care professionals in app use, and seven trials reported measures to ensure app-based intervention adherence. Mobile applications targeting stroke survivors primarily encompassed three areas: rehabilitation, education and self-care. The participants in the studies primarily included young and middle-aged stroke survivors. Meta-analysis results demonstrated that mobile application intervention significantly improved trunk control ability (mean differences [MD] 3.00, 95% CI [1.80 to 4.20]; P < 0.00001), Fugl-Meyer assessment of upper extremity (MD 9.81, 95% CI [8.72 to 10.90]; P < 0.00001), low-density lipoprotein cholesterol (MD - 0.33, 95% CI [- 0.54 to - 0.11]; P = 0.003) and glycosylated haemoglobin A1c (HbA1c)<7 levels (MD 1.95, 95% CI [1.17 to 3.25]; P = 0.01). However, the mobile application intervention did not differ significantly in medication adherence, 10-min walk test (10 MWT), Barthel index, systolic blood pressure, diastolic blood pressure, high-density lipoprotein cholesterol, body mass index, smoking, health-related quality of life and knowledge of stroke.

CONCLUSION

Our study suggested that mobile application interventions may have a potential benefit to stroke survivors, but clinical effectiveness should be established. More studies using rigorous designs are warranted to understand their usefulness. Future research should also involve more older adult stroke survivors.

A mixed-methods study on the implementation of a mobile health application (mHealth app) for stroke caregivers in Malaysia: healthcare providers' perspective

Introduction

Recognizing the burden experienced by caregivers of stroke survivors, an intervention using mobile health applications (mHealth apps) has been proposed to support and empower stroke caregivers. This study aimed to assess the acceptability and expectations of healthcare providers, who play a vital role as gatekeepers in the healthcare system, to ensure the effectiveness and sustainability of the intervention.

Methods

This was a concurrent mixed-method study design, with healthcare providers involved in stroke care management in the northeast regions of Malaysia as study participants. The qualitative component of the study was conducted using a phenomenological approach that involved in-depth interviews to explore the acceptability and expectations of healthcare providers regarding the adoption of mHealth apps in the context of stroke caregiving. The study was complemented by quantitative data collected through an online survey using an adjusted version of the technology acceptance model tool.

Results

In total, 239 participants from diverse backgrounds and professions were enrolled in the study, with 12 in the qualitative component and 227 in the quantitative component. The findings from the quantitative survey showed that over 80% of the participants expressed their intention to use mHealth apps. The qualitative component generated two themes related to the acceptability and expectations of mHealth apps, which were integrated with the quantitative findings. Additionally, in-depth interviews revealed a new theme, namely the key features of mHealth, with three sub-themes: availability of services for caregivers, provision of knowledge skills, and supporting caregivers in managing stroke patients.

Conclusion

Healthcare providers demonstrated excellent acceptability of this mHealth intervention as part of caregiving assistance, particularly with the inclusion of essential key features. However, future investigations are necessary to establish the feasibility of integrating the mHealth app into the healthcare system and to ensure its long-term sustainability.

Exploring the needs of stroke patients after discharge from rehabilitation centres in Saudi Arabian communities: An IPA qualitative exploratory study design

There are about 29 strokes per 100,000 people, annually, in the Kingdom of Saudi Arabia (KSA). These patients require long-term rehabilitation services to enhance recovery and independence in the community. Currently there are limited long-term rehabilitation services in KSA and research is needed to establish pathways for provision of community-based rehabilitation (CBR). To develop effective new CBR models, understanding the experiences and needs of stroke patients in KSA who have undergone poststroke care services is essential. This study aims to gain insight into stroke patients' needs after their discharge from rehabilitation centres in Saudi Arabia. An interpretive phenomenological analysis (IPA) study was undertaken using semi-structured interviews. Participants were eligible if they had a stroke, completed their in-hospital rehabilitation sessions and had been discharged within the past three years. Semi-structured interviews were conducted using interview guides. Transcripts were translated and analysed using interpretive phenomenological analysis. Twenty-four (15 males and 9 females) participants were recruited from two hospitals in KSA. The key findings suggested that patients experienced limited community rehabilitation services postdischarge unless they were financially able to pay for private therapy. Coping barriers including Medical, Psychological, Social, and Financial and facilitators including Faith, Recovery, Social support and leisure were identified. Participants suggested strategies to improve services within hospital and community for rehabilitation, needs of staff, access to services and ongoing care. Further work is required to develop, implement and evaluate a community rehabilitation intervention that includes education, and self-management elements to support stroke survivors in the community in KSA.

Evaluation of a stroke rehabilitation training programme for community-based primary healthcare

Background

Family caregiver training is an integral part of stroke rehabilitation programmes and is associated with improved caregiver and stroke survivor outcomes. In the Cape Winelands District, a low-resourced rural community-based setting in South Africa, stroke survivors and family caregivers mostly rely on assistance from community health workers (CHWs), despite their lack of stroke-specific rehabilitation training.

Objectives

To evaluate the implementation and immediate effects of a bespoke, 16 session, 21 h stroke rehabilitation training programme for CHWs to better support family caregivers.

Methods

Two cooperative inquiry groups participated in participatory action research to design and develop the programme. This article reports on the implementation of this programme. Inquiry group members directly observed the training, obtained written and verbal feedback, interviewed CHWs and observed them in the community. Consensus on their learning was achieved after reflection on their experience and observations.

