Feasibility of a meditation intervention for stroke survivors and informal caregivers: a randomized controlled trial

BACKGROUND

Depressive symptoms are a significant psychological complication of stroke, impacting both survivors and informal caregivers of survivors. Randomized controlled trials are needed to determine optimal non-pharmacological strategies to prevent or ameliorate depressive symptoms in stroke survivors and their informal caregivers.

METHODS

A prospective, randomized, parallel-group, single-center, feasibility study. Participants were assigned to a 4-week meditation intervention or expressive writing control group. The intervention comprised four facilitator-led group meditation sessions, one session per week and building upon prior session(s). Descriptive statistics were used to examine the proportion of eligible individuals who enrolled, retention and adherence rates, and the proportion of questionnaires completed. Data were collected at baseline, immediately after the 4-week intervention period, and 4 and 8 weeks after the intervention period. Secondary analysis tested for changes in symptoms of depression (Center for Epidemiologic Studies-Depression [CES-D]), anxiety [State-Trait Anxiety Inventory for Adults (STAI)], and pain (Brief Pain Inventory-Short Form) in the intervention group via paired t tests. Linear mixed models were used to compare longitudinal changes in the measures between the groups. Intervention and trial design acceptability were preliminary explored.

RESULTS

Seventy-one (77%) individuals enrolled and 26 (37%) completed the study (baseline and 8-week post-intervention visits completed). Forty-two (66%) participants completed baseline and immediate post-intervention visits. Mean questionnaire completion rate was 95%. The median meditation group session attendance rate for the intervention group was 75.0%, and the mean attendance rate was 55%. Non-significant reductions in CES-D scores were found. Paired t tests for stroke survivors indicated a significant reduction from baseline through week 8 in BPI-sf severity scores (p = 0.0270). Repeated measures analysis with linear mixed models for informal caregivers indicated a significant reduction in in STAI-Trait scores (F [3,16.2] = 3.28, p = 0.0479) and paired t test showed a significant reduction from baseline to week 4 in STAI-Trait scores (mean = - 9.1250, 95% CI [- 16.8060 to 1.4440], p = 0.0262). No between-group differences were found.

CONCLUSIONS

Future trials will require strategies to optimize retention and adherence before definitive efficacy testing of the meditation intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03239132. Registration date: 03/08/2017.

An Intervention Mapping Approach to Developing a Stroke Literacy Video for Recent Stroke Survivors: Development and Usability Study

BACKGROUND

Most vascular events after stroke may be prevented by modifying vascular risk factors through medical and behavioral interventions. Stroke literacy-an understanding of stroke symptoms, risk factors, and treatment-likely contributes to vascular risk factor control and in turn stroke recurrence risk. Stroke literacy is the lowest among adults belonging to racial and ethnic minority populations in the United States. Video-based interventions targeting stroke literacy may help acute stroke survivors understand stroke and subsequently reduce the risk of stroke recurrence. However, the failure of prior stroke literacy interventions may be due in part to the fact that the interventions were not theory-driven. Intervention mapping (IM) provides a framework for use in the development, implementation, and evaluation of evidence-informed, health-related interventions.

OBJECTIVE

We aimed to develop a video-based educational intervention to improve stroke literacy in hospitalized patients with acute stroke.

METHODS

The 6-step iterative process of IM was used to develop a video-based educational intervention and related implementation and evaluation plans. The six steps included a needs assessment, the identification of outcomes and change objectives, the selection of theory- and video-based intervention methods and practical applications, the development of a video-based stroke educational intervention, plans for implementation, and evaluation strategies.

RESULTS

A 5-minute video-based educational intervention was developed. The IM approach led to successful intervention development by emphasizing stakeholder involvement, generation and adoption, and information retainment in the planning phase of the intervention. A planned approach to video adoption, implementation, and evaluation was also developed.

CONCLUSIONS

An IM approach guided the development of a 5-minute video-based educational intervention to promote stroke literacy among acute stroke survivors. Future studies are needed to assess the use of technology and digital media to support widespread access and participation in video-based health literacy interventions for populations with acute and chronic stroke. Studies are needed to assess the impact of video-based educational interventions that are paired with stroke systems of care optimization to reduce the risk of stroke recurrence. Furthermore, studies on culturally and linguistically sensitive video-based stroke literacy interventions are needed to address known racial and ethnic disparities in stroke literacy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1371/journal.pone.0171952.

