Recruitment rate and retention of stroke subjects in cross-sectional studies

Occupational balance and stroke impact among community-dwelling stroke survivors 65 years or older: a cross-sectional study

INTRODUCTION

Occupational balance has been investigated in different populations but less in stroke survivors. Previous studies have focussed on occupational balance among stroke survivors of working age (15-64 years of age), showing they did not perceive they had occupational balance. There is, therefore, a lack of knowledge of how older stroke survivors perceive their occupational balance. The aims of this study were to describe occupational balance in community-dwelling stroke survivors 65 years or older and to investigate if there were any associations between their perceived stroke impact and occupational balance.

METHODS

A cross-sectional study was performed with 58 stroke survivors, with a median age of 75 years at stroke onset and a median time since stroke onset of 11 months. The participants were recruited from a local stroke register and answered questionnaires on occupational balance and stroke impact. Data were analysed with descriptive statistics, correlations and logistic regression.

RESULTS

The participants had a median score of 29 (min 12 to max 33), indicating a very high occupational balance, a low stroke impact, and a good recovery (median 82.5; min 0 to max 100). An association between participation and occupational balance (OR 1.13; 95% CI 1.04-1.23) was found.

CONCLUSION

The stroke survivors perceived a low stroke impact and a high occupational balance. It is possible that older community-dwelling stroke survivors, of whom many have retired, juggle less occupations leaving them with more time to engage in those occupations they want to, leading to a better occupational balance.

Stroke survivors’ preferences regarding study participation in rehabilitation research

Background

To pursue high quality research, successful participant recruitment is essential, but recruitment rates are often low. This is specifically true in target populations with impairments, for instance, among stroke survivors. Previous studies focusing on recruitment have mainly relied on information from professionals, and there is therefore a need to contribute with new methodological insights to how potential rehabilitation research participants describe their interest and preferences to participate in research. The purpose of this study was to generate knowledge about stroke survivors’ interest in participating in rehabilitation research, reasons for being interested or not, and preferred forms and foci of rehabilitation interventions. An additional aim was to describe preferences regarding survey administration modes and processes for recruitment to studies.

Method

This cross-sectional study recruited Swedish residents who had sustained a stroke, initially by using advertisement on the National Stroke Association’s website, flyers posted at local occupational and physical therapy offices and at local stroke/senior organization meetings. Secondly, participants were recruited through a local stroke register. The survey, administered either in a paper form returned by postal mail; online or as a phone interview with 128 stroke survivors.

Results

Most of the participants were interested in participating in rehabilitation research, particularly younger persons (p = 0.001) and those closer to stroke onset (p = 0.047). Contribution to research, possibility to try new rehabilitation interventions and meeting others in the same situation were reasons that attracted an interest to participate. Other important aspects were related to motivation, individual needs, as well as how skilled the people who provided the intervention were. Participants preferred group-based programs, and programs focusing on regaining lost functions were highly requested. A majority wanted to be contacted through postal mail (70%) and most of them (90%) used the paper form to respond to the survey.

Conclusions

A range of personal and external aspects, including challenges related to digitized administration modes, should be considered to achieve high participation rates in rehabilitation research targeting stroke survivors. The importance of addressing individual needs and prerequisites in an individualized manner should not be underestimated and might be a useful strategy to recruitment success.

High-intensity treadmill training and self-management for stroke patients undergoing rehabilitation: a feasibility study

BACKGROUND

Physical activity undertaken by stroke survivors is generally low. This trial investigated the feasibility of delivering a high-intensity treadmill and self-management program to people with stroke undergoing inpatient rehabilitation and determine whether physical activity, walking ability and cardiorespiratory fitness could be increased.

METHOD

A phase I, single-group, pre-post intervention study was conducted with stroke survivors undergoing inpatient rehabilitation who could walk. Participants undertook a high-intensity treadmill and self-management program for up to 30 min, three times a week for 8 weeks under the supervision of their usual physiotherapist. Feasibility was determined by examining compliance, satisfaction and adverse events. Clinical outcomes were amount of physical activity, walking ability, and cardiorespiratory fitness collected pre-training (week 0), post-training (week 8), and at follow-up (week 26).

RESULTS

Forty stroke survivors participated, completing 10 (SD 6) sessions, 94% at the specified training intensity, with high satisfaction and no adverse events related to the intervention. At week 8, participants completed 2749 steps/day (95% CI 933 to 4564) more physical activity than at week 0. Walking distance increased by 110 m (95% CI 23 to 196), walking speed by 0.24 m/s (95% CI 0.05 to 0.42), and VO2 peak by 0.29 ml/kg/min (95% CI 0.03 to 0.56). At week 26, increases in physical activity, walking distance and speed, and cardiorespiratory fitness were maintained.