Results

Learning of the cooperative inquiry groups was categorised into the effect on community-based care, the training programme's design and development, how training was delivered and implications for service delivery. Community health workers empowered caregivers and stroke survivors and enabled access to care, continuity, coordination and person-centredness. The need for experiential learning and a spiral curriculum was confirmed. Therapists needed a different set of skills to deliver training. A systems approach and effective leadership were needed to enable community health workers to use their new skills.

Conclusion

The stroke rehabilitation training programme demonstrated potential for integration into service delivery and equipping CHWs to support family caregivers and stroke survivors. Further evaluation of the programme's effectiveness and scale-up is needed.

Contribution

Evidence of an intervention to train CHWs to support stroke survivors and family caregivers.

A stroke rehabilitation training program for community-based primary health care, South Africa

Background

With an increasing burden of stroke and a lack of access to rehabilitation services in rural South African settings, stroke survivors rely on untrained family caregivers for support and care. Community health workers (CHWs) support these families but have no stroke-specific training.

Objectives

To describe the development of a contextually appropriate stroke training program for CHWs in the Cape Winelands District, South Africa.

Method

Twenty-six health professionals and CHWs from the local primary healthcare services participated in action research over a 15-month period from September 2014 to December 2015. The groups participated in two parallel cooperative inquiry (CI) groups. The inquiry followed the cyclical steps of planning, action, observation and reflection. In this article, the planning step and how the CI groups used the first three steps of the analyse, design, develop, implement, evaluate (ADDIE) instructional design model are described.

Results

The CHWs' scope of practice, learning needs, competencies and characteristics, as well as the needs of the caregivers and stroke survivors, were identified in the analysis step. The program design consisted of 16 sessions to be delivered over 20 h. Program resources were developed with appropriate technology, language and instructional methodology.

Conclusion

The program aims to equip CHWs to support family caregivers and stroke survivors in their homes as part of their generalist scope of practice. The implementation and initial evaluation will be described in a future article.

Contribution

The study developed a unique training program for CHWs to support caregivers and stroke survivors in a resource-constrained, rural, middle-income country setting.

Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis

BACKGROUND

To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve.

OBJECTIVES

To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation.

SEARCH METHODS

We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022.  SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions.   DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.  MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members.  Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation  Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others.  Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members.  In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services.  Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances.

AUTHORS' CONCLUSIONS

This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.

Lived experiences of stroke survivors in India: A phenomenological study

BACKGROUND

Stroke is a major cause of long-term disability and has a potentially enormous emotional and socio-economic impact on patients, their families, and health services. Perceptions of patients with stroke have already been studied worldwide, which are unique in terms of their cultural background. However, in India, there is a lack of studies about the experience of the disease by stroke survivors and their perspectives of understanding the situation.

OBJECTIVE

This study aimed to explore lived experience of stroke survivors in India.

METHODS

A phenomenological study design was used. In-depth interviews were conducted with a purposive sample of ten stroke survivors who had experienced post-stroke deficits three months to one year after stroke. Data were analyzed using Diekelmann's hermeneutical approach to identify underlying themes.

RESULTS

Two main themes emerged: (1) emergence of stroke (actual occurrence, mental perception, and recognition of illness) and (2) therapeutic concerns (enhanced and weakened recovery).

CONCLUSION

Recognizing how patients experience the illness is crucial in planning care for stroke survivors. Strengthening factors enhancing recovery and limiting the hindering factors through effective therapeutic management is a necessity. The findings might also contribute to refining existing interventions and designing holistic multi-component rehabilitation programs that facilitate easy recovery. The study also highlights the need for providing information to general public on recognizing warning signs of stroke.

Exploring Stroke Patients’ Needs after Discharge from Rehabilitation Centres: Meta-Ethnography

Healthcare providers must consider stroke survivors needs in order to enable a good quality of life after stroke. This review aimed to investigate the perceived needs of the stroke survivors across various domains of care following their discharge from hospital. A meta-ethnographic review of qualitative studies that reported needs of stroke patients after discharge from rehabilitation services was conducted. Main searches were conducted on the following electronic databases: Ovid Medline (1946 to 2021), CINAHL plus (EBSCO), AMED (EBSCO), PsycINFO (1967 to 2021), the Cochrane Library, and PubMed in June 2022. Main outcomes were related to stroke survivors’ views, experiences, and preferences on physical, psychological, social, rehabilitation needs, and other identified needs. Twenty-seven studies were included in the final analysis. The findings show that existing rehabilitation provision for stroke survivors does not address the long-term needs of stroke survivors. Two main issues were revealed concerning the unmet needs of stroke survivors: (1) a lack of information availability and suitability and (2) inadequacy of care and services. It is crucial to further investigate the needs of patients in Asian countries and the Middle East as there is very limited understanding of patients’ needs in the community in these regions.

Coverage and equity of essential care services among stroke survivors in the Western Province of Sri Lanka: a community-based cross-sectional study

BACKGROUND

Stroke survivors require continuing services to limit disability. This study assessed the coverage and equity of essential care services received during the first six months of post-stroke follow-up of stroke survivors in the Western Province of Sri Lanka.

METHODS

A multidisciplinary team defined the essential post-stoke follow-up care services and agreed on a system to categorize the coverage of services as adequate or inadequate among those who were identified as needing the said service. We recruited 502 survivors of first ever stroke of any type, from 11 specialist hospitals upon discharge. Six months following discharge, trained interviewers visited their homes and assessed the coverage of essential services using a structured questionnaire.