A Person-Centered Approach Understanding Stroke Survivor and Family Caregiver Emotional Health

ABSTRACT

BACKGROUND: The purpose of this study was to incorporate a person-centered approach to understand the emotional health needs and perspectives of stroke survivors (SSs) and their caregivers. METHODS: In collaboration with 4 SSs and caregivers as research partners, quantitative data were collected to assess poststroke emotional health needs, and qualitative data were collected to gain insight into SS and caregiver emotional health perspectives after stroke. RESULTS: Forty surveys (n = 26 SSs, n = 14 caregivers) were collected. The predominate emotional health needs were frustration (65%), anxiety (54%), and stress (50%) for SSs and stress (71%), worry (57%), and frustration (57%) for caregivers. Two group interviews (n = 7 SSs, n = 3 caregivers) were completed. Four emerging themes were identified: receiving support from those in similar situations, poststroke emotional responses, situations experienced in healthcare settings, and a hypervigilance for sudden and unexpected events. CONCLUSION: Emotional healthcare services for SSs and their caregivers may consider providing reoccurring mental health education and multifaceted treatment approaches, including provision of peer support, and addressing the unique emotional stressors SSs and caregivers may be experiencing. The small sample size precludes generalizing the results into the broader stroke population. However, by leveraging the lived experience of SSs and their caregivers, the results may help find ways to support SSs' and caregivers' emotional health.

RAPIDO: Promoting stroke awareness among Spanish speakers

ABSTRACT

The mnemonic BE-FAST (Balance, Eyes, Face, Arm, Speech, Time) has been developed for the public to better remember and identify the warning signs of stroke. However, discrepancies may arise when translating stroke educational materials from English to Spanish. This article discusses the use of a culturally tailored tool, RAPIDO, to raise stroke awareness in Spanish-speaking populations.

Early screening for post-stroke depression, and the effect on functional outcomes, quality of life and mortality: a protocol for a systematic review and meta-analysis

INTRODUCTION

Post-stroke depression (PSD) is a severe complication of cerebrovascular stroke affecting about one-third of stroke survivors. Moreover, PSD is associated with functional recovery and quality of life (QOL) in stroke survivors. Screening for PSD is recommended. There are, however, differences in the literature on the impact of early screening on functional outcomes. In this systematic review, we synthesise the currently available literature regarding the associations between timing and setting of PSD screening and mortality, QOL and functional outcomes in stroke survivors.

METHODS AND ANALYSIS

We will systematically search electronic databases including PubMed, Embase, APA PsycINFO, Web of Science, Scopus and CINAHL from inception to August 2021. Four reviewers will screen the title and abstract and full-text level records identified in the search in a blinded fashion to determine the study eligibility. Any selection disagreements between the reviewers will be resolved by the study investigator. Data extraction of eligible studies will be conducted by two reviewers using a predefined template. We will complete the quality assessment of included articles independently by two reviewers using the Newcastle Ottawa Scale. Eventual discrepancies will be resolved by the principal investigator.

ETHICS AND DISSEMINATION

Due to the nature of the study design, ethical approval is not required. The systematic review and meta-analysis findings will be published and disseminated in a peer-reviewed journal. Our results will also be disseminated through posters and presentations at appropriate scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42021235993.

Internet Access and Usage Among Stroke Survivors and Their Informal Caregivers: Cross-sectional Study

Background

Web-based interventions have shown promise for chronic disease management but have not been widely applied to populations with stroke. Existing barriers may inhibit the adoption of web-based interventions among stroke survivors and necessitate the involvement of informal caregivers. However, limited information is available on internet accessibility and usability among stroke survivors and their caregivers.

Objective

This study aims to investigate internet access and usage in a cohort of stroke survivors and their caregivers.

Methods

A cross-sectional survey was conducted with 375 participants (248 stroke survivors and 127 caregivers). Descriptive statistics were generated using cross-tabulation. Comparisons with categorical data were conducted using the chi-square test, whereas the Mann-Whitney U test was used for comparisons involving ordinal variables.

Results

Overall, 86.1% (323/375) of the participants reported having internet access. Caregivers were more likely than stroke survivors to access the internet (N=375, χ²₁=18.5, P<.001) and used text messaging (n=321, χ²₁=14.7, P<.001). Stroke survivors and caregivers with internet access were younger than stroke survivors and caregivers without internet access. The highest number of participants who reported internet access were non-Hispanic White. Smartphones were the most common devices used to access the internet. Email was the most common type of internet usage reported. Patients who survived for >12 months after a stroke reported higher internet access than those who survived <3 months (P<.001). The number of hours per week spent using the internet was higher for caregivers than for stroke survivors (P<.001).