CONCLUSIONS

A high-intensity treadmill training program embedded within a self-management approach during inpatient rehabilitation appears feasible and potentially may offer sustained improvements in physical activity, walking ability, fitness, and quality of life. A randomised trial is warranted.

TRIAL REGISTRATION

This feasibility study was registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000764730 ).

Upper Limb Energy Demand During Unilateral Arm Crank Submaximal Exercise Testing in Individuals With Chronic Stroke

OBJECTIVE

To investigate upper limb (UL) energy demand during unilateral arm crank submaximal exercise testing in individuals with stroke compared with healthy controls and the relationship between UL energy demand and UL activity in individuals with stroke.

DESIGN

Cross-sectional, observational study.

SETTING

Research laboratory.

PARTICIPANTS

Individuals with chronic stroke (n=14) and controls (n=12), matched for age, sex, and body mass index (N=26).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

UL energy demand was measured as peak oxygen consumption (V̇o₂)/peak load during unilateral arm crank submaximal exercise testing. UL activity was measured using the Box and Block Test (BBT) and Grooved Pegboard Test (GPT).

RESULTS

The energy demand of the paretic side compared with the nonparetic side of the stroke group was 0.43 mL/kg/min/W (95% confidence interval, 0.03-0.83, P=.005) greater than the dominant compared with the nondominant side of the control group. The median difference between sides in peak V̇o₂/peak load was 52% for the group with stroke compared with 11% for the control group. Positive correlations between the median percentage difference between the paretic and the nonparetic side of peak V̇o₂/peak load and BBT were 0.72 (P=.004) and of V̇o₂/peak load and GPT was 0.77 (P=.002).

CONCLUSIONS

The higher energy demand of the paretic UL during unilateral arm crank submaximal exercise testing than the nonparetic and both UL of the controls together with the strong relationship between energy demand and UL activity suggest that the energy demand of the paretic UL has the potential to affect real-life UL activity after stroke.

Cardiopulmonary exercise testing and aerobic treadmill training after stroke: Feasibility of a controlled trial

PURPOSE

To investigate the feasibility and safety of a randomized controlled trial that performed cardiopulmonary exercise testing and 12 weeks of aerobic treadmill training in individuals in the chronic phase after stroke.

METHODS

The following data were recorded: number of individuals contacted to participate, that attended in the evaluation session, and that were included (recruited) in the study; retention, attendance and adherence rates; reasons for exclusion, withdrawal, non-attendance and non-completing exercise; adverse events.

RESULTS

From 230 individuals that were contacted, 39 (17%) attended the evaluation session and 22 (9.6%) were recruited in the study, 11 in each group (control and experimental). The main source of recruitment was other research projects (43.5%). The main reason for exclusion was unavailability (22%). Six out of 39 individuals (15.4%) that attended in the evaluation session were not able to perform the cardiopulmonary exercise testing. All subjects included showed a respiratory exchange ratio ≥1.0 (considered as maximal effort in the CPET). Retention rate was 81% and the main reason of withdrawal was unavailability (75%). The overall attendance rate was 88% and the main reason for non-attendance was illness/sickness (20.8%). The adherence rate was 99% and the reasons for non-completing sessions were illness/sickness (60%) or delay (40%). No serious adverse events occurred.

CONCLUSION

Recruitment rate was low, retention rate was moderate, attendance and adherence rates were high. No serious adverse events occurred. It was feasible and safe to execute a randomized clinical trial that performed cardiopulmonary exercise testing and 12 weeks of aerobic treadmill training.

Recruitment challenges in stroke neurorecovery clinical trials

There are multiple available treatments to enhance stroke rehabilitation, although few interventions have confirmed significant clinical improvements on motor function in pivotal Randomized Clinical Trials. Development of large Randomized Clinical Trials is limited by several barriers and low enrollment rate is considered an important factor. Consequently, most of the evidence comes from small sample size studies, often leading to limited conclusions. According to the National Institute of Health (NIH), about 80% of clinical trials in the United States do not achieve their timelines, increasing research costs and postponing regulatory approval of new therapies. Given that the success of a Randomized Clinical Trial is dependent on enrolling an adequate number of subjects, effective strategies to enhance recruitment rates are highly desirable. In addition, given the resources and time limitations, it is important to understand which strategies are most cost-effective. In this manuscript, we summarize and discuss nine recruitment strategies used in an NIH R21 sponsored clinical trial, including medical records review and online advertising, among others. In addition, we developed an index to compare the time spent benefit of each approach and guide the allocation of the recruitment efforts. For this trial, online advertising and referral from health care professionals other than physicians were the strategies with greater time-benefit, leading to the largest number of stroke subjects enrolled.