Feasibility of ActivABLES to promote home-based exercise and physical activity of community-dwelling stroke survivors with support from caregivers: A mixed methods study

Feasibility of Smartphone-Based Exercise Training Integrated with Functional Electrical Stimulation After Stroke (SETS): A Preliminary Study

One emerging method in home stroke rehabilitation is digital technology. However, existing approaches typically target one domain (e.g., upper limb). Moreover, existing interventions do not cater to older adults with stroke (OAwS), especially those with high motor impairment, who require adjunct therapeutic agents to independently perform challenging exercises. We examined the feasibility of Smartphone-based Exercise Training after Stroke (SETS) with Functional Electrical Stimulation (FES). A total of 12 participants (67 ± 5 years) with stroke (onset > 6 months) exhibiting moderate-to-high motor impairment (Chedoke McMaster Leg ≤ 4/7) underwent 6 weeks of multicomponent (gait, functional strength, dynamic balance) training integrated with FES to paretic lower limb muscles. Primary measures included safety and adherence. Secondary measures included motivation, acceptability and attitude, usability, and clinical measures of gait and balance function like the 10-Meter Walk Test and Mini-BESTest. Participants reported no adverse events and moderate-to-high adherence (84.17 ± 11.24%) and improvement (up to 40%) in motivation, acceptability, and attitude and system usability. Participants also showed pre-post improvements in all measures of gait and balance function (p < 0.05). Integrating SETS and FES is feasible and yields short-term gains in gait and balance function among OAwS. Future studies could validate our findings by examining its efficacy with control groups to identify the differential effects of SETS and FES.

Exploring physical activity in people after stroke: a substudy of the Falls After Stroke Trial

PURPOSE

The Falls After Stroke Trial (FAST) intervention involves habit-forming functional exercise and mobility practice which may increase physical activity. This substudy of FAST explores physical activity in community-dwelling people after stroke comparing the FAST intervention to usual care.

METHODS

This study used a subset of 49 participants from a randomised trial. Outcome measures were taken at baseline, 6- and 12-months. The primary outcome was physical activity (step count, upright time and sedentary time, activPAL4™ micro).

RESULTS

Thirty-nine participants (80%) had valid primary outcome data at 6 months and 36 participants (73%) at 12 months. Compared to baseline, the experimental group completed 485 (95% CI -434 to 1405) more steps/day than the control group at 6 months and 724 (95% CI -239 to 1667) more steps/day at 12 months; and spent 36 (95% CI -46 to 118) fewer min/day in sedentary behaviour than the control group at 6 months and 34 (95% CI -51 to 119) fewer min/day at 12 months, although the differences were not significant.

CONCLUSIONS

FAST may improve physical activity more than usual care at 6- and 12-months but results are inconclusive. Further research could be conducted to confirm any benefit in a larger sample.

Gamified devices for stroke rehabilitation: A systematic review

BACKGROUND AND OBJECTIVE

Rehabilitation after stroke is essential to minimize permanent disability. Gamification, the integration of game elements into non-game environments, has emerged as a promising strategy for increasing motivation and rehabilitation effectiveness. This article systematically reviews the gamified devices used in stroke rehabilitation and evaluates their impact on emotional, social, and personal effects on patients, providing a comprehensive view of gamified rehabilitation.

METHODS

A comprehensive search using the PRISMA 2020 guidelines was conducted using the IEEE Xplore, PubMed, Springer Link, APA PsycInfo, and ScienceDirect databases. Empirical studies published between January 2019 and December 2023 that quantified the effects of gamification in terms of usability, motivation, engagement, and other qualitative patient responses were selected.

RESULTS

In total, 169 studies involving 6404 patients were included. Gamified devices are categorized into four types: robotic/motorized, non-motorized, virtual reality, and neuromuscular electrical stimulation. The results showed that gamified devices not only improved motor and cognitive function but also had a significant positive impact on patients' emotional, social and personal levels. Most studies have reported high levels of patient satisfaction and motivation, highlighting the effectiveness of gamification in stroke rehabilitation.

CONCLUSIONS

Gamification in stroke rehabilitation offers significant benefits beyond motor and cognitive recovery by improving patients' emotional and social well-being. This systematic review provides a comprehensive overview of the most effective gamified technologies and highlights the need for future multidisciplinary research to optimize the design and implementation of gamified solutions in stroke rehabilitation.