RESULTS

Forty-nine essential post-stroke follow-up care services were identified and categorized into six domains: monitoring of risk conditions, treatment, services to limit disabilities, services to prevent complications, lifestyle modification and supportive services. Of the recruited 502 stroke survivors, 363 (72.3%) were traced at the end of 6 months. Coverage of antiplatelet therapy was the highest (97.2% (n = 289, 95% CI 95.3- 99.1)) while referral to mental health services (3.3%, n = 12, 95% CI 1.4-5.1) and training on employment for the previously employed (2.2%, n = 4, 95% CI- 0.08-4.32), were the lowest among the six domains of care. In the sample, 59.8% (95% CI 54.76-64.48) had received an 'adequate' level of essential care services related to treatment while none received an 'adequate' level of services in the category of support services. Disaggregated service coverage by presence and type of limb paralysis within the domain of services to prevent complications, and by sex and education level within the domain of education level, show statistically significant differences (p < 0.05).

CONCLUSIONS

Apart from treatment services to limit disabilities, coverage of essential care services during the post-stroke period was inadequate. There were no apparent inequities in the coverage of vast majority of services. However focused policy decisions are required to address these gaps in services.

Experiences and needs of the caregivers of stroke survivors in Malaysia-A phenomenological exploration

Introduction

Informal caregivers play a crucial role in supporting the activities of daily living, rehabilitation, and the road to recovery for stroke survivors. However, these informal caregivers are often reported as experiencing neglect and lack of recognition despite their primary contribution to stroke recovery. This study investigated the experiences of the caregivers of stroke survivors and access to stroke care in Malaysia.

Method

This qualitative study with a phenomenological approach utilized in-depth interviews, including ten primary caregivers, one formal caregiver, and stroke healthcare providers as the participants. The interviews were done until the data saturation was achieved, and the data was analyzed using thematic analysis.

Result

Three primary themes and 14 subthemes were identified from the interviews. The role of primary caregivers of stroke survivors had tremendous physical, mental and social impact on the caregivers. Caregivers had two primary needs. The need for information about comprehensive stroke care at home and the need for psychological support to themselves. The key internal driver for providing care was identified to be the motivation level of the stroke survivor and the external driver was identified to be the societal support with access to comprehensive stroke care.

Conclusion

The role of informal caregivers becomes critical for continuum of stroke care. As caregivers take up the roles and responsibilities of those who contribute to stroke rehabilitation single-handedly soon after hospital discharge. Results of this study highlights the needs for providing systematic support to caregivers for engaging them in effective stroke care, particularly in the community. Stroke service providers, policy makers and program planners must be sensitized to empower caregivers of stroke survivors in effectively supporting stroke survivor in their family on the road of recovery.

Home-based self-help telerehabilitation of the upper limb assisted by an electromyography-driven wrist/hand exoneuromusculoskeleton after stroke

BACKGROUND

Most stroke survivors have sustained upper limb impairment in their distal joints. An electromyography (EMG)-driven wrist/hand exoneuromusculoskeleton (WH-ENMS) was developed previously. The present study investigated the feasibility of a home-based self-help telerehabilitation program assisted by the aforementioned EMG-driven WH-ENMS and its rehabilitation effects after stroke.

METHODS

Persons with chronic stroke (n = 11) were recruited in a single-group trial. The training progress, including the training frequency and duration, was telemonitored. The clinical outcomes were evaluated using the Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Functional Independence Measure (FIM), and Modified Ashworth Scale (MAS). Improvement in muscle coordination was investigated in terms of the EMG activation level and the Co-contraction Index (CI) of the target muscles, including the abductor pollicis brevis (APB), flexor carpi radialis-flexor digitorum (FCR-FD), extensor carpi ulnaris-extensor digitorum (ECU-ED), biceps brachii (BIC), and triceps brachii (TRI). The movement smoothness and compensatory trunk movement were evaluated in terms of the following two kinematic parameters: number of movement units (NMUs) and maximal trunk displacement (MTD). The above evaluations were conducted before and after the training.

RESULTS

All of the participants completed the home-based program with an intensity of 63.0 ± 1.90 (mean ± SD) min/session and 3.73 ± 0.75 (mean ± SD) sessions/week. After the training, motor improvements in the entire upper limb were found, as indicated by the significant improvements (P < 0.05) in the FMA, ARAT, WMFT, and MAS; significant decreases (P < 0.05) in the EMG activation levels of the APB and FCR-FD; significant decreases (P < 0.05) in the CI of the ECU-ED/FCR-FD, ECU-ED/BIC, FCR-FD/APB, FCR-FD/BIC, FCR-FD/TRI, APB/BIC and BIC/TRI muscle pairs; and significant reductions (P < 0.05) in the NMUs and MTD.

CONCLUSIONS

The results suggested that the home-based self-help telerehabilitation program assisted by EMG-driven WH-ENMS is feasible and effective for improving the motor function of the paretic upper limb after stroke. Trial registration ClinicalTrials.gov. NCT03752775; Date of registration: November 20, 2018.

Effects of peer support interventions on physical and psychosocial outcomes among stroke survivors: A systematic review and meta-analysis

BACKGROUND

High level of unmet needs were reported by stroke survivors after hospital discharge. Peer support interventions may play a valuable role in the management of stroke, but the evidence is unclear.

OBJECTIVES

To determine the effects of peer support interventions on physical and psychosocial outcomes of stroke survivors; and to identify the key characteristics of peer support interventions for stroke survivors.cv DESIGN: A systematic review and meta-analysis.

