Building Bridges between healthcare professionals, patients and families: A coproduced and integrated approach to self-management support in stroke

Fatigue after CriTical illness (FACT): Co-production of a self-management intervention to support people with fatigue after critical illness

PURPOSE

Fatigue is a common and debilitating problem in patients recovering from critical illness. To address a lack of evidence-based interventions for people with fatigue after critical illness, we co-produced a self-management intervention based on self-regulation theory. This article reports the development and initial user testing of the co-produced intervention.

METHODS

We conducted three workshops with people experiencing fatigue after critical illness, family members, and healthcare professionals to develop a first draft of the FACT intervention, designed in web and electronic document formats. User testing and interviews were conducted with four people with fatigue after critical illness. Modifications were made based on the findings.

RESULTS

Participants found FACT acceptable and easy to use, and the content provided useful strategies to manage fatigue. The final draft intervention includes four key topics: (1) about fatigue which discusses the common characteristics of fatigue after critical illness; (2) managing your energy with the 5 Ps (priorities, pacing, planning, permission, position); (3) strategies for everyday life (covering physical activity; home life; leisure and relationships; work, study, and finances; thoughts and feelings; sleep and eating); and (4) goal setting and making plans. All material is presented as written text, videos, and supplementary infographics. FACT includes calls with a facilitator but can also be used independently.

CONCLUSIONS

FACT is a theory driven intervention co-produced by patient, carer and clinical stakeholders and is based on contemporary available evidence. Its development illustrates the benefits of stakeholder involvement to ensure interventions are informed by user needs. Further testing is needed to establish the feasibility and acceptability of FACT.

IMPLICATIONS FOR CLINICAL PRACTICE

The FACT intervention shows promise as a self-management tool for people with fatigue after critical illness. It has the potential to provide education and strategies to patients at the point of discharge and follow-up.

Stroke rehabilitation adaptive approaches: A theory-focused scoping review

BACKGROUND

Stroke rehabilitation consists of restorative and adaptive approaches. Multiple adaptive approaches exist.

AIMS/OBJECTIVES

The objective of this study was to develop a framework for categorising adaptive stroke rehabilitation interventions, based on underlying theory.

MATERIAL AND METHODS

We searched multiple databases to April 2020 to identify studies of interventions designed to improve participation in valued activities. We extracted the name of the intervention, underlying explicit or implicit theory, intervention elements, and anticipated outcomes. Using this information, we proposed distinct groups of interventions based on theoretical drivers.

RESULTS

Twenty-nine adaptive interventions were examined in at least one of 77 studies. Underlying theories included Cognitive Learning Theory, Self-determination Theory, Social Cognitive Theory, adult learning theories, and Psychological Stress and Coping Theory. Three overarching theoretical drivers were identified: learning, motivation, and coping.

CONCLUSIONS

At least 29 adaptive approaches exist, but each appear to be based on one of three underlying theoretical drivers. Consideration of effectiveness of these approaches by theoretical driver could help indicate underlying mechanisms and essential elements of effective adaptive approaches.

SIGNIFICANCE

Our framework is an important advance in understanding and evaluating adaptive approaches to stroke rehabilitation.

Co-creation of self-management support during inpatient stroke rehabilitation

Objective

This study aimed to identify priority self-management skills and behaviours in partnership with stroke survivors, and to co-create approaches to support self-management during inpatient stroke rehabilitation.

Methods

Three stroke survivors and two communication partners participated in the three-stage Participatory Action Research project with embedded co-design processes after undertaking inpatient rehabilitation at a metropolitan tertiary hospital.

Results

Participants identified key factors influencing self-management during inpatient rehabilitation including motivation, emotional well-being, and fatigue. Three approaches to support people to self-manage post-stroke were co-created. (1) A health professional concierge and early family meeting. (2) A peer support person. (3) Adapting the hospital environment.

Conclusion

Findings suggest post-stroke self-management support should commence during inpatient rehabilitation to optimise its research-informed benefits. This support should focus on empowering stroke survivors and their key support people through active involvement in decision-making, and provision of multi-modal individualised education. The impact of hospital environments on emotional-wellbeing and self-management post-stroke also requires further investigation.

Innovation

The identification of a health professional concierge as a co-designed solution to the current challenges with self-management support is an innovative recommendation for practice. The findings support changes to the traditional processes of rehabilitation towards a consumer and family-led practices.

Using Intervention Mapping and Behavior Change Techniques to Develop a Digital Intervention for Self-Management in Stroke: Development Study

BACKGROUND

Digital therapeutics, such as interventions provided via smartphones or the internet, have been proposed as promising solutions to support self-management in persons with chronic conditions. However, the evidence supporting self-management interventions through technology in stroke is scarce, and the intervention development processes are often not well described, creating challenges in explaining why and how the intervention would work.

OBJECTIVE

This study describes a specific use case of using intervention mapping (IM) and the taxonomy of behavior change techniques (BCTs) in designing a digital intervention to manage chronic symptoms and support daily life participation in people after stroke. IM is an implementation science framework used to bridge the gap between theories and practice to ensure that the intervention can be implemented in real-world settings. The taxonomy of BCTs consists of a set of active ingredients designed to change self-management behaviors.

