What matters to program partners when implementing a community-based exercise program for people post-stroke? A theory-based qualitative study and cost analysis.

Background: Community-based exercise programs integrating a healthcare-community partnership (CBEP-HCP) can facilitate lifelong exercise participation for people post-stroke. Understanding the process of implementation from multiple perspectives can inform strategies to promote program sustainability. Purpose: To explore stakeholders' experiences with undertaking first-time implementation of a group, task-oriented CBEP-HCP for people post-stroke and describe associated personnel and travel costs. Methods: We conducted a descriptive qualitative study within a pilot randomized controlled trial. In three cities, trained fitness instructors delivered a 12-week CBEP-HCP targeting balance and mobility limitations to people post-stroke at a recreation centre with support from a healthcare partner. Healthcare and recreation managers and personnel at each site participated in semi-structured interviews or focus groups by telephone post-intervention. Interviews and data analysis were guided by the Consolidated Framework of Implementation Research and Theoretical Domains Framework, for managers and program providers, respectively. We estimated personnel and travel costs associated with implementing the program. Results: Twenty individuals from three sites (4 recreation and 3 healthcare managers, 7 fitness instructors, 3 healthcare partners, and 3 volunteers) participated. We identified two themes related to the decision to partner and implement the program: (1) Program quality and packaging, and cost-benefit comparisons influenced managers' decisions to partner and implement the CBEP-HCP, and (2) Previous experiences and beliefs about program benefits influenced staff decisions to become instructors. We identified two additional themes related to experiences with training and program delivery: (1) Program staff with previous experience and training faced initial role-based challenges that resolved with program delivery, and (2) Organizational capacity to manage program resource requirements influenced managers' decisions to continue the program. Participants identified recommendations related to partnership formation, staff/volunteer selection, training, and delivery of program activities. Costs (in CAD) for first-time program implementation were: healthcare partner ($680); fitness coordinators and instructors ($3,153); and participant transportation (personal vehicle: $283; public transit: $110). Conclusion: During first-time implementation of a CBEP-HCP, healthcare and hospital managers focused on cost, resource requirements, and the added-value of the program, while instructors and healthcare partners focused on their preparedness for the role and their ability to manage individuals with balance and mobility limitations. Trial Registration: ClinicalTrials.gov, NCT03122626. Registered April 17, 2017-Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03122626.

Conditions and strategies influencing sustainability of a community-based exercise program incorporating a healthcare-community partnership for people with balance and mobility limitations in Canada: A collective case study of the Together in Movement and Exercise (TIME™) program.

Background: Community-based exercise programs delivered through healthcare-community partnerships (CBEP-HCPs) are beneficial to individuals with balance and mobility limitations. For the community to benefit, however, these programs must be sustained over time. Purpose: To identify conditions influencing the sustainability of CBEP-HCPs for people with balance and mobility limitations and strategies used to promote sustainability based on experiences of program providers, exercise participants, and caregivers. Methods: Using a qualitative collective case study design, we invited stakeholders (program providers, exercise participants, and caregivers) from sites that had been running a CBEP-HCP for people with balance and mobility limitations for ≥4 years; and sites where the CBEP-HCP had been discontinued, to participate. We used two sustainability models to inform development of interview guides and data analysis. Qualitative data from each site were integrated using a narrative approach to foster deeper understanding of within-organization experiences. Results: Twenty-nine individuals from 4 sustained and 4 discontinued sites in Ontario (n = 6) and British Columbia (n = 2), Canada, participated. Sites with sustained programs were characterized by conditions such as need for the program in the community, presence of secure funding or cost recovery mechanisms, presence of community partners, availability of experienced and motivated instructors, and the capacity to allocate resources towards program marketing and participant recruitment. For sites where programs discontinued, diminished participation and/or enrollment and an inability to allocate sufficient financial, human, and logistical resources towards the program affected program continuity. Participants from discontinued sites also identified issues such as staff with low motivation and limited experience, and presence of competing programs within the organization or the community. Staff associated the absence of referral pathways, insufficient community awareness of the program, and the inability to recover program cost due to poor participation, with program discontinuation. Conclusion: Sustainability of CBEP-HCPs for people with balance and mobility limitations is influenced by conditions that exist during program implementation and delivery, including the need for the program in the community, and organization and community capacity to bear the program's financial and resource requirements. Complex interactions among these factors, in addition to strategies employed by program staff to promote sustainability, influence program sustainability.

How Community-Based Teams Use the Stroke Recovery in Motion Implementation Planner: Longitudinal Qualitative Field Test Study.