REVIEW METHODS

Seven English databases and four Chinese databases were searched to identify eligible articles. Two reviewers screened the eligible studies, appraised the risk of bias, and extracted the data independently. Version 2 of the Cochrane risk-of-bias tool was used to evaluate the risk of bias for randomized controlled trials, while the Risk of Bias in Non-randomized Studies of Interventions tool was used for the quasi-experimental studies. The Grading of Recommendations Assessment, Development and Evaluation profiler Guideline Development Tool was used to assess the quality of evidence. Meta-analyses were conducted using Review Manager 5.3, and narrative analyses were performed when meta-analysis was inappropriate.

RESULTS

Eleven studies were included. Peer support interventions could improve the activities of daily living (MD = 15.53, 95% CI: 1.39 to 29.68; P = 0.03, I2 = 99%; very low quality of evidence), limb function, depression (SMD = -1.27, 95% CI: -2.18 to -0.36; P = 0.006, I2 = 91%; very low quality of evidence) and anxiety. Although pooled analysis showed that social participation (SMD= 0.74, 95% CI: 0.09 to 1.39; P = 0.03, I2 = 69%; low quality of evidence) and quality of life (SMD = 0.41, 95% CI: 0.09 to 0.73; P = 0.01, I2 = 0%; low quality of evidence) improved after peer support interventions, the studies which were not pooled due to insufficient data drew inconsistent results.

CONCLUSIONS

Stroke survivors may benefit from peer support interventions to improve their physical and psychological outcomes. The evidence about the impact of peer support interventions on social participation and quality of life is very uncertain. It should be noted that the quality of evidence ranged from very low to low, thus highlighting the need for more research of higher quality to substantiate these findings.

What would 'upscaling' involve? A qualitative study of international variation in stroke rehabilitation

BACKGROUND

Demand for stroke rehabilitation is expected to grow dramatically; with the estimated prevalence of stroke survivors rising to 70 million worldwide by 2030. The World Health Organization's (WHO) report - Rehabilitation 2030: A call for action - has introduced the objective of 'upscaling' rehabilitation globally to meet demand. This research explored what upscaling stroke rehabilitation might mean for health professionals from countries at different stages of economic development.

METHODS

Qualitative descriptive study design using semi-structured interviews was employed. Purposively sampled, clinical leaders in stroke rehabilitation were recruited for interviews from low through to high-income countries.

RESULTS

Twelve rehabilitation professionals (medicine, physical therapy, occupational therapy, and speech and language therapy) from high (United States of America, Germany, United Kingdom, United Arab Emirates, New Zealand), upper-middle (Colombia and Turkey), lower-middle (Vietnam, Pakistan, Ghana), and low-income countries (Nepal and Sierra Leone) were interviewed. Upscaling was seen as a necessity. Successful scaling up will require initiatives addressing: political governance and managerial leadership, increasing knowledge and awareness of the value of rehabilitation, financial support, workforce developments, physical space and infrastructure, and the development of community services and reintegration.

CONCLUSION

Although there have been many gains within the development of stroke rehabilitation internationally, further investment is required to ensure that this patient population group continues to receive the best quality services. For the WHO to be successful in implementing their objective to upscale rehabilitation, specific attention will need to be paid to political, professional, economic, and sociocultural issues at global and local levels.

Stroke Rehabilitation for Falls and Risk of Falls in Southeast Asia: A Scoping Review With Stakeholders' Consultation

Background: Research on rehabilitation for falls after stroke is warranted. However, published evidence on fall interventions with stroke survivors is limited and these are mainly international studies that may be less relevant for Southeast Asia. Objective: This review aims to systematically identify literature related to stroke rehabilitation for falls and risk of falls in Southeast Asia. Methods: A scoping review with stakeholders' consultation was implemented. An electronic search was conducted up to December 2020 on 4 databases (Medline, CINAHL, Scopus, ASEAN Citation Index). Only original studies conducted in Southeast Asia were selected. Results: The initial search yielded 3,112 articles, however, only 26 were selected in the final analysis. Most of the articles focused on physical rehabilitation and implemented conventional therapies. While the literature may reflect practice in Southeast Asia, stakeholders perceived that the literature was inadequate to show true practice, was not informative and missed several aspects such as functional, cognitive, and psychological interventions in managing falls. Individual-centric interventions dominated the review while community-based and environmental-focused studies were limited. Majority of the articles were written by physiotherapists while others were from physicians, occupational therapists, and an engineer but few from other healthcare practitioners (i.e., speech therapists, psychologists) or disciplines interested in falls. Conclusions: Falls prevention among stroke survivors has received a lack of attention and is perceived as an indirect goal in stroke rehabilitation in Southeast Asia. More innovative research adopted from falls research with older people is needed to advance falls prevention and intervention practice with stroke survivors.

Effectiveness of post-stroke social rehabilitation in patients with moderate impairments

The importance of post-stroke rehabilitation cannot be overestimated. The aim of this study was to assess the effectiveness of a standardized post-stroke rehabilitation program for patients with moderate impairments. A total of 122 stroke survivors participated in the study. Group 1 (the comparison group) consisted of 59 patients undergoing standard rehabilitation. Group 2 (the main group) consisted of 63 patients participating in a specially designed social rehabilitation program. The functional, cognitive, psychological and emotional states and the level of social activity were monitored for 6 months. Group 2 demonstrated more pronounced improvement than group 1 after 6 months of follow-up, confirmed by higher Rivermead (p = 0.011) and SS-QOL (p < 0.05) scores and lower DASH and Beck scores (p = 0.015 and p < 0.001, respectively). In both groups, MMSE (cognitive function) scores slightly increased, but the differences between the groups were insignificant. The proposed post-stroke rehabilitation program is effective in helping patients regain their independence and improve social adaptation. The scales and scores used in the study, especially DASH and SS-QOL, are sensitive to changes in the functional state of stroke survivors with moderate impairments.