METHODS

We used the first 4 steps of the IM process to develop a technology-supported self-management intervention, interactive Self-Management Augmented by Rehabilitation Technologies (iSMART), adapted from a face-to-face stroke-focused psychoeducation program. Planning group members were involved in adapting the intervention. They also completed 3 implementation measures to assess the acceptability, appropriateness, and feasibility of iSMART.

RESULTS

In step 1, we completed a needs assessment consisting of assembling a planning group to codevelop the intervention, conducting telephone surveys of people after stroke (n=125) to identify service needs, and performing a systematic review of randomized controlled trials to examine evidence of the effectiveness of digital self-management interventions to improve patient outcomes. We identified activity scheduling, symptom management, stroke prevention, access to care resources, and cognitive enhancement training as key service needs after a stroke. The review suggested that digital self-management interventions, especially those using cognitive behavioral theory, effectively reduce depression, anxiety, and fatigue and enhance self-efficacy in neurological disorders. Step 2 identified key determinants, objectives, and strategies for self-management in iSMART, including knowledge, behavioral regulation, skills, self-efficacy, motivation, negative and positive affect, and social and environmental support. In step 3, we generated the intervention components underpinned by appropriate BCTs. In step 4, we developed iSMART with the planning group members. Especially, iSMART simplified the original psychoeducation program and added 2 new components: SMS text messaging and behavioral coaching, intending to increase the uptake by people after stroke. iSMART was found to be acceptable (mean score 4.63, SD 0.38 out of 5), appropriate (mean score 4.63, SD 0.38 out of 5), and feasible (mean score 4.58, SD 0.34 out of 5).

CONCLUSIONS

We describe a detailed example of using IM and the taxonomy of BCTs for designing and developing a digital intervention to support people after stroke in managing chronic symptoms and maintaining active participation in daily life.

Self-management from the perspective of people with stroke - An interview study

OBJECTIVE

Self-management support can improve quality of life, mood, self-efficacy, and physical function following a stroke. Knowledge of how people with stroke understand and experience self-management in different contexts is crucial to developing effective self-management support. This study explored how people with stroke understand and practice self-management during the post-acute phase.

METHOD

A descriptive study using qualitative content analysis to explore data from semistructured interviews RESULTS: Eighteen participants were interviewed. Most participants interpreted self-management as 'taking care of their business' and 'being independent". However, they encountered difficulties performing daily activities, for which they felt unprepared. Although interest in implementing self-management support increases, participants did not report receiving specific advice from healthcare professionals.

CONCLUSION

People continue to feel unprepared to manage everyday activities after hospital discharge and must largely work things out for themselves. There is an overlooked opportunity to start the process of self-management support earlier in the stroke pathway, with healthcare professionals and people with stroke combining their skills, ideas and expertise. This would enable confidence to self-management to flourish rather than decrease during the transition from hospital to home.

PRACTICAL IMPLICATIONS

Individual tailored self-management support could help people with stroke more successfully manage their daily lives post-stroke.

Healthcare professional students' perceptions of supporting patient self-management: A mixed method study

OBJECTIVES

Individuals self-manage chronic illnesses daily with episodic support provided by healthcare professionals. Learning about supporting self-management should be part of healthcare professional student programme curricular and training. However, little is known about the perceptions and attitudes students hold about supporting patient self-management and whether support for self-management is implemented on clinical placement.

METHODS

A mixed method approach explored students' perceptions and attitudes to supporting patient self-management via e-survey and semi-structured interviews.

RESULTS

Survey data (n = 96; 11 programmes) were analysed descriptively and interviews thematically (n = 10; F = 9; aged 19-34 years; 8 programmes). Survey data suggested participants had a positive attitude towards, and were confident in providing support for self-management, but did not implement it frequently in clinical environments. One main theme "Self-management support is puzzling" identified the uncertainty around what students thought their role was or how to enact support within the patient interaction. A smaller theme "Self-management support is valuable" showed participants were open to learning more about how to support patient self-management.

DISCUSSION

We suggest more explicit and frequent learning opportunities need to be provided for healthcare professional students to learn how to support patient self-management, with particular emphasis on involving family and incorporating self-management tools within the patient encounter.

Effectiveness and cost-effectiveness of a personalised self-management intervention for living with long COVID: protocol for the LISTEN randomised controlled trial

BACKGROUND

Individuals living with long COVID experience multiple, interacting and fluctuating symptoms which can have a dramatic impact on daily living. The aim of the Long Covid Personalised Self-managemenT support EvaluatioN (LISTEN) trial is to evaluate effects of the LISTEN co-designed self-management support intervention for non-hospitalised people living with long COVID on participation in routine activities, social participation, emotional well-being, quality of life, fatigue, and self-efficacy. Cost-effectiveness will also be evaluated, and a detailed process evaluation carried out to understand how LISTEN is implemented.