BACKGROUND: The Stroke Recovery in Motion Implementation Planner guides teams through the process of planning for the implementation of community-based exercise programs for people with stroke, in alignment with implementation science frameworks. OBJECTIVE: The purpose of this study was to conduct a field test with end users to describe how teams used the Planner in real-world conditions; describe the effects of Planner use on participants' implementation-planning knowledge, attitudes, and activities; and identify factors influencing the use of the Planner. METHODS: This field test study used a longitudinal qualitative design. We recruited teams across Canada who intended to implement a community-based exercise program for people with stroke in the next 6 to 12 months and were willing to use the Planner to guide their work. We completed semistructured interviews at the time of enrollment, monitoring calls every 1 to 2 months, and at the end of the study to learn about implementation-planning work completed and Planner use. The interviews were analyzed using conventional content analysis. Completed Planner steps were plotted onto a timeline for comparison across teams. RESULTS: We enrolled 12 participants (program managers and coordinators, rehabilitation professionals, and fitness professionals) from 5 planning teams. The teams were enrolled in the study between 4 and 14 months, and we conducted 25 interviews. We observed that the teams worked through the planning process in diverse and nonlinear ways, adapted to their context. All teams provided examples of how using the Planner changed their implementation-planning knowledge (eg, knowing the steps), attitudes (eg, valuing community engagement), and activities (eg, hosting stakeholder meetings). We identified team, organizational, and broader contextual factors that hindered and facilitated uptake of the Planner. Participants shared valuable tips from the field to help future teams optimize use of the Planner. CONCLUSIONS: The Stroke Recovery in Motion Implementation Planner is an adaptable resource that may be used in diverse settings to plan community-based exercise programs for people with stroke. These findings may be informative to others who are developing resources to build the capacity of those working in community-based settings to implement new programs and practices. Future work is needed to monitor the use and understand the effect of using the Planner on exercise program implementation and sustainability.

The Stroke Recovery in Motion Implementation Planner: Mixed Methods User Evaluation.

BACKGROUND: As more people are surviving stroke, there is a growing need for services and programs that support the long-term needs of people living with the effects of stroke. Exercise has many benefits; however, most people with stroke do not have access to specialized exercise programs that meet their needs in their communities. To catalyze the implementation of these programs, our team developed the Stroke Recovery in Motion Implementation Planner, an evidence-informed implementation guide for teams planning a community-based exercise program for people with stroke. OBJECTIVE: This study aimed to conduct a user evaluation to elicit user perceptions of the usefulness and acceptability of the Planner to inform revisions. METHODS: This mixed methods study used a concurrent triangulation design. We used purposive sampling to enroll a diverse sample of end users (program managers and coordinators, rehabilitation health partners, and fitness professionals) from three main groups: those who are currently planning a program, those who intend to plan a program in the future, and those who had previously planned a program. Participants reviewed the Planner and completed a questionnaire and interviews to identify positive features, areas of improvement, value, and feasibility. We used descriptive statistics for quantitative data and content analysis for qualitative data. We triangulated the data sources to identify Planner modifications. RESULTS: A total of 39 people participated in this study. Overall, the feedback was positive, highlighting the value of the Planner's comprehensiveness, tools and templates, and real-world examples. The identified areas for improvement included clarifying the need for specific steps, refining navigation, and creating more action-oriented content. Most participants reported an increase in knowledge and confidence after reading the Planner and reported that using the resource would improve their planning approach. CONCLUSIONS: We used a rigorous and user-centered process to develop and evaluate the Planner. End users indicated that it is a valuable resource and identified specific changes for improvement. The Planner was subsequently updated and is now publicly available for community planning teams to use in the planning and delivery of evidence-informed, sustainable, community-based exercise programs for people with stroke.

Community-based exercise programs incorporating healthcare-community partnerships to improve function post-stroke: feasibility of a 2-group randomized controlled trial.