Conclusions

Future feasibility and acceptability studies should consider the role of the informal caregiver, participant age, race and ethnicity, the use of smartphone apps, email and text correspondence, and the amount of time elapsed since the stroke event in the design and implementation of web-based interventions for populations with stroke.

Abstract 48: An Updated Early Stroke Recognition Tool for the Inclusivity of Spanish-Speakers: RAPIDO

Background and Issues: Hispanics have higher stroke incidence and recurrence and are less likely to know the signs and symptoms of stroke compared to non-Hispanic Whites. Stroke awareness education promotes the recognition of the common signs and symptoms of stroke and subsequent treatment-seeking behaviors resulting in improved outcomes. Acronyms have been created to bring awareness to key stroke sign and symptom indicators; however, there are discrepancies when translating existing acronyms for Spanish-speakers.

Purpose: The purpose of this project was to create and update a stroke awareness acronym for the inclusivity of Spanish-speakers.

Methods: We searched the literature and were unable to identify translations of the commonly publicized FAST or BE-FAST acronyms into recognizable and relatable Spanish words across various dialects. Led by a Spanish-speaking nurse with experience working with stroke patients, our research team identified Spanish words that are used across various dialects for the translation of the BE-FAST acronym (balance, eyes, face, arm, speed, and time). Diverse Spanish-speaking members of our research team incorporated relatable images and reviewed the translated acronym for content and clarity.

Results: We created the acronym RAPIDO for Spanish-speakers. Similar to FAST and BE-FAST, RAPIDO illustrates warning signs and symptoms of stroke and the need to seek treatment quickly.

Conclusions: The creation of the RAPIDO acronym constitutes an important step in providing stroke awareness education to Spanish-speakers. If validated with the broader healthcare professional and lay community, adding the RAPIDO acronym to public stroke educational programs may be warranted.

Abstract TMP103: Meditation for Post-Stroke Depression: A Pilot Randomized Controlled Trial

Background and Purpose: Despite the high prevalence of post-stroke depression (PSD) and negative impact on stroke survivors (SS) and their informal caregivers ([IC]; e.g., unpaid spouses), treatment of PSD is inadequate. Meditation has been associated with improved psychological outcomes. The purpose of this study was to establish the feasibility and acceptability of a 12-week randomized controlled trial (RCT) of a meditation intervention with SS and IC. Secondary objectives were to explore the effects of the intervention on symptoms of PSD, anxiety, and pain.

Methods: Participants were randomized to the 4-week meditation intervention (n=27 SS; n=16 IC) or expressive writing control (n=14 SS; n=7 IC). Descriptive statistics were used to examine feasibility. Acceptability data included interviews and field notes. Repeated measures analysis with linear mixed models were used to test for change over time in Center for Epidemiological Studies Depression Scale (CES-D), State-Trait Anxiety Inventory (STAI), and Brief Pain Inventory (BPI) Severity and Intensity subscale scores.

Results: Of the 92 eligible, 71 (77%) enrolled. Of the 64 randomized (7 were lost-to-follow-up or withdrawn due to ineligibility prior to randomization), 25 (39%) completed the study. The mean intervention attendance rate was 55%. Assessment completion rate for the intervention was 96%. For intervention SS, BPI severity scores were significantly lower at 8 weeks (p=.0270), while non-significant reductions across CES-D and STAI scores were noted. For intervention IC, a significant reduction in STAI-Trait scores was noted at 4 weeks (p=.0262). Data indicated distance was a primary barrier; however, the majority voiced favorable responses to the meditation.

Conclusions: A meditation RCT in the post-stroke environment is acceptable; however, consideration needs to be given to the feasibility of an in-person, multiple-visit intervention. Further efficacy testing is needed in a larger RCT.

Abstract TP398: Comparable Internet Access And Usage Among Stroke Survivors And Informal Caregivers

Background and Purpose: Web-based interventions have shown promise as a cost-effective and convenient delivery platform for supporting chronic disease self-management. However, studies suggest that web-based interventions are not widely available. The purpose of this study was to describe access and usage of web-based electronics in a cohort of stroke survivors (SS) and their informal caregivers (IC).