The effectiveness of home-based therapy on functional outcome, self-efficacy and anxiety among discharged stroke survivors

INTRODUCTION

Stroke survivors are commonly at risk of functional decline following discharge from rehabilitation, which increase their susceptibility to falls, dependency in activities of daily living and emotional disturbances. To combat these, continued therapy is important. Home-based therapy (HBT) has been shown to be useful in maintaining functional performance and quality of life of chronic stroke survivors. However, evidence on its effectiveness remains limited, while no studies are available to date which report the benefit of HBT on stroke survivors self-efficacy and emotional status. Therefore, this study aims to assess the effectiveness of post-discharge HBT in comparison to usual practice on functional outcome (mobility and gait speed), self-efficacy and anxiety level among stroke survivors.

METHODS

This is an assessor-blinded randomized control trial comparing 2 types of intervention which are HBT (experimental group) and usual practice (UP) (control group). Based on sample size calculation using GPower, a total number of 42 participants will be recruited and allocated into either the HBT or the UP group. Participants in HBT group will receive a set of structured exercise therapy consisting of progressive strengthening, balance and task-related exercises. While participants in UP group will receive a usual "intervention" practised by rehabilitation professional prior to discharging stroke patients from their care. Both groups are advised to perform the given interventions for 3 times per week for 12 weeks under the supervision of their caregiver. Outcomes of interventions will be measured using timed up and go test (for mobility), ten-meter walk test (for gait speed), stroke self-efficacy questionnaire (for self-efficacy) and hospital anxiety and depression scale (for anxiety level). All data will be analyzed using descriptive and inferential statistics.

DISCUSSION

This study will provide the information on the effectiveness of HBT in comparison to UP among stroke population who are discharged from rehabilitation. Findings from the study will enable rehabilitation professionals to design effective discharge care plan for stroke survivors in combating functional decline when no longer receiving hospital-based therapy.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12619001182189 (last updated 22/11/2019).

Figuring it out by yourself: Perceptions of home-based care of stroke survivors, family caregivers and community health workers in a low-resourced setting, South Africa

BACKGROUND

In less resourced settings, formal rehabilitation services for stroke survivors were often absent. Stroke survivors were referred to community health workers (CHWs) who were untrained in rehabilitation.

AIM

To describe the experience and perceived needs of stroke survivors, their caregivers and CHWs in a context with limited access to and support from formal rehabilitation services.

SETTING

The Breede Valley subdistrict, Western Cape, South Africa, a rural, less resourced setting.

METHODS

A descriptive exploratory qualitative study. Four focus group interviews were held with purposively selected stroke survivors and caregivers and four with CHWs. A thematic approach and the framework method were used to analyse the transcripts.

FINDINGS

A total of 41 CHWs, 21 caregivers and 26 stroke survivors participated. Four main themes and 11 sub-themes were identified. Because of the lack of knowledge, training and rehabilitation services, the main theme for all groups was having to 'figure things out' independently, with incontinence management being particularly challenging. Secondly was the need for emotional support for stroke survivors and caregivers. Thirdly, contextual factors such as architectural barriers and lack of assistive products negatively impacted care and function. Lastly, the organisation of health and rehabilitation services negatively impacted home-based services and professional support.

CONCLUSIONS

With appropriate training, the CHWs can be pivotal in the training and support of family caregivers and stroke survivors. Care pathways and the role and scope of both CHWs and therapists in home-based stroke rehabilitation should be defined and restructured, including the links with formal services.

Experiences accessing and using rehabilitation services for people with physical disabilities in Sierra Leone

Purpose: To explore the experiences of persons with physical disabilities accessing and using rehabilitation services in Sierra Leone.Materials and methods: Interviews of 38 individuals with differing physical disabilities in three locations across Sierra Leone. An inductive approach was applied, and qualitative content analysis used.Results: Participants faced several barriers to accessing and using rehabilitation services. Six themes emerged: The initial and ongoing need for rehabilitation throughout life; challenges with the cost of rehabilitation and transportation to reach rehabilitation services; varied experiences with rehabilitation staff; coming to terms with disability and encountering stigma; the struggles without and opportunities with rehabilitation services; and limited knowledge and availability of rehabilitation services.Conclusions: There is a continued need to address the barriers associated with the affordability of rehabilitation through the financing of rehabilitation and transportation and exploring low-cost care delivery models. Rehabilitation services, assistive devices, and materials need to be available in existing rehabilitation centres. A national priority list is recommended to improve the availability and coordination of rehabilitation services. Improved knowledge about disability and rehabilitation services in the wider community is needed. Addressing discriminatory health beliefs and the stigma affecting people with disabilities through community interventions and health promotion is recommended.Implications for RehabilitationFinancing for rehabilitation, transportation to services and low-cost delivery models of care areneeded to reduce financial barriers and increase affordability of access and use.Community interventions and health promotion can provide information about the utility and availability of rehabilitation services, while addressing health beliefs and stigma towards persons with disabilities.The availability of both rehabilitation services and information, that is relevant and accessible is required to facilitate improved access and use of rehabilitation services.

