Stroke survivors’ and family members’ perspectives of multimodal lifestyle interventions for secondary prevention of stroke and transient ischemic attack: a qualitative review and meta-aggregation

In-person and online mixed method non-randomised studies exploring feasibility and acceptability of HEADS: UP, an adapted Mindfulness-Based Stress Reduction programme for stroke survivors experiencing symptoms of anxiety and depression

BACKGROUND

Depression and anxiety are prevalent after stroke and associated with poor outcomes. We previously co-developed a stroke-specific self-management intervention, HEADS: UP (Helping Ease Anxiety and Depression after Stroke). The two studies reported here aimed to test the feasibility and acceptability of the HEADS: UP course and supporting materials, and research processes ahead of a definitive trial.

METHODS

We recruited community-dwelling stroke survivors (SS) ≥ 3 months post-stroke, with symptoms of mood disorder (Hospital Anxiety and Depression Scale ≥ 8). Participants could 'enrol' a family member/ 'other' to take part with them, if desired. Study 1 tested HEADS: UP delivered in-person, and informed optimisation of research processes and intervention delivery and materials. In a pragmatic response to Covid-related socialising restrictions, HEADS: UP was then adapted for online delivery, tested in Study 2. The primary outcome (both studies) was the feasibility (acceptability, fidelity) of the intervention and of research processes. Quantitative data (including patient-reported outcome measures (PROMs) assessing mood and quality of life) and qualitative data were collected pre-/post-intervention. Descriptive statistics were used to analyse quantitative data; a thematic framework approach was used to analyse qualitative data. Both studies received ethical approval prior to commencement.

RESULTS

Study 1 Feasibility: 13 (59.1%) of 22 potentially eligible stroke survivors consented; aged 66 (median, interquartile range (IQR) 14); male (n = 9; 69%); 28 (IQR 34) months post-stroke. Of these, n = 10 (76.9%) completed PROMS pre-intervention; n = 6 (46.2%) post-intervention. Acceptability: Nine (69.2%) of the 13 participants attended ≥ 4 core intervention sessions. Aspects of screening and data collection were found to be burdensome. Study 2 Feasibility: SS n = 9 (41%) of 22 potentially eligible stroke survivors consented; aged 58 years (median; IQR 12); male (n = 4; 44.4%); 23 (IQR 34) months post-stroke. Of these, n = 5 (55.6%) completed PROMS pre-intervention; n = 5 (55.6%) post-intervention. Acceptability: Five (55.6%) of the 9 participants attended ≥ 4 core sessions. They found online screening and data collection processes straightforward.

Effects of a lifestyle counselling intervention on adherence to lifestyle changes 7 years after stroke - A quasi-experimental study

BACKGROUND

Adherence to medication and healthy lifestyle is crucial for preventing secondary strokes and other vascular events. However, there is not enough evidence on the long-term effects of hospital-initiated lifestyle counselling.

AIM

To determine the effects of The Risk Factor Targeted Lifestyle Counselling Intervention, which is implemented during acute hospitalisation, on adherence to lifestyle changes 7 years after stroke or TIA.

METHODS

Quasi-experimental design with 7-year follow-up period. Baseline data (n = 150) were gathered from a neurology unit in Finland between 2010 and 2011. Patients received either the studied intervention (n = 75) or the prevailing form of counselling at the time (n = 75). Data concerning lifestyle and clinical values were measured at the baseline time point, while adherence to lifestyle changes was assessed 7 years later (2017-2018). Analysis of covariance and multivariate ordinal logistic regression were used to describe the mean differences between the intervention and control groups.

RESULTS

Several between-group differences were detected, namely, members of the intervention group reported consuming less alcohol and having lost more weight during hospitalisation relative to the control group. No between-group differences in the prevalence of smokers were found, but the intervention group reported a greater number of daily cigarettes than the control group. Adherence to medication, importance of adherence to a healthy lifestyle, support from family and friends, and support from nurses were all significantly higher in the intervention group than in the control group.

CONCLUSIONS

The results suggest that the lifestyle counselling intervention was effective in decreasing alcohol use and weight, as well as increasing factors that are known to support adherence to a healthy lifestyle.