METHODS

The study is a pragmatic randomised effectiveness and cost-effectiveness trial in which a total of 558 non-hospitalised people with long COVID will be randomised to either the LISTEN intervention or usual care. Recruitment strategies have been developed with input from the LISTEN Patient and Public Involvement and Engagement (PPIE) advisory group and a social enterprise, Diversity and Ability, to ensure inclusivity. Eligible participants can self-refer into the trial via a website or be referred by long COVID services. All participants complete a range of self-reported outcome measures, online, at baseline, 6 weeks, and 3 months post randomisation (the trial primary end point). Those randomised to the LISTEN intervention are offered up to six one-to-one sessions with LISTEN-trained intervention practitioners and given a co-designed digital resource and paper-based book. A detailed process evaluation will be conducted alongside the trial to inform implementation approaches should the LISTEN intervention be found effective and cost-effective.

DISCUSSION

The LISTEN trial is evaluating a co-designed, personalised self-management support intervention (the LISTEN intervention) for non-hospitalised people living with long COVID. The design has incorporated extensive strategies to minimise participant burden and maximise access. Whilst the duration of follow-up is limited, all participants are approached to consent for long-term follow-up (subject to additional funding being secured).

TRIAL REGISTRATION

LISTEN ISRCTN36407216. Registered on 27/01/2022.

Co-creation and stroke rehabilitation: a scoping review

PURPOSE

Co-creation is identified as a concept with potential to address many challenges in modern healthcare systems. Its application within stroke rehabilitation is yet to be reviewed. The purpose of this paper is to identify when and how co-creation has been used in the literature to develop services and approaches to stroke survivor care and rehabilitation.

MATERIALS AND METHODS

A scoping review was conducted guided by the framework outlined by Arksey and O'Malley. Articles were included if they involved co-creation with stroke survivors and identified co-creation as their methodology to develop post-stroke services. Quality appraisal of included articles was completed.

RESULTS

The search strategy identified 565 articles. Fourteen articles met inclusion criteria. The results demonstrate that co-creation as a methodology to develop stroke rehabilitation services is a contemporary field, producing both technology and non-technology-based interventions, predominately in the community context. Co-creation application was inconsistent, with a plethora of methodologies used, and terminology to describe co-creation varying between the studies.

CONCLUSIONS

Co-creation in stroke rehabilitation is currently in an expanding and rudimentary phase. This review identified the variability of its application, with future work needed to establish clarity and consistency in terminology and methodologies utilised to operationalise co-creation in stroke rehabilitation.Implications for rehabilitationCo-creation is a contemporary and evolving service improvement approach in stroke rehabilitation, utilised most commonly in the community context.Inconsistent terminology and diverse methodologies are utilised to enact co-creation in stroke rehabilitation.Opportunities exist to advance co-creation in the stroke rehabilitation space through developing consistency in its application, and further investigation into its use with the stroke survivor population.

Protocol for a hybrid II study exploring the feasibility of delivering, evaluating, and implementing a self-management programme for people with neuromuscular diseases at a specialist neuromuscular centre

BACKGROUND

Self-management support (SMS) forms a central pillar in the management of long-term conditions. It is firmly aligned with UK health policy but there is a paucity of evidence exploring how it is enacted in the context of neuromuscular diseases (NMDs). Bridges is a SMS programme originally developed in stroke. A new version of the programme (Neuromuscular Bridges) has recently been co-designed with people with lived experience of NMD and requires evaluation. The implementation of SMS is inherently complex with potential barriers at the level of the patient, provider, and wider organisation. The success of implementing programmes can be highly dependent on context, indicating a rationale for considering implementation determinants at an early stage. This study aims to explore the feasibility of (1) delivering, (2) evaluating, and (3) implementing Neuromuscular Bridges at a specialist neuromuscular centre.

METHODS

This study employs a hybrid II design underpinned by Normalisation Process Theory (NPT), which has been used prospectively to inform the implementation plan and will also inform the analysis. The feasibility of delivering, evaluating, and implementing Neuromuscular Bridges will be assessed using a single-arm pre-post design. In terms of delivery and evaluation, we will explore acceptability, demand within the service, performance of outcome measures, recruitment, and retention. Implementation strategies have been selected from a refined taxonomy of strategies, mapped to NPT, and targeted at known barriers and facilitators at the specialist centre that were identified from preliminary stakeholder engagement activities. The impact of the strategy bundle on fidelity, acceptability, appropriateness, and adoption will be evaluated using qualitative interviews, administrative data, surveys, and a notes audit.

CONCLUSIONS

This this study will provide valuable feasibility data on a co-designed SMS programme for people with NMDs that will be used to inform a larger implementation study, requirements for embedding it in a specialist centre, and rollout to other specialist centres. Using hybrid methodology at the feasibility stage is unusual and this study will provide important insights into the usefulness of taking this approach at this point in the research pipeline.

TRIAL REGISTRATION

ISRCTN Trial ID: ISRCTN14208138 . Date registered: 18/08/2021.