Methods: A 14-question electronic usage survey was created with input from experts in neurology, nursing and bioinformatics. Two urban sites recruited participants from inpatient stroke centers, outpatient stroke clinics and stroke support groups. Surveys were completed in person or via telephone. Descriptive data were generated to evaluate internet access and usage.

Results: Data were analyzed from 251 SS and 127 IC. Participants were primarily recruited from outpatient settings, with inpatient recruits constituting 15%. Internet users were on average 8 years younger than non-users in both groups. African Americans constituted a third in each group and 1 out of 8 were Hispanic. Compared to an estimate that 89% of American adults have internet access, 200 (81%) SS (p < .001) and 123 (97%) IC (p = .005) had internet access.

Conclusions: In our diverse cohort of relatively young SS, we found IC had more internet access than SS, and more so than the general population. This study is an important step towards delineating the potential use of web-based environments as a platform for interventions to improve stroke risk factor management and stroke recovery.

A Retrospective Study to Identify Novel Factors Associated with Post-stroke Anxiety

BACKGROUND AND PURPOSE

Post-stroke anxiety (PSA) is common and disabling. PSA should be considered as an important outcome in stroke. However, there is a lack of understanding of factors that may be linked to PSA. The purpose of this study was to determine the frequency of PSA and sociodemographic and clinical factors associated with PSA in a cohort of racially and ethnically diverse stroke patients.

METHODS

We conducted a retrospective study of ischemic and hemorrhagic stroke patients seen in a stroke outpatient clinic from August 1, 2017 to June 30, 2018. Patients were eligible if a Generalized Anxiety Disorder 7-Item (GAD-7) instrument was available. GAD-7 scores greater than or equal to 10 indicated the presence of moderate to severe PSA. Multivariable logistic regression was used to identify independent sociodemographic and clinical factors associated with PSA.

RESULTS

Records from 289 stroke patients with a GAD-7 instrument were analyzed. PSA was common (21%; GAD-7 ≥ 10). Fifty-seven percent of females had a GAD-7 greater than or equal to 10 compared to 41% of females who had a GAD-7 less than 10 (P = .03). Multivariable analysis found that self-reported nonmarried status (odds ratio, 3.27; 95% confidence interval, 1.44-7.44), excessive fatigue (odds ratio, 4.46; 95% confidence interval, 1.87-10.63), and depression (odds ratio, 1.24; 95% confidence interval, 1.16-1.33) were independently associated with PSA.

CONCLUSIONS

PSA may occur more frequently in those who report non-married, excessive fatigue, or depression. Trials of PSA interventions should consider the potential impact of social support, depression, and comorbid conditions contributing to post-stroke fatigue, including sleep apnea.

Abstract NS7: Identifying and Understanding Factors Associated with Post-Stroke Anxiety

Background and Purpose: Prior data indicate that the profile of stroke survivors differs from those with anxiety in the absence of other clinical comorbidities. The purpose of this study was to determine the prevalence of PSA and to understand factors associated with PSA in a cohort of stroke survivors.

Methods: A retrospective study (August 2017-May 2018) of electronic health records from 194 ischemic stroke survivors were examined. Stroke survivors were screened for PSA using the Generalized Anxiety Disorder 7-Item (GAD-7; range 0-21) scale two to eight weeks post-hospitalization for stroke during a stroke clinic visit. GAD-7 scores ≥ 10 indicated moderate to severe anxiety. Examples of factors examined included medical, social, stroke severity, excessive daytime sleepiness (Epworth Sleepiness Scale; ESS), and depression (Patient Health Questionnaire-9; PHQ-9). Univariable analysis were used to determine significance (p < 0.05). T-tests were used for continuous variables and the chi-square test for categorical variables.

Results: Twenty-five percent of stroke survivors had a GAD-7 score ≥ 10 and significantly higher mean ESS (11 ± 5) and PHQ-9 (13 ± 6) scores (p<.0001) indicating co-morbid symptoms. Although not significantly different in this sample size, 32% of women had a GAD-7 score ≥ 10 compared to 21% men (p = .05). Stroke survivors with moderate to severe anxiety were more likely to be single, divorced, or widowed (p = 0.0006).

Conclusions: PSA is common after ischemic stroke and may occur more frequently in women and those who are single, divorced, or widowed. Post-stroke trials of psychological interventions should consider PSA and its relationship to excessive daytime sleepiness and depression as well as treatment approaches for concurrent co-morbid conditions.