RELEVANCE TO CLINICAL PRACTICE

The results indicate that the adherence process already begins during acute phase counselling. To ensure long-lasting lifestyle changes, counselling should be started at the hospital, after which it can be provided by friends and family members.

Understanding the facilitators and barriers of stroke survivors' adherence to recovery-oriented self-practice: a thematic synthesis

PURPOSE

Stroke survivors receive considerable rehabilitation efforts as inpatients, but one-on-one therapy decreases after discharge. The gap between the amount of required therapy and the lack of its availability in this phase of care may be partly overcome by self-practice. However, patient's adherence to prescribed programs is often low. While single studies have examined factors affecting adherence in this specific case, they have not been reviewed and synthesised previously.

METHODS

A thematic synthesis of qualitative studies explored factors affecting stroke survivors' adherence to prescribed, recovery-oriented self-practice. Five databases were systematically searched for references: Medline, Psycinfo, CINAHL, Embase, and ASSIA. Quality assessment was undertaken using the CASP tool.

RESULTS

From 1308 references, 68 potential papers were read in full, and 12 were included in the review. An overarching theme was identified as: "Tailoring and personalization rather than standardization." It was informed by the following three analytical themes: "The meaning of 'self' in self-practice," "Identifying self-practice as a team effort," and "Self-practice that is grounded in one's reality."

CONCLUSION

To have a positive effect on adherence to self-practice, clinicians are advised to spend time learning about each individual's life circumstances, so they can tailor proposed exercise programs to patients' personal situations, preferences, and needs.IMPLICATIONS FOR REHABILITATIONThe topic of patient's adherence to self-practice of prescribed exercise is a common concern, often voiced by frustrated rehabilitation health professionals. Bridging the gap between the patient's needs for post-discharge intensive therapy and the inability of healthcare systems to provide it could be filled partly by self-practice.Adherence to self-practice has become even more essential since the COVID 19 pandemic and the decrease in face-to-face delivery of rehabilitation due to social distancing requirements.Adherence to exercise is a broad topic. Reasons for poor adherence differ between patient populations and the exercises they are prescribed. This study focuses on post-discharge stroke survivors' adherence to recovery targeted exercise that could be described as repetitive and less physically demanding movements and functions.Reviewed studies were qualitative and usually included a relatively small number of participants within a specific context. Using thematic synthesis, we combined these small pieces of the puzzle into a larger picture, to produce recommendations that could be drawn on by clinicians to improve self-practice adherence.

Mastering health following minor stroke-A qualitative explorative study

BACKGROUND

Patients with minor stroke or transient ischemic attack are encouraged to adopt a healthy lifestyle to prevent recurrent stroke. After discharge health behaviour is performed in an individual everyday context and must be properly understood within this context, including which aspects act as facilitators or barriers for healthy behaviour.

OBJECTIVES

To explore the experience of daily life in patients discharged home after minor stroke or transient ischemic attack, focusing on perceived health and reflection on health behaviour, and how this is associated with their overall experience of returning to their everyday context in relation to potential sequelae of stroke.

METHODS

Semi-structured qualitative interviews were conducted 3 - 13 months after discharge with sixteen patients discharged home after minor stroke or transient ischemic attack. Inductive thematic analysis was performed to analyse the interviews.

RESULTS

Participants associated their health and behaviour within a lens of worrying for future life prospect and triggered by perceived intrusive changes in their life condition. Even though some found it possible to resume participation in everyday life within weeks, they became increasingly aware that minor cognitive deficits, difficulties with planning, multi-tasking, memory, and fatigue influenced their health believes and behavioural patterns. The need for social and professional support had to be balanced against a wish for independence.

CONCLUSION

Patients with minor stroke or transient ischemic attacks experience changes as both being concrete in the form of persisting symptoms and abstract in the form of worries and uncertainty about the future. Perceived health was associated with a new sense of vulnerability due to realisations about the risk of recurrent stroke. Worries were anchored within the individual to handle, but for some they serve as a motivator to regulate their behaviour in order to master health.