Treatment of spasticity

Spasticity is characterized by an enhanced size and reduced threshold for activation of stretch reflexes and is associated with "positive signs" such as clonus and spasms, as well as "negative features" such as paresis and a loss of automatic postural responses. Spasticity develops over time after a lesion and can be associated with reduced speed of movement, cocontraction, abnormal synergies, and pain. Spasticity is caused by a combination of damage to descending tracts, reductions in inhibitory activity within spinal cord circuits, and adaptive changes within motoneurons. Increased tone, hypertonia, can also be caused by changes in passive stiffness due to, for example, increase in connective tissue and reduction in muscle fascicle length. Understanding the cause of hypertonia is important for determining the management strategy as nonneural, passive causes of stiffness will be more amenable to physical rather than pharmacological interventions. The management of spasticity is determined by the views and goals of the patient, family, and carers, which should be integral to the multidisciplinary assessment. An assessment, and treatment, of trigger factors such as infection and skin breakdown should be made especially in people with a recent change in tone. The choice of management strategies for an individual will vary depending on the severity of spasticity, the distribution of spasticity (i.e., whether it affects multiple muscle groups or is more prominent in one or two groups), the type of lesion, and the potential for recovery. Management options include physical therapy, oral agents; focal therapies such as botulinum injections; and peripheral nerve blocks. Intrathecal baclofen can lead to a reduction in required oral antispasticity medications. When spasticity is severe intrathecal phenol may be an option. Surgical interventions, largely used in the pediatric population, include muscle transfers and lengthening and selective dorsal root rhizotomy.

Co-designing personalised self-management support for people living with long Covid: The LISTEN protocol

BACKGROUND

Long Covid is recognised as a complex condition characterised by multiple, interacting and fluctuating symptoms which impact everyday life in diverse ways. The extent of symptom clusters and variability supports interventions that can accommodate heterogeneity, such as personalised self-management support. This approach is also advocated by people living with long Covid and guidelines published by the UK's National Institute for Health and Care Excellence. Long Covid Personalised Self-managemenT support co-design and EvaluatioN (LISTEN) is one of 15 research projects funded by the UK's National Institute of Health Research long Covid research programme. LISTEN aims to work with people living with or recovered from long Covid to co-design self-management resources, and a training programme for rehabilitation practitioners to deliver personalised support. The intervention will focus on people not hospitalised for Covid. The protocol presented here details the co-design of the LISTEN intervention which, on completion, will be evaluated in a randomised controlled trial.

METHODS

The study will utilise an Accelerated Experience-Based Co-Design approach, and involve 30 people from England and Wales with lived experience of long Covid, and 15 rehabilitation practitioners living with, or supporting people with, long Covid. Through online meetings, participants will share their stories of long Covid, their challenges and strategies to live better with or recover from long Covid, their priorities for self-management resources and the practitioner training andcreate, review and refine these resources and the training. Throughout, LISTEN will draw upon the UK standards of public involvement in research.

DISCUSSION

If effective and cost-effective, the intervention will be available across the UK's National Health Service. The first of its kind, this study could make a difference to the lives of people with long Covid. To ensure impact, we have developed strategies to involve people from diverse backgrounds and mitigate potential barriers to involvement.

The use of self-management strategies for stroke rehabilitation: a scoping review

INTRODUCTION

Self-management is generally considered a dynamic and collaborative process by individuals and caregivers to manage a chronic condition. Self-management has recently emerged as a promising strategy for stroke rehabilitation. This scoping review aims to examine and summarize self-management strategies utilized by stroke survivors for stroke rehabilitation.

METHODS

PubMed, Scopus, CINAHL (EBSCO), Embase, and ProQuest were searched for articles published between January 2010 and December 2021. Studies were selected if they were published in English in a peer-reviewed journal, utilized a non-experimental research design, and focused on adult stroke survivors. All relevant information from the included articles was extracted in a systematic way using a pre-developed data extraction form. Two authors performed data extraction and quality evaluation independently. All issues were resolved through discussion among the authors.

RESULTS

We narratively summarized the findings of 15 quantitative, qualitative, and mixed-method studies, including a total of 1,494 stroke survivors. The stroke survivors used a range of self-management strategies for their stroke rehabilitation, including domains related to lifestyle, social support, communication, knowledge and information, and goal-setting. Gender, age, stroke-related disability, fatigue, self-management education, social support, and communication with others were found to be associated with self-management use in stroke rehabilitation.

CONCLUSIONS

This scoping review provides an important overview on stroke survivors' use of self-management strategies and their experience. Their use of self-management strategies is complicated and multifaceted, comprising several domains and involving a diverse range of approaches and personal experiences. However, we identified several gaps in the literature and more research is required.

Optimising rehabilitation and recovery after a stroke

Stroke can cause significant disability and impact quality of life. Multidisciplinary neurorehabilitation that meets individual needs can help to optimise recovery. Rehabilitation is essential for best quality care but should start early, be ongoing and involve effective teamwork. We describe current stroke rehabilitation processes, from the hyperacute setting through to inpatient and community rehabilitation, to long-term care and report on which UK quality care standards are (or are not) being met. We also examine the gap between what stroke rehabilitation is recommended and what is being delivered, and suggest areas for further improvement.