Virtual Reality Games as an Adjunct in Improving Upper Limb Function and General Health among Stroke Survivors

Virtual reality (VR) games has the potential to improve patient outcomes in stroke rehabilitation. However, there is limited information on VR games as an adjunct to standard physiotherapy in improving upper limb function. This study involved 36 participants in both experimental (n = 18) and control (n = 18) groups with a mean age (SD) of 57 (8.20) and 63 (10.54) years, respectively. Outcome measures were the Fugl-Meyer assessment for upper extremities (FMA-UE), Wolf motor function test (WMFT), intrinsic motivation inventory (IMI), Lawton of instrumental activities of daily living (IADL), and stroke impact scale (SIS) assessed at pre-post intervention. The experimental group had 0.5 h of upper limb (UL) VR games with 1.5 h of standard physiotherapy, and the control group received 2 h of standard physiotherapy. The intervention for both groups was performed once a week for eight consecutive weeks. The results showed a significant time-group interaction effect for IMI (p = 0.001), Lawton IADL (p = 0.01) and SIS domain of communication (p = 0.03). A significant time effect was found in FMA-UE (p = 0.001), WMFT (p = 0.001), Lawton IADL (p = 0.01), and SIS domains; strength, ADL and stroke recovery (p < 0.05). These results indicated an improvement in UL motor ability, sensory function, instrumental ADL, and quality of life in both groups after eight weeks of intervention. However, no significant (p > 0.05) group effect on all the outcome measures was demonstrated. Thus, replacing a portion of standard physiotherapy time with VR games was equally effective in improving UL function and general health compared to receiving only standard physiotherapy among stroke survivors.

Facilitating Exercise Engagement among Community Dwelling Stroke Survivors: Is a once Per Week Group Session Sufficient?

Although exercise is proven as an effective strategy to combat post-stroke complications and the risk of stroke recurrence, many stroke survivors fail to engage in this activity following rehabilitation. In this study, we assessed the feasibility and usefulness of a low-frequency group exercise to determine its suitability as an approach to facilitate exercise engagement among stroke survivors. Forty-one stroke survivors, mean (SD) age 59.34 (10.02) years, mean time post-stroke 17.13 (17.58) months, completed a 90 minute, once per week, group exercise supervised by therapists for 12 weeks. The exercise outcomes were measured using standardized clinical tests. We observed improvement in the group's physical performance; balance score by 3 units (Z = -3.88, p < 0.001), speed of repetitive sit to stand by 3.4 s (Z = -4.69, p < 0.001), and walking speed by 8.22 m/min (Z = -3.25, p < 0.001). Scores of seven out of 14 Berg's balance scale items increased significantly, indicating better balance ability among the survivors. In conclusion, a 12-week, once per week group exercise session seems feasible and sufficient to improve the physical performance of community dwelling stroke survivors. This exercise arrangement may be offered to stroke survivors to facilitate exercise practice following rehabilitation.

Systematic Review and Meta-Analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-Dwelling Patients With a Stroke

OBJECTIVE

To evaluate the effects of home-based rehabilitation on improving physical function in home-dwelling patients after a stroke.

DATA SOURCES

Various electronic databases, including PubMed, Cumulative Index to Nursing and Allied Health, Embase, the Cochrane Central Register of Controlled Trials, and 2 Chinese data sets (ie, Chinese Electronic Periodical Services and China Knowledge Resource Integrated) were searched for studies published before March 20, 2019.

STUDY SELECTION

Randomized controlled trials conducted to examine the effect of home-based rehabilitation on improving physical function in home-dwelling patients with a stroke and published in English or Chinese were included. In total, 49 articles in English (n=23) and Chinese (n=26) met the inclusion criteria.

DATA EXTRACTION

Data related to patient characteristics, study characteristics, intervention details, and outcomes were extracted by 2 independent reviewers.

DATA SYNTHESIS

A random-effects model with a sensitivity analysis showed that home-based rehabilitation exerted moderate improvements on physical function in home-dwelling patients with a stroke (g=0.58; 95% CI, 0.45∼0.70). Moderator analyses revealed that those patients with stroke of a younger age, of male sex, with a first-ever stroke episode, in the acute stage, and receiving rehabilitation training from their caregiver showed greater improvements in physical function.

CONCLUSIONS

Home rehabilitation can improve functional outcome in survivors of stroke and should be considered appropriate during discharge planning if continuation care is required.

Effectiveness of home-based carer-assisted in comparison to hospital-based therapist-delivered therapy for people with stroke: A randomised controlled trial

BACKGROUND

The benefits of engaging informal carers or family in the delivery of therapy intervention for people with stroke have not been well researched.

OBJECTIVES

To assess the effectiveness of a home-based carer-assisted in comparison to hospital-based therapist-delivered therapy for community-dwelling stroke survivors.

METHODS

An assessor blinded randomised controlled trial was conducted on 91 stroke survivors (mean age 58.9±10.6 years, median time post-onset 13.0 months, 76.5% males) who had completed individual rehabilitation. The control group received hospital-based group therapy delivered by physiotherapists as out-patients and the test group was assigned to a home-based carer-assisted therapy. Targeted primary outcomes were physical functions (mobility, balance, lower limb strength and gait speed). A secondary outcome index was health-related quality of life. An intention-to-treat analysis was used to evaluate outcomes at week 12 of intervention.