Systematic Review of Tongxinluo Capsule on the Therapeutic Effect and Hemorheology of Patients with Transient Ischemic Attack

OBJECTIVES

This study aims to systematically evaluate the clinical efficacy of Tongxinluo capsule in the treatment of transient ischemic attack (TIA) and its effect on hemorheology, thereby providing scientific basis for clinical decision making.

METHODS

A comprehensive and systematic literature retrieval was conducted in the CNKI, Wanfang database, SinoMed, EMbase, and PubMed to screen the randomized controlled trials (RCTs) of Tongxinluo capsule in the treatment of TIA. The retrieval time was from the inception of each database to September 10, 2020. Endnote X9 was used to screen the literature. Cochrane Collaboration tool for assessing risk of bias was used to evaluate the quality of the included studies. Stata16.0 statistical software was used for meta-analysis.

RESULTS

A total of 12 RCTs were included, involving 946 subjects. (1) The clinical efficacy of the Tongxinluo group was better than that of the control group (RR = 1.19, 95% CI (1.09, 1.30), P ≤ 0.001). (2) The hemorheological characteristics of the Tongxinluo group were significantly improved compared with those of the control group (whole blood high shear viscosity: SMD = -1.61, 95% CI (-1.89, -1.34); P ≤ 0.001, whole blood low shear viscosity: SMD = -1.06, 95% CI (-1.31, -0.80), P ≤ 0.001, fibrinogen: SMD = -1.12, 95% CI (-1.94, -0.29), P = 0.008, plasma specific viscosity: SMD = -1.00, 95% CI (-1.69, -0.31), P = 0.004, and hematocrit: SMD = -1.47, 95% CI (-2.16, -0.77), P ≤ 0.001). (3) There was no significant difference in the incidence of adverse reactions between the Tongxinluo group and control group (RR = 7.76, 95% CI (0.98, 61.28), P = 0.052).

CONCLUSION

Tongxinluo capsule is superior to conventional treatment in improving clinical overall response rate and hemorheological indexes and is relatively safe. Due to the deficiencies of the existing studies, more high-quality studies with rigorous design are required for further verification.

Mindfulness-based interventions for people with multiple sclerosis: a systematic review and meta-aggregation of qualitative research studies

PURPOSE

Mindfulness-based interventions (MBIs) are effective treatments for stress, anxiety, and depression in PwMS. However, low adherence and high attrition may limit effectiveness. Qualitative research can provide important insights into MBI acceptability, accessibility, and implementation. This systematic review and meta-aggregation evaluated qualitative research findings on the use of MBIs for PwMS.

METHODS

Systematic searches were undertaken in six major electronic databases. Studies using qualitative or mixed methods were included. Two reviewers screened, data extracted, and critically appraised studies. Meta-aggregation was performed following the Joanna Briggs Institute approach, extracting findings, developing categories, and synthesizing findings.

RESULTS

Six eligible papers, including 136 PwMS were included in meta-aggregation. 136 findings were extracted, grouped into 17 categories, with four synthesized findings: (1) "accessing mindfulness," (2) "a sense of belonging," (3) "experiencing mindfulness," and (4) "making mindfulness more relevant and sustainable for PwMS."

CONCLUSIONS

MBIs for PwMS need to take into consideration disability which can limit accessibility. Online MBIs (synchronous and asynchronous) appear acceptable alternatives to traditional face-to-face courses. However, PwMS benefit from shared (mindful) experiencing and highlight MBI instructors as crucial in helping them understand and practice mindfulness. Involving PwMS in design, delivery, and iterative refinement would make MBIs more relevant to those taking part.IMPLICATIONS FOR REHABILITATIONBoth face-to-face and online Mindfulness-based interventions (MBIs) appear acceptable to PwMS and, ideally, people should be offered a choice in training modality.PwMS derive benefit from undertaking MBIs with their peers, where a sense of camaraderie and belonging develop through shared (mindful) experiences.Instructors delivering MBIs for PwMS should be knowledgeable about the condition; participants describe how the instructor has a key role in helping them practice mindfulness effectively in the context of unpleasant experiences associated with MS.MBIs tailored for PwMS should include a pre-course orientation session, clearly articulate how mindfulness practices can help with MS, provide well-organized course materials in large font size, and deliver individual mindfulness practices flexibly depending on participant need.