Care Dependency of Hospitalized Stroke Patients Based on Family Caregivers’ and Nurses’ Assessments: A Comparative Study

Stroke impacts care dependency, and thus the patient needs home care after suffering a stroke. This study was carried out to investigate similarities and differences between the assessments made by family caregivers and nurses regarding the care dependency level of stroke patients in Indonesian hospitals. This study was a comparative study of the care dependency of stroke patients. Data were collected on the stroke wards on the day of admission using the Care Dependency Scale (CDS). The sample consisted of 118 family caregivers and 21 nurses. The Wilcoxon signed-rank test was performed to determine the mean differences between the paired data collected by family caregivers and nurses. The results of this study show that significant differences exist between the family caregivers’ and nurses’ assessments regarding the care dependency levels of stroke patients. Nurses assigned higher scores to all CDS items than family caregivers did. Significant differences between the family caregivers’ and nurses’ assessments were observed on numerous items of the Care Dependency Scale. This study contributes to efforts to raise awareness of potential differences in perceived care dependency levels of stroke patients. The findings can help nurses plan the patient’s discharge together with family caregivers.

Tailoring and Evaluating an Intervention to Support Self-management After Stroke: Protocol for a Multi-case, Mixed Methods Comparison Study

Background

Self-management programs are recognized as a valuable approach to supporting people with long-term conditions, such as stroke, in managing their daily lives. Bridges Self-Management (Bridges) focuses on how practitioners interact and support patients’ confidence, skills, and knowledge, and it is an example of a complex intervention. Bridges has been developed and used across multiple health care pathways in the United Kingdom and is theoretically informed by social cognition theory and self-efficacy principles. Evidence shows that self-management programs based on the construct of self-efficacy can be effective. There is still much to learn about how health care services or pathways should implement support for self-management in a sustainable way and whether this implementation process is different depending on the context or culture of the team or service provided.

Objective

The aim of this study is to tailor and evaluate an intervention (Bridges) to support self-management after stroke in a Swedish context.

Methods

We will use a pretest-posttest design with a case study approach to evaluate the feasibility and implementation of self-management support in two stroke settings. This project includes a complex intervention and depends on the actions of individuals, different contexts, and the adaptation of behavior over time. A mixed methods approach was chosen to understand both outcomes and mechanisms of impact. Data collection will comprise outcome measurements and assessment tools as well as qualitative interviews. Data will be collected concurrently and integrated into a mixed methods design.

Results

Recruitment and data collection for the first site of the project ran from September 1, 2021, to January 17, 2022. The intervention at the first site was conducted from November 1, 2021, to March 5, 2022. The evaluation will start after the implementation phase. The second site has been recruited, and the baseline data collection will start in spring 2022. The intervention will start in early autumn 2022. Data collection will be completed by the end of 2022.

Conclusions

This study represents a unique, highly relevant, and innovative opportunity to maximize knowledge and minimize practice gaps in rehabilitation stroke care. The study will produce robust data on the intervention and in-depth data on the contextual factors and mechanisms related to the feasibility of the intervention and for whom it is feasible. Bridges has been used in the United Kingdom for more than 10 years, and this study will explore its contextualization and implementation within a Swedish stroke environment. The evaluation will study results at the patient, staff, and organizational levels and provide recommendations for the adoption and refinement of future efforts to support self-management.

International Registered Report Identifier (IRRID)

DERR1-10.2196/37672

Self-management interventions for adults with stroke: A scoping review

BACKGROUND

Stroke is a principal cause of mortality and disability globally. Numerous studies have contributed to the knowledge base regarding self-management interventions among chronic disease patients, but there are few such studies for patients with stroke. Therefore, it is necessary to analyze self-management interventions among stroke patients. This scoping review aimed to systematically identify and describe randomized controlled trials (RCTs) of self-management interventions for adults with stroke.

METHODS

A review team carried out a scoping review on stroke and self-management interventions based on the methodology of Arksey and O'Malley, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). PubMed, Embase, Web of Science, CINAHL Plus Full Text, Medline Plus Full Text, and Cochrane Central Register of Controlled Trials were searched from inception to July 2020.

RESULTS

Fifty-four RCTs were included. The most popular study design is comparing a self-management intervention to usual care or waitlist control condition. Physical activity is the most common intervention topic, and interventions were mainly delivered face to face. The majority of interventions were located in inpatient and multiple settings. Interventions were conducted by various providers, with nurses the most common provider group. Symptom management was the most frequently reported outcome domain that improved.

CONCLUSIONS

Self-management interventions benefit the symptom management of stroke patients a lot. The reasonable time for intervention is at least 6-12 months. Multifarious intervention topics, delivery formats, and providers are adopted mostly to meet the multiple needs of this population. Physical activity was the most popular topic currently. Studies comparing the effect of different types of self-management interventions are required in the future.

'Emotion is of the essence. … Number one priority': A nested qualitative study exploring psychosocial adjustment to stroke and aphasia

BACKGROUND

Stroke and aphasia can have a profound impact on people's lives, and depression is a common, frequently persistent consequence. Social networks also suffer, with poor social support associated with worse recovery. It is essential to support psychosocial well-being post-stroke, and examine which factors facilitate successful adjustment to living with aphasia.

AIMS

In the context of a feasibility randomized controlled trial of peer-befriending (SUPERB), this qualitative study explores adjustment for people with aphasia in the post-acute phase of recovery, a phase often neglected in previous research.