Feasibility of a 10-week community-based mobile health rehabilitation program using the WalkWithMe application in late sub-acute and chronic stroke survivors in a low resource setting: A pilot study

 Physical functioning can be increased in people with stroke by using a mobile health application. This study aimed to investigate the feasibility of a 10-week community-based program using the WalkWithMe (WWM) application in people with late sub-acute and chronic stroke in Benin. An interventional pilot study with mixed methods research design was used examining the application of an unsupervised individualized mobile Health (mHealth) instructed training program. Main outcome included the application usage, safety, adherence, perceived enjoyment, mHealth quality, patient experiences and pre-post efficacy measures. Nine adults, five males, median age of 60 years and time since stroke of 12 months participated in this study. For most participants adherence with the application was over 70%. However, some usability problems were observed due to incorrect understanding and use by participants and technical problems. The application was very fun, stimulating and enjoyable. Significant improvements were found with median (pre/post measures) of locomotors skill (1.4/3.4); impairments (38/40), Barthel Index (85/95), activity limitation (2.1/3.1), and quality of life (194/218). A trend towards significant improvement was found with 6 minutes walking test (181/220, p = 0.06). The WWM application is perceived as a potential approach to increase physical activity and functioning among people with stroke in Benin.

Carer-supported home-based exercises designed to target physical activity levels and functional mobility after stroke: a scoping review

PURPOSE

To explore the literature on carer-supported home-based exercise programs for people after stroke, as a form of physical activity. The review focus was to examine the training carers receive, the content of programs, and investigate the physical activity levels and functional mobility of people after stroke.

MATERIALS AND METHODS

A scoping review was undertaken, guided by Joanna Briggs Institute methodology. The concept of home-based carer-supported exercise, in people after stroke, was searched across five databases. Outcomes of interest were physical activity levels and functional mobility.

RESULTS

We screened 2285 references and included 10 studies: one systematic review, five randomised controlled trials, one trial with non-equivalent control, and four uncontrolled studies. Carer training ranged from one to twelve sessions. Exercise interventions commonly including walking, other whole body functional exercises and balance activities. In eight studies interventions were in addition to standard care. Five studies reported significant between-group differences for functional mobility, favouring the intervention. One study reported physical activity levels.

CONCLUSION

There was large variation in the volume and content of training provided to carers. Physical activity levels were infrequently objectively reported. Future studies should include greater details on their protocols to allow for replication and implementation into clinical practice.

Effective evaluations of community nursing on rehabilitation for stroke survivors: A meta-analysis

BACKGROUND

Long-term rehabilitation of stroke survivors is often difficult and new tools to improve quality of life should be proposed. Community nursing can be a cost-effective tool to positively impact the lives of stroke survivors. This meta-analysis aimed to comprehensively evaluate the effects of community nursing on rehabilitation for stroke survivors.

METHODS

The Cochrane Library, PubMed, Web of Science, CINAHL Plus, Embase, PEDro, China Knowledge Resource Integrated Database (CNKI), WANFANG, and WEIPU databases were comprehensively searched from their inception to April 18, 2023. The revised Cochrane risk-of-bias tool for RCTs(RoB 2 tool) was used to assess the quality of the included studies. Meta-analysis was conducted using the Stata 12.0 software package and Review Manager v5.3 software.

RESULTS

A total of 25 randomized controlled trials with 2537 participants were included in the meta-analysis. Compared with the control group, community nursing combined with routine nursing had a significantly superior effect on the Barthel Index(BI), Fugl-Meyer(FMA), National Institutes of Health Stroke Scale(NIHSS), Self-rating Anxiety Scale(SAS), and Self-rating Depression Scale(SDS) scores for stroke survivors (BI: MD: 18.48, 95 % CI [16.87, 20.08], P < 0.00001; FMA: MD: 12.61, 95 % CI [10.44, 14.78], P < 0.00001; NIHSS: MD: -2.94, 95 % CI [-3.50, -2.37], P < 0.00001; SAS: MD: -8.19; 95 % CI: [-9.46, -6.92], P < 0.00001; SDS: MD: -6.46 95 % CI [-7.23, -5.70], P < 0.00001). Subgroup analysis demonstrated that routine nursing, health education, exercise rehabilitation nursing and psychological nursing combined with different community nursing measures were significant in rehabilitation for stroke survivors and there was no heterogeneous in the studies of each subgroup(P > 0.1, I2 < 50 %).

CONCLUSION

This meta-analysis demonstrated that community nursing combined with routine nursing might improve activities of daily living, motor function and nerve function, and relieve anxiety and depression in stroke survivors. Overall, community nursing had a significant effect on rehabilitation of stroke survivors. However, this study still has limitations such as the overestimation effects caused by the sample size and the risk of bias caused by interventions. Future research will attempt to overcome these limitations and comprehensively assess the effect of community nursing on the rehabilitation of stroke survivors.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

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.

Age differences in functioning and contextual factors in community-dwelling stroke survivors: A national cross-sectional survey

Background

Our study aimed to map functioning and contextual factors among community-dwelling stroke survivors after first stroke, based on the International Classification of Functioning, Disability and Health (ICF), and to explore if these factors differ among older-old (75 years and older), younger-old (65–74 years), and young (18–65 years) stroke survivors.