Effect and efficacy of lifestyle interventions as secondary prevention

INTRODUCTION

Improvements in health behaviour are often recommended as part of secondary prevention in patients with stroke and transient ischaemic attack. However, there is a lack of knowledge as to how this is applied in clinical practice.

AIM

In this systematic review and meta-analysis, we examined the effect of counselling or educational intervention directed at individual or multiple behavioural risk factors on blood pressure and other reported outcomes.

METHODS

PubMed, Embase, PsycInfo, CINAHL, Scopus and Web of Science were systematically searched. Meta-analyses were conducted on all outcome measures if appropriate. A qualitative analysis of the content of the interventions was conducted to review which elements the interventions consisted of.

RESULTS

Twenty-nine randomized controlled trials were identified. Fourteen reported effects on systolic blood pressure, and pooled results showed a significant beneficial effect (n = 2,222; -3.85 mmHg [95%CI -6.43; -1.28]). The effect was greatest in the four interventions which included supervised training (n = 174; -9.83 mmHg [95%CI -16.56; -3.09]).

CONCLUSION

Modifying health behaviour in stroke survivors might have a moderate beneficial effect on blood pressure, especially if the intervention includes supervised physical training.

Patient readiness for risk-reduction education and lifestyle change following transient ischemic attack

PURPOSE

Patient readiness for secondary prevention and lifestyle change following transient ischemic attack is not well understood. Understanding patient perspectives about the timing and delivery of secondary prevention education is essential to promote meaningful risk factor reduction in this population.

MATERIALS AND METHODS

A single, semi-structured, telephone interview was conducted with ten individuals (7 male, 3 female) within three months following a transient ischemic attack. Interviews explored transient ischemic attack experiences and post-event education. Data were analyzed using inductive thematic analysis.

RESULTS

Individuals had a variety of experiences with secondary prevention education. Four themes emerged from these experiences including "what the hell happened?", "I mustn't have been quite ready", "what should I be doing?" and "we all see it in different ways." Individual knowledge, personal experience of transient ischemic attack, socio-environmental factors, and the format and content of education influenced patient readiness to receive secondary prevention education and adopt lifestyle changes.

CONCLUSION

Readiness for risk-reduction education and lifestyle change following transient ischemic attack is individual and complex. Logistical factors including the location, time, and cost of education, timing of education delivery, and patient perspectives should be considered in the development and delivery of secondary prevention interventions for these people. Implications for rehabilitation Risk reduction and lifestyle change following transient ischemic attack is vital to prevent recurrent stroke. Patients are ready to receive risk reduction and lifestyle advice approximately one week after their transient ischemic attack. Programs designed to provide risk reduction and lifestyle education should be informed by the unique requirements of this population. Uptake of participation in secondary prevention programs may be maximized by offering flexibility in terms of timing post-event and modes of delivery (e.g. Telehealth).

Redeveloping the JBI Model of Evidence Based Healthcare

BACKGROUND

In 2005, Pearson et al. presented a developmental framework of evidence-based practice that sought to situate healthcare evidence and its role and use within the complexity of practice settings globally. A decade later, it was deemed timely to re-examine the Model and its component parts to determine whether they remain relevant and a true and accurate reflection of where the evidence-based movement is today.

METHODS

A two-phase process was employed for this project. Phase 1 involved a citation analysis, conducted using the index citation of the original source article on the Joanna Briggs Institute (JBI) Model by Pearson et al. The databases searched were Web of Science and Google Scholar from year of publication (2005) to July 2015. Duplicates and articles in languages other than English were removed, and all results were imported and combined in an Excel spreadsheet for review, coding and interpretation. Phase 2 (model revision) occurred in two parts. Part 1 involved revision of the Model by an internal working group. This revised version of the Model was then subjected to a process of focus group discussion (Part 2) that engaged staff of the Joanna Briggs Collaboration during the 2015 annual general meeting. These data were recorded then transcribed for review and consideration.