METHODS & PROCEDURES

Semi-structured interviews were conducted with 20 people with aphasia and 10 significant others, who were purposively sampled from the wider group of 56 people with aphasia and 48 significant others. Interviews took place in participants' homes; they were analysed using framework analysis.

OUTCOMES & RESULTS

Participants with aphasia were 10 women and 10 men; their median (interquartile range-IQR) age was 70 (57.5-77.0) years. Twelve participants had mild aphasia, eight moderate-severe aphasia. Significant others were six women and four men with a median (IQR) age of 70.5 (43-79) years. They identified a range of factors that influenced adjustment to aphasia post-stroke. Some were personal resources, including mood and emotions; identity/sense of self; attitude and outlook; faith and spirituality; and moving forward. Significant others also talked about the impact of becoming carers. Other factors were external sources of support, including familial and other relationships; doctors, nurses and hospital communication; life on the ward; therapies and therapists; psychological support, stroke groups; and community and socializing.

CONCLUSIONS & IMPLICATIONS

To promote adjustment in the acute phase, hospital staff should prioritize the humanizing aspects of care provision. In the post-acute phase, clinicians play an integral role in supporting adjustment and can help by focusing on relationship-centred care, monitoring mental health, promoting quality improvement across the continuum of care and supporting advocacy. What this paper adds What is already known on the subject Anxiety and depression are common consequences of stroke, with depression rates high at 33% at 1 year post-onset. There is evidence that the psychological needs of people with aphasia are even greater than those of the general stroke population. Social support and social networks are also negatively impacted. Few studies have examined adjustment when people are still in hospital or in the early stages of post-stroke life in the community (< 6 months). Further, many stroke studies exclude people with aphasia. What this paper adds to existing knowledge Adjustment to living with stroke and aphasia begins in the early stages of recovery. While this partly depends on personal resources, many factors depend on external sources of help and support. These include doctors, nurses and hospital communication, their experience of life on the ward, and their therapists' person-centred care. What are the potential or actual clinical implications of this work? Clinicians play an integral role in facilitating people with aphasia to utilize their personal resources and support systems to adjust to life after stroke. They can help by focusing on relationship-centred care, monitoring mental health, promoting quality improvement across the continuum of care and supporting advocacy.

Exploring physiotherapists' and occupational therapists' perceptions of the upper limb prediction algorithm PREP2 after stroke in a rehabilitation setting: a qualitative study

OBJECTIVE

To explore how physiotherapists (PTs) and occupational therapists (OTs) perceive upper limb (UL) prediction algorithms in a stroke rehabilitation setting and identify potential barriers to and facilitators of their implementation.

DESIGN

This was a qualitative study.

SETTING

The study took place at a neurorehabilitation centre.

PARTICIPANTS

Three to six PTs and OTs.

METHODS

We conducted four focus group interviews in order to explore therapists' perceptions of UL prediction algorithms, in particular the Predict Recovery Potential algorithm (PREP2). The Consolidated Framework for advancing Implementation Research was used to develop the interview guide. Data were analysed using a thematic content analysis. Meaning units were identified and subthemes formed. Information gained from all interviews was synthesised, and four main themes emerged.

RESULTS

The four main themes were current practice, perceived benefits, barriers and preconditions for implementation. The participants knew of UL prediction algorithms. However, only a few had a profound knowledge and few were using the Shoulder Abduction Finger Extension test, a core component of the PREP2 algorithm, in their current practice. PREP2 was considered a potentially helpful tool when planning treatment and setting goals. A main barrier was concern about the accuracy of the algorithm. Furthermore, participants dreaded potential dilemmas arising from having to confront the patients with their prognosis. Preconditions for implementation included tailoring the implementation to a specific unit, sufficient time for acquiring new skills and an organisation supporting implementation.

CONCLUSION

In the present study, experienced neurological therapists were sceptical towards prediction algorithms due to the lack of precision of the algorithms and concerns about ethical dilemmas. However, the PREP2 algorithm was regarded as potentially useful.

Web-based physical activity intervention for people with progressive multiple sclerosis: application of consensus-based intervention development guidance

OBJECTIVES

People with progressive multiple sclerosis (PwPMS) report that they recognise the benefits of activity on their physical and psychological health but need support to achieve their physical activity goals. We aimed to systematically develop a theoretically informed intervention that would enable PwPMS to more readily engage in regular physical activity.

DESIGN

We used an intervention mapping approach to inform intervention development.

SETTING

We conducted semistructured interviews with PwPMS and their families/carers and physiotherapists recruited from secondary care settings.

PARTICIPANTS

Fourteen PwPMS with an Expanded Disability Status Scale score of between 6 and 8 and 7 of their families/carers and 13 physiotherapists and 1 physiotherapy technician participated.