Methods

A cross-sectional population-based national survey among community-dwelling stroke survivors, 1–2 years after their first stroke. Potential participants were approached through hospital registries. The survey had 56.2% response rate. Participants (N = 114, 50% men), 27 to 94 years old (71.6±12.9 years), were categorized as: older-old (n = 51), younger-old (n = 34) and young (n = 29). They answered questions on health, functioning and contextual factors, the Stroke Impact Scale (SIS) and the Behavioural Regulation Exercise Questionnaire-2. Descriptive analysis was used, along with analysis of variance for continuous data and Fisher´s exact tests for categorical variables. TukeyHSD, was used for comparing possible age-group pairings.

Results

The responses reflected ICF´s personal and environmental factors as well as body function, activities, and participation. Comparisons between age-groups revealed that the oldest participants reported more anxiety and depression and used more walking devices and fewer smart devices than individuals in both the younger-old and young groups. In the SIS, the oldest participants had lower scores than both younger groups in the domains of activities of daily living and mobility.

Conclusion

These findings provide important information on needs and opportunities in community-based rehabilitation for first-time stroke survivors and reveal that this population has good access to smart devices which can be used in community integration. Moreover, our results support the need for analysis in subgroups of age among the heterogenous group of older individuals in this population.

Mobile Health Application to Support Family Caregivers in Recurrent Stroke Prevention: Scoping Review

BACKGROUND OF THE STUDY: Caregivers play a vital role in continuum care for stroke patients. Involvement of caregivers in stroke care was important. With the advancement of information technology and the rapid growth worldwide in cell-phone use and internet connectivity, additional evidence may be needed in the use of mobile applications to support caregivers in stroke care. AIM OF THE STUDY: The aims of this review was to identify existing mobile application designed to support family caregivers of people with stroke disease. METHODOLOGY: A scoping review study framework was carried out in this study, using the EBSCO, Cochrane, PubMed, ProQuest, and Science Direct databases using search keywords: ‘family caregiver’, ‘mobile health application’,  and ‘recurrent stroke or secondary stroke prevention’. This review examined studies published between January 2011 and December 2020. Of a total of 728 papers found, 9 journals were selected. RESULTS: The results founded three categories and their attendant sub-categories. The categories was caregivers support, involvement caregivers in stroke care, and barriers. The majority of mobile application was used to provide video education for caregivers. Caregivers involved in stroke care including emotional care, nutrition, exercise, and recurrent stroke prevention. Poor connection was the most barrier in using mobile application. CONCLUSION: Mobile application can support caregivers in stroke care. Healthcare providers are expected to utilize mobile applications in helping caregivers in post-stroke care.

Stroke survivors' experiences with rebuilding life in the community and exercising at home: A qualitative study

Aim

This study aimed to explore how stroke survivors deal with stroke‐related impairments when rebuilding their lives in the community and their experiences of exercising at home.

Design

An explorative and descriptive qualitative study.

Methods

A purposive sample of ten stroke survivors residing at home was recruited to explore experiences of rebuilding their lives in the community and exercising at home. One focus group interview was conducted followed by semi‐structured interviews. Data were analysed using thematic analysis.

Results

Three main themes were identified: “Framing exercise within the context of everyday life” describes how stroke survivors integrate exercise in everyday activities with varying success and the social importance of exercising; “Managing the challenges of physical impairment” describes the taxing undertakings in daily living, loss of concentration and identity; “Long‐term challenges of everyday life” describes how the stroke survivors manage depression and live with a sense of uncertainty.

Development and Evaluation of a Classified and Tailored Community-Based Exercise Program According to the Mobility Level of People with Stroke Using the Knowledge to Action Framework

Attempts to classify the mobility levels of people with stroke (PWS) for a tailored exercise program in community settings have been few. We developed and evaluated a classified and tailored community-based (CTC) exercise program according to the mobility level of PWS. Forty-two PWS were classified into the Supine and Sitting, Sitting and Standing, and Standing and Gait groups, based on a newly developed classification model and participated in a group-based CTC exercise program for 1 h/day twice/week for 10 weeks. The health outcome measures were blood pressure, lipid profile, glucose control, body composition, ventilatory capacity, and physical and psychological function. The rate of agreement on classification results among the physiotherapists was analysed. For all participants, significant improvements were noted in the blood pressure, lipid profile, body composition, ventilatory capacity, and physical and psychological function. The lower mobility groups showed significant improvements in a greater number of health outcomes than the higher mobility group. The physiotherapists’ agreement regarding the classification results was 91.16 ± 5.14%, verifying the model’s possible high relevance to the community. The effective improvement in participant health implied that the CTC exercise program was well tailored to the participants’ mobility levels, particularly the lower mobility groups.