RESULTS

The citation analysis revealed that the Model was primarily utilized to conceptualize evidence and evidence-based healthcare, but that language used in relation to concepts within the Model was variable. Equally, the working group and focus group feedback confirmed that there was a need to ensure the language utilized in the Model was internationally appropriate and in line with current international trends. This feedback and analysis informed the revised version of the JBI Model.

CONCLUSION

Based on the citation analysis, working group and focus group feedback the new JBI Model for Evidence Based Healthcare attempts to utilize more internationally appropriate language to detail the intricacies of the relationships between systems and individuals across different settings and the need for contextual localization to enable policy makers and practitioners to make evidence-based decisions at the point of care.

Interventions for behaviour change and self-management in stroke secondary prevention: protocol for an overview of reviews

BACKGROUND

Stroke secondary prevention guidelines recommend medication prescription and adherence, active education and behavioural counselling regarding lifestyle risk factors. To impact on recurrent vascular events, positive behaviour/s must be adopted and sustained as a lifestyle choice, requiring theoretically informed behaviour change and self-management interventions. A growing number of systematic reviews have addressed complex interventions in stroke secondary prevention. Differing terminology, inclusion criteria and overlap of studies between reviews makes the mechanism/s that affect positive change difficult to identify or replicate clinically. Adopting a two-phase approach, this overview will firstly comprehensively summarise systematic reviews in this area and secondly identify and synthesise primary studies in these reviews which provide person-centred, theoretically informed interventions for stroke secondary prevention.

METHODS

An overview of reviews will be conducted using a systematic search strategy across the Cochrane Database of Systematic Reviews, PubMed and Epistomonikas.

INCLUSION CRITERIA

systematic reviews where the population comprises individuals post-stroke or TIA and where data relating to person-centred risk reduction are synthesised for evidence of efficacy when compared to standard care or no intervention. Primary outcomes of interest include mortality, recurrent stroke and other cardiovascular events. In phase 1, two reviewers will independently (1) assess the eligibility of identified reviews for inclusion; (2) rate the quality of included reviews using the ROBIS tool; (3) identify unique primary studies and overlap between reviews; (4) summarise the published evidence supporting person-centred behavioural change and self-management interventions in stroke secondary prevention and (5) identify evidence gaps in this field. In phase 2, two independent reviewers will (1) examine person-centred, primary studies in each review using the Template for Intervention Description and Replication (TIDieR checklist), itemising, where present, theoretical frameworks underpinning interventions; (2) group studies employing theoretically informed interventions by the intervention delivered and by the outcomes reported (3) apply GRADE quality of evidence for each intervention by outcome/s identified from theoretically informed primary studies. Disagreement between reviewers at each process stage will be discussed and a third reviewer consulted.

DISCUSSION

This overview will comprehensively bring together the best available evidence supporting person-centred, stroke secondary prevention strategies in an accessible format, identifying current knowledge gaps.

Patient reported experiences of using community rehabilitation and/or support services whilst living with a long-term neurological condition: a qualitative systematic review and meta-aggregation

Objectives: The objective of this study is to identify patient reported experiences of using community rehabilitation and/or support services whilst living with a long-term neurological condition, and perceptions of their impact on quality of life.Methods: Nine electronic databases were searched for peer-reviewed qualitative studies from 2005 to 2016, which met the inclusion criteria. Critical appraisal, data extraction, and quality assessment of 37 included papers were performed by three reviewers. One hundred and one findings were extracted. Meta-aggregation was used to synthesize findings.Findings: Seven 'synthesized findings' [SF] were produced: Interactions with some professionals provide active participation, choice, confidence and autonomy [SF1]; Interactions with some professionals are disempowering and depersonalized [SF2]; Effective communication, specialist knowledge and an individualized approach to information provision is needed [SF3]; Indicators of success vary and may not be clear [SF4]; Informal support from family/friends is valued [SF5]; Opportunities for peer support/social interaction is valued [SF6]; Coordination required to ensure continuity during transition to community [SF7].Conclusion: Patient reported experiences identified common factors associated with process quality (respect, choice, autonomy, information provision, communication) and activities of patient centered care (personalized care, shared decision-making, self-management support) despite heterogeneity of neurological conditions, service configurations, and geographical location. These factors impact quality of life.Implications for RehabilitationPatient reported experiences provide useful information about courtesy, respect, choice, autonomy, information provision, and communication.Outcomes of self-efficacy and self-management are important for people with stable and progressive long-term neurological conditions.Interactions with individual professionals influence engagement, self-efficacy, and self-management for people with long-term neurological conditions.Training for health and social care professionals should develop the advanced communication skills and behavior required to facilitate self-efficacy and self-management.