RESULTS

Interview data suggested that the development of supportive coaching relationships with physiotherapists could promote the ability of PwPMS to achieve a desirable and achievable physical activity plan. These interview data informed the prototype 'Lifestyle Exercise and Activity Package for Multiple Sclerosis' (LEAP-MS) consisting of a secure multiuser web-based platform (with an education and activity suite, interactive components enabling selection of exercises, goal setting and activity logging), up to six flexible face-to-face or web-based physiotherapy coaching sessions and remote support via an embedded web-based messaging function that all together draw on specific theory-based methods to achieve physical activity behaviour change, namely active learning, reinforcement, modelling, feedback, facilitation, goal setting and guided practice. Implementation is within a multiuser platform accessible to participants, trained physiotherapists and researchers.

CONCLUSIONS

We have followed an inclusive, systematic and transparent process to develop the LEAP-MS intervention that enables detailed description of components, context and guiding principles to inform ongoing evaluation. Importantly, PwPMS expressed the need for autonomy in developing physical activity plans. This has been achieved through the embedding of self-management principles in the design and delivery of the LEAP-MS intervention.

The problem with self-management: Problematising self-management and power using a Foucauldian lens in the context of stroke care and rehabilitation

Self-management is a concept which is now firmly established in Western healthcare policy and practice. However, the term remains somewhat ambiguous, multi-faceted and contentious. This is evident in stroke care and rehabilitation, in which a self-management approach is increasingly adopted and advocated, yet interpreted in different ways, resulting in contradictions and tensions around control, responsibility, power and discipline. This paper aims to further our understanding of tensions and contradictions in stroke self-management, by critically examining contemporary self-management practices. We use a Foucauldian theoretical lens to explore the various power dynamics in the operationalisation of self-management, in addition to the complexity of the term self-management itself. Conducting a secondary analysis of interview and focus group data from the Self-Management VOICED study, supplemented with analysis of relevant documentary evidence from policy and practice, we describe the multiple aspects of power in operation. These include rhetorical, hierarchical, personal and mutual forms of power, representing interweaving dynamics evident in the data. These aspects of power demonstrate underlying agendas and tacit and explicit understandings of self-management which exist in clinical practice. These aspects of power also give insight into the multiple identities of ‘self-management’, acting as a simultaneous repressor and liberator, directly in keeping with Foucauldian thinking. The findings are also consistent with Foucault’s notions of bodily docility, discussions around governance and biopower, and contemporary discipline. Our analysis positions self-management as a highly nuanced and complex concept, which can fluctuate in its conceptualisation depending on the structures, routines, and the individual. We encourage healthcare professionals, policymakers and commissioners in the field of self-management to reflect on these complexities, to make transparent their assumptions and to explicitly position their own practice accordingly.

Exploring challenges at 6 months after stroke: what is important to patients for self-management?

Background/Aims:

Self-management models have recently been applied to stroke, but the most effective components are yet to be determined. To inform the ongoing refinement of stroke self-management programmes, this study explored challenges at 6 months after stroke.

Methods:

A total of 53 stroke survivors and 26 significant others were interviewed 6 months after stroke. Results were analysed qualitatively using thematic analysis.

Findings:

Stroke was experienced as a shocking and frightening event regardless of severity, and participants struggled to manage the consequences of their stroke. The stroke experience occurred within the context of more than one chronic condition and with competing demands of everyday life. Participants struggled to formulate a model of causation for their stroke, yet this appeared a necessary basis for action.

Conclusions:

The findings suggest that health care targeted at enhancing self-management, including self-management programmes, may benefit from encompassing a specific focus on participants' beliefs as an important foundation for recovery after stroke.

Shifting mindsets: a realist synthesis of evidence from self-management support training

CONTEXT

Accompanying the growing expectation of patient self-management is the need to ensure health care professionals (HCPs) have the required attitudes and skills to provide effective self-management support (SMS). Results from existing training interventions for HCPs in SMS have been mixed and the evidence base is weaker for certain settings, including supporting people with progressive neurological conditions (PNCs). We set out to understand how training operates, and to identify barriers and facilitators to training designed to support shifts in attitudes amongst HCPs.

METHODS

We undertook a realist literature synthesis focused on: (i) the influence of how HCPs, teams and organisations view and adopt self-management; and (ii) how SMS needs to be tailored for people with PNCs. A traditional database search strategy was used alongside citation tracking, grey literature searching and stakeholder recommendations. We supplemented PNC-specific literature with data from other long-term conditions. Key informant interviews and stakeholder advisory group meetings informed the synthesis process. Realist context-mechanism-outcome configurations were generated and mapped onto the stages described in Mezirow's Transformative Learning Theory.

RESULTS

Forty-four original articles were included (19 relating to PNCs), from which seven refined theories were developed. The theories identified important training elements (evidence provision, building skills and confidence, facilitating reflection and generating empathy). The significant influence of workplace factors as possible barriers or facilitators was highlighted. Embracing SMS often required challenging traditional professional role boundaries.

CONCLUSION

The integration of SMS into routine care is not an automatic outcome from training. A transformative learning process is often required to trigger the necessary mindset shift. Training should focus on how individual HCPs define and value SMS and how their work context (patient group and organisational constraints) influences this process. Proactively addressing potential contextual barriers may facilitate implementation. These findings could be applied to other types of training designed to shift attitudes amongst HCPs.