RESULTS

Both therapy groups improved significantly in all the functional measures; mobility (p < 0.01), balance (p < 0.01), lower limb strength (p < 0.01), gait speed (p < 0.05), and in the quality of life score (p < 0.05) at trial completion. No statistical differences were found between the two groups in any outcome indices (all p > 0.05).

CONCLUSIONS

The home-based carer-assisted therapy is as effective as the hospital-based therapist-delivered training in improving post-stroke functions and quality of life.

Facilitators and Barriers to the Rehabilitation Workforce Capacity Building in Low- to Middle-Income Countries

An increase in population and chronic conditions leading to disability require increasing emphasis on rehabilitation and health intervention. Poorer countries do not usually have the rehabilitation workforce needed to promote societal inclusion and participation. The roles of the rehabilitation workforce were often not clearly defined, leading to task shifting among rehabilitation professionals. Barriers to capacity building were poor availability of human resources and insufficient training program/supports for their professional development. Facilitators were local government support and international non-governmental organizations collaboration. Recommendations for capacity building effort are for collaboration with the developed nations to encourage funding, training, education, and sharing of resources.

Profile and outcome of post stroke patients managed at selected public primary care health centres in Peninsular Malaysia: A retrospective observational study

Data on post stroke outcomes in developing countries are scarce due to uncoordinated healthcare delivery systems. In Malaysia, the national stroke clinical practice guideline does not address transfer of care and longer term post stroke care beyond tertiary care. Hence, post stroke care delivery may be delivered at either tertiary or primary care facilities. This study aimed at describing patients' characteristics and outcomes of post stroke care delivered by the primary care teams at public primary care healthcentres across Peninsular Malaysia. Multi staged sampling was done to select public primary care health centres to recruit post stroke patients. At each health centre, convenience sampling was done to recruit adult patients (≥18 years) who received post stroke care between July-December 2012. Baseline measurements were recorded at recruitment and retrospective medical record review was done simultaneously, for details on medical and / or rehabilitation treatment at health centre. Changes in the measurements for post stroke care were compared using paired t-tests and Wilcoxon Rank test where appropriate. Total of 151 patients were recruited from ten public primary care healthcentres. The mean age at stroke presentation was 55.8 ± 9.8 years. Median duration of follow up was 2.3 (IQR 5.1) years. Majority co-resided with a relative (80.8%), and a family member was primary caregiver (75.%). Eleven percent were current smokers. Almost 71.0% of patients achieved BP ≤ 140/90 mmHg. Only 68.9% of the patients had been referred for neurorehabilitation. Percentage of recorded data was highest for blood pressure (88.1%) while lowest was HbA1c (43.0%). For clinical outcomes, systolic and diastolic blood pressure, triglyceride level and calculated GFR (eGFR) showed statistically significant changes during follow up (p < 0.05). Post stroke care at public primary care healthcentres showed benefits in stroke risk factors control (i.e. hypertension and dyslipidaemia) but deterioration in renal function. A more structured coordination is needed to optimise post stroke care beyond acute phase management for patients who reside at home in the community.

Adapting Tai Chi for Upper Limb Rehabilitation Post Stroke: A Feasibility Study

Background: Tai chi (TC) has been reported as being beneficial for improving balance post stroke, yet its utility in upper limb rehabilitation remains unknown. Methods: Twelve chronic stroke survivors with persistent paresis of an upper limb underwent 60 minutes of adapted TC twice a week for eight weeks, with a 4-week follow up. A 10-min TC home program was recommended for the days without sessions. TC level of performance, attendance to the sessions, duration of self-practice at home, and adapted TC movements used were recorded. Results: Eleven participants completed the study. A clinical reasoning algorithm underlying the adaptation of TC was elaborated throughout the trial. Participants with varying profiles including a severely impaired upper limb, poor balance, shoulder pain, and severe spasticity were not only capable of practicing the adapted TC, but attended all 16 sessions and practiced TC at home for a total of 16.51 ± 9.21 h. The degree of self-practice for subgroups with low upper limb function, shoulder pain, or moderate-to-severe spasticity was similar to that of subgroups with greater upper limb function, no shoulder pain, and minimal-to-no spasticity. Conclusion: Adapted TC seems feasible for upper limb rehabilitation post stroke. Although the study was based on a small sample size and requires confirmation, low upper limb function, insufficient balance, spasticity, and shoulder pain do not appear to hinder the practice of TC.

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review

Background: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. Aims and Objectives: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. Methods: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. Results: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. Conclusion: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.

Patient-centered mobility outcome preferences according to individuals with stroke and caregivers: a qualitative analysis

PURPOSE

To explore the mobility-related preferences among stroke survivors and caregivers following post-acute rehabilitation at inpatient or skilled nursing facilities.

METHODS

In this cross-sectional study; semi-structured, qualitative interviews of stroke survivors (n = 24) and informal caregivers (n = 15) were conducted. The participants were recruited from the community.

RESULTS

Comparative content analysis was used to identify themes by two independent coders. The survivors (68 years) and caregivers (58 years) mentioned mobility-related consequences including inability to walk, balance, drive, and transfer; and increased falls. The survivors (63%) and caregivers (73%) also mentioned the use of assistive devices. The common rehabilitation activities included: walking (62%); followed by standing and mobility; strength and balance; and wheelchair skills. Some stroke survivors were dissatisfied as their rehabilitation was not patient-centered. Frequently mentioned outcome preferences by survivors were ability to walk (88%), move, and balance. They also wanted to acquire assistive devices to move independently. Caregivers were concerned with the survivor's safety and wanted them to drive (53%), prevent falls, have home accommodations, and transfer independently. Caregivers (40%) also expressed the importance of receiving realistic information.