Breast cancer survivors' perceptions of participating in a supervised exercise intervention: An exploratory review of the literature

BACKGROUND

Despite the reported beneficial effects of physical activity (PA) during and after cancer diagnosis, current research data suggest that the percentages of breast cancer survivors who adhere to PA recommendations are low. The objective of the present systematic, critical review was to identify, analyze, and provide a summary of qualitative literature findings, which have explored breast cancer survivors' experiences of participating in an exercise/PA intervention after cancer treatment.

METHODS

A systematic search was conducted using CINAHL, PsychINFO, PubMed, and Scopus electronic databases to search for qualitative literature published during 2000-2016. A total of six studies that met the inclusion criteria were reviewed. Thematic synthesis, following Thomas and Harden's methods, were used to analyze the data.

FINDINGS

Seven descriptive themes were developed: control, focus, transitioning phase, regaining a sense of confidence, enhanced spirits, social support, and safe environment. The findings suggested that participation in supervised exercise interventions enhanced the self-confidence and mood of breast cancer survivors. It allowed them to regain control and provide a focus, thereby allowing them to move forward in their lives.

CONCLUSION

The results of this systematic critical review indicated that the supervised exercise was a positive experience for breast cancer survivors.

A mixed methods study of multiple health behaviors among individuals with stroke

Background

Individuals with stroke often have multiple cardiovascular risk factors that necessitate promoting engagement in multiple health behaviors. However, observational studies of individuals with stroke have typically focused on promoting a single health behavior. Thus, there is a poor understanding of linkages between healthy behaviors and the circumstances in which factors, such as stroke impairments, may influence a single or multiple health behaviors.

Methods

We conducted a mixed methods convergent parallel study of 25 individuals with stroke to examine the relationships between stroke impairments and physical activity, sleep, and nutrition. Our goal was to gain further insight into possible strategies to promote multiple health behaviors among individuals with stroke. This study focused on physical activity, sleep, and nutrition because of their importance in achieving energy balance, maintaining a healthy weight, and reducing cardiovascular risks. Qualitative and quantitative data were collected concurrently, with the former being prioritized over the latter. Qualitative data was prioritized in order to develop a conceptual model of engagement in multiple health behaviors among individuals with stroke. Qualitative and quantitative data were analyzed independently and then were integrated during the inference stage to develop meta-inferences. The 25 individuals with stroke completed closed-ended questionnaires on healthy behaviors and physical function. They also participated in face-to-face focus groups and one-to-one phone interviews.

Results

We found statistically significant and moderate correlations between hand function and healthy eating habits (r = 0.45), sleep disturbances and limitations in activities of daily living (r =  − 0.55), BMI and limitations in activities of daily living (r =  − 0.49), physical activity and limitations in activities of daily living (r = 0.41), mobility impairments and BMI (r =  − 0.41), sleep disturbances and physical activity (r =  − 0.48), sleep disturbances and BMI (r = 0.48), and physical activity and BMI (r =  − 0.45). We identified five qualitative themes: (1) Impairments: reduced autonomy, (2) Environmental forces: caregivers and information, (3) Re-evaluation: priorities and attributions, (4) Resiliency: finding motivation and solutions, and (5) Negative affectivity: stress and self-consciousness. Three meta-inferences and a conceptual model described circumstances in which factors could influence single or multiple health behaviors.

Discussion

This is the first mixed methods study of individuals with stroke to elaborate on relationships between multiple health behaviors, BMI, and physical function. A conceptual model illustrates addressing sleep disturbances, activity limitations, self-image, and emotions to promote multiple health behaviors. We discuss the relevance of the meta-inferences in designing multiple behavior change interventions for individuals with stroke.