"I'm still me - I'm still here!" Understanding the person's sense of self in the provision of self-management support for people with progressive neurological long-term conditions

PURPOSE

There is increasing interest in tailoring self-management support, but little detail is available on the relevance and impact of such approaches for people with progressive neurological conditions. The aim of this study was to draw on individuals' experiences to inform the practice of self-management support for these groups.

METHOD

Community rehabilitation service users were purposively recruited and took part in in-depth qualitative interviews. Interviews were audio-recorded and transcribed. Data analysis was iterative and interpretative, taking a phenomenological approach. Strategies to enhance rigor were auditability, peer review, and researcher reflexivity.

RESULTS

The sample consisted of 10 adults (age 20-79 years) who were living with a range of progressive neurological conditions. Individuals demonstrated resourcefulness in developing practice-based self-management strategies. Beyond practical strategies, interviewees' experiences were signified by reflecting on and upholding a sense of identity and a desire for purpose against the background of losses and gains over time. Linking with this overarching theme of "Sense of self" were aspects of "My body and mind", "Time", "Space", "Relationships", and "What I do".

CONCLUSIONS

Self-management approaches for individuals with progressive neurological conditions will benefit from incorporating ways of recognizing, articulating, and supporting the person's sense of identity and purpose. Implications for rehabilitation Self-management approaches for people with progressive neurological conditions need to take account of individuals' wishes to contribute, connect with others, and be valued as a person. Person-centred self-management support can be realized through a broader approach than solely managing disease progression. The experiences and words of people with progressive neurological conditions can be used to inform meaningful evaluation of self-management support to drive service delivery by measuring what really matters. Rehabilitation practitioners need to adapt their conceptualisations of goal setting to account for how people with progressive neurological conditions themselves interpret "progress" and "improvement". Person-centred conversation that values who the person is can be an effective starting point for self-management interventions in people with progressive neurological conditions.

Research protocol: investigating the feasibility of a group self-management intervention for stroke (the GUSTO study)

BACKGROUND

Life after stroke can be an ongoing struggle with over half of all survivors reporting unmet emotional and social needs. In the United Kingdom's (UK) national clinical guidelines for stroke, self-management is suggested as one approach which can support long-term needs. In the UK NHS, self-management interventions are delivered in various ways. Regardless of the delivery mechanism, a tailored approach and ways to integrate peer support are advocated. Group delivery offers a platform for peer support and has the potential to remain individualised. However, before the efficacy of a group self-management intervention can be tested, the feasibility must be explored. This research investigates the feasibility of a GroUp Self-management intervention for sTrOke (GUSTO).

METHODS

A randomised waitlist control design will be used to investigate the feasibility of a group self-management intervention adapted from an existing one-to-one intervention called Bridges. A mixed methods approach will be used. Qualitative work will capture participant experience, while quantitative work will allow preliminary comparison between the intervention and waitlist groups (between subjects) and pre-post intervention measures (within subjects). Interviews will be conducted with stroke survivors and focus groups with family and friends to assess acceptability of the intervention.

DISCUSSION

There is a growing interest in group-based self-management interventions for stroke as a method of supporting stroke survivors' ongoing unmet needs. This is an area with limited research to date. This study will inform design of a fully powered trial which would assess the efficacy of a group self-management intervention following stroke.

TRIAL REGISTRATION

ISRCTN19867168.

Utilization of Mobile Applications in Collaborative Patient-Provider Monitoring of Chronic Health Conditions: An Examination of Three Theoretical Frameworks to Guide Practice

Mobile health (mHealth) applications may improve chronic disease management through enhanced patient-provider communication and collaboration. The aim of this review was to compare and critique the application of three theoretical frameworks to guide mHealth research and practice in patient-provider interactions.

Beliefs of rehabilitation professionals towards guided self-rehabilitation contracts for post stroke hemiparesis

Purpose To investigate the beliefs of physiotherapy students (ST), professionals (PT) and physicians (MD) about engaging patients with post-stroke hemiparesis into Guided Self-Rehabilitation Contracts (GSC), to increase their exercise intensity and responsibility level. Method A survey examining beliefs about post-stroke rehabilitation was completed by first (n = 95), second (n = 105), and third (n = 48) year STs; PTs (n = 129) and MDs (n = 65) in France. Results The belief about whether a patient may exercise alone varied between the professional groups with more STs and MDs finding it acceptable: 62% of PTs vs. 74% of STs (p = 0.005) and 79% of MDs (p = 0.02). For 93% of therapists (STs and PTs together), the caregiver may take part in physical therapy sessions. The appropriate weekly duration of exercises in chronic hemiparesis should be over 5 h for 19% of PTs, 37% of STs, and 51% of MDs (MDs vs. PTs, p < 0.005). After stroke, functional progress through rehabilitation is possible all lifelong for 11% of STs, 19% of PTs (p < 0.05, STs vs. PTs), and 29% of MDs (MD vs. PT, NS). Conclusions The strategy of asking patients to perform exercises alone, in the practice or at home, is still not accepted by a large proportion of physical therapy professionals as compared with students or with physicians. Most therapists still see a <5-h weekly duration of exercise as sufficient after stroke. Few therapists are ready to utilize the persistence of behavior-induced brain plasticity regardless of age or delay after the lesion.