CONCLUSIONS

This study suggests a need to consider the stroke survivors' and caregivers' mobility outcome preferences to improve the patient-centered rehabilitation care. Implications for Rehabilitation Stroke survivors and caregivers tend to differ in their outcome preferences. Caregivers expressed concern for transfers, driving, fall prevention, home modifications, and wished for realistic information. Incorporating stroke survivors and their families' perspectives during rehabilitation may enhance patient-centered outcomes.

The integrated care pathway for post stroke patients (iCaPPS): a shared care approach between stakeholders in areas with limited access to specialist stroke care services

BACKGROUND

Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking.

METHODS

Expert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres.

RESULTS

Indication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems.

CONCLUSION

Coordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services.

TRIAL REGISTRATION

No.: ACTRN12616001322426 (Registration Date: 21st September 2016).

Play-based interventions improve physical function for people with adult-acquired brain injury: a systematic review and meta-analysis of randomised controlled trials

Objective:

To undertake a systematic review and meta-analysis of the effectiveness of play-based interventions compared to traditional therapy in rehabilitation of adults with adult-acquired brain injury.

Data sources:

The search was performed using Medline; Cinahl Plus; Health Source (Nursing/Academic Edition); Psychology and behavioural sciences collection; Biomedical reference collection (basic).

Review methods:

Studies included were randomised controlled trials that investigated the effect of play-based interventions on physical function of adults with adult acquired brain injury. Two independent reviewers identified eligible studies and assessed methodological quality using a modified Downs and Black. Meta-analysis compared standardised differences in means, to determine effect sizes for grouped functional outcome measures. The GRADE scoring system was used to determine the level of clinical evidence.

Results:

Thirty studies met the inclusion criteria, 13 were considered high quality and 17 moderate quality. Studies predominantly involved post-stroke participants, with only three studies including participants with traumatic brain injury. When compared to traditional therapy, dose-matched studies of play-based interventions showed a significant effect on independence (Effect size (ES) = 0.6) and physical performance (ES = 0.43), as measured using the Fugl –Meyer. For non-dose matched studies, play-based interventions showed a significant improvement for balance (ES = 0.76) compared with traditional therapy. In all studies that measured participant enjoyment, play-based therapy was rated as more enjoyable than traditional therapy.

Conclusion:

Play-based interventions for people with adult acquired brain injury are more effective in improving balance and independence, which may be due to them being more enjoyable than traditional therapy.

The Importance of Patient Involvement in Stroke Rehabilitation

OBJECTIVE

To investigate the perceived needs for health services by persons with stroke within the first year after rehabilitation, and associations between perceived impact of stroke, involvement in decisions regarding care/treatment, and having health services needs met.

METHOD

Data was collected, through a mail survey, from patients with stroke who were admitted to a university hospital in 2012 and had received rehabilitation after discharge from the stroke unit. The rehabilitation lasted an average of 2 to 4.6 months. The Stroke Survivor Needs Survey Questionnaire was used to assess the participants' perceptions of involvement in decisions on care or treatment and needs for health services in 11 problem areas: mobility, falls, incontinence, pain, fatigue, emotion, concentration, memory, speaking, reading, and sight. The perceived impact of stroke in eight areas was assessed using the Stroke Impact Scale (SIS) 3.0. Eleven logistic regression models were created to explore associations between having health services needs met in each problem area respectively (dependent variable) and the independent variables. In all models the independent variables were: age, sex, SIS domain corresponding to the dependent variable, or stroke severity in cases when no corresponding SIS domain was identified, and involvement in decisions on care and treatment.

RESULTS

The 63 participants who returned the questionnaires had a mean age of 72 years, 33 were male and 30 were female. Eighty percent had suffered a mild stroke. The number of participants who reported problems varied between 51 (80%, mobility) and 24 (38%, sight). Involvement in decisions on care and treatment was found to be associated with having health services needs met in six problem areas: falls, fatigue, emotion, memory, speaking, and reading.

CONCLUSIONS

The results highlight the importance of involving patients in making decisions on stroke rehabilitation, as it appears to be associated with meeting their health services needs.

Modeling Age-Friendly Environment, Active Aging, and Social Connectedness in an Emerging Asian Economy

This paper empirically tested eight key features of WHO guidelines to age-friendly community by surveying 211 informal caregivers and 402 self-care adults (aged 45 to 85 and above) in Malaysia. We examined the associations of these eight features with active aging and social connectedness through exploratory and confirmatory factor analyses. A structural model with satisfactory goodness-of-fit indices (CMIN/df = 1.11, RMSEA = 0.02, NFI = 0.97, TLI = 1.00, CFI = 1.00, and GFI = 0.96) indicates that transportation and housing, community support and health services, and outdoor spaces and buildings are statistically significant in creating an age-friendly environment. We found a statistically significant positive relationship between an age-friendly environment and active aging. This relationship is mediated by social connectedness. The results indicate that built environments such as accessible public transportations and housing, affordable and accessible healthcare services, and elderly friendly outdoor spaces and buildings have to be put into place before social environment in building an age-friendly environment. Otherwise, the structural barriers would hinder social interactions for the aged. The removal of the environmental barriers and improved public transportation services provide short-term solutions to meet the varied and growing needs of the older population.