BACKGROUND: Despite the potential for community-based exercise programs supported through healthcare-community partnerships (CBEP-HCPs) to improve function post-stroke, insufficient trial evidence limits widespread program implementation and funding. We evaluated the feasibility and acceptability of a CBEP-HCP compared to a waitlist control group to improve everyday function among people post-stroke. METHODS: We conducted a 3-site, pilot randomized trial with blinded follow-up evaluations at 3, 6, and 10 months. Community-dwelling adults able to walk 10 m were stratified by site and gait speed and randomized (1:1) to a CBEP-HCP or waitlist control group. The CBEP-HCP involved a 1-h, group exercise class, with repetitive and progressive practice of functional balance and mobility tasks, twice a week for 12 weeks. We offered the exercise program to the waitlist group at 10 months. We interviewed 13 participants and 9 caregivers post-intervention and triangulated quantitative and qualitative results. Study outcomes included feasibility of recruitment, interventions, retention, and data collection, and potential effect on everyday function. RESULTS: Thirty-three people with stroke were randomized to the intervention (n = 16) or waitlist group (n = 17). We recruited 1-2 participants/month at each site. Participants preferred being recruited by a familiar healthcare professional. Participants described a 10- or 12-month wait in the control group as too long. The exercise program was implemented per protocol across sites. Five participants (31%) in the intervention group attended fewer than 50% of classes for health reasons. In the intervention and waitlist group, retention was 88% and 82%, respectively, and attendance at 10-month evaluations was 63% and 71%, respectively. Participants described inclement weather, availability of transportation, and long commutes as barriers to attending exercise classes and evaluations. Among participants in the CBEP-HCP who attended ≥ 50% of classes, quantitative and qualitative results suggested an immediate effect of the intervention on balance, balance self-efficacy, lower limb strength, everyday function, and overall health. CONCLUSION: The CBEP-HCP appears feasible and potentially beneficial. Findings will inform protocol revisions to optimize recruitment, and program and evaluation attendance in a future trial. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03122626 . Registered April 21, 2017 - retrospectively registered.

Distance-limited walk tests post-stroke: A systematic review of measurement properties.

BACKGROUND: Improving walking capacity is a key objective of post-stroke rehabilitation. Evidence describing the quality and protocols of standardized tools for assessing walking capacity can facilitate their implementation. OBJECTIVE: To synthesize existing literature describing test protocols and measurement properties of distance-limited walk tests in people post-stroke. METHODS: Electronic database searches were completed in 2017. Records were screened and appraised for quality. RESULTS: Data were extracted from 43 eligible articles. Among the 12 walk tests identified, the 10-metre walk test (10mWT) at a comfortable pace was most commonly evaluated. Sixty-three unique protocols at comfortable and fast paces were identified. Walking pace and walkway surface, but not walkway length, influenced walking speed. Intraclass correlation coefficients for test-retest reliability ranged from 0.80-0.99 across walk tests. Measurement error values ranged from 0.04-0.40 and 0.06 to 0.20 for the 10mWT at comfortable and fast and paces, respectively. Across walk tests, performance was most frequently correlated with measures of strength, balance, and physical activity (r = 0.26-0.8, p < 0.05). CONCLUSIONS: The 10mWT has the most evidence of reliability and validity. Findings indicate that studies that include people with severe walking deficits, in acute and subacute phases of recovery, with improved quality of reporting, are needed.

Healthy young adults implement distinctive avoidance strategies while walking and circumventing virtual human vs. non-human obstacles in a virtual environment.

This study examines how three types of obstacles (cylinder, virtual human and virtual human with footstep sounds) affect circumvention strategies of healthy young adults. Sixteen participants aged 25.2 ±â€¯2.5 years (mean ±â€¯1SD) were tested while walking overground and viewing a virtual room through a helmet mounted display. As participants walked towards a stationary target in the far space, they avoided an obstacle (cylinder or virtual human) approaching either from the right (+40°), left (-40°) or head-on (0°). Obstacle avoidance strategies were characterized using the position and orientation of the head. Repeated mixed model analysis showed smaller minimal distances (p = 0.007) while avoiding virtual humans as compared to cylinders. Footstep sounds added to virtual humans did not modify (p = 0.2) minimal distances compared to when no sound was provided. Onset times of avoidance strategies were similar across conditions (p = 0.06). Results indicate that the nature of the obstacle (human-like vs. non-human object) matters and can modify avoidance strategies. Smaller obstacle clearances in response to virtual humans may reflect the use of a less conservative avoidance strategy, due to a resemblance of obstacles to pedestrians and a recall of strategies used in daily locomotion. The lack of influence of footstep sounds supports the fact that obstacle avoidance primarily relies on visual cues and the principle of 'inverse effectiveness' whereby multisensory neurons' response to multimodal stimuli becomes weaker when the unimodal sensory stimulus (vision) is strong. Present findings should be taken into consideration to optimize the ecological validity of VR-based obstacle avoidance paradigms used in research and rehabilitation.

Effect of visuospatial neglect on spatial navigation and heading after stroke.

BACKGROUND: Visuospatial neglect (VSN) impairs the control of locomotor heading in post-stroke individuals, which may affect their ability to safely avoid moving objects while walking. OBJECTIVE: We aimed to compare VSN+ and VSN- stroke individuals in terms of changes in heading and head orientation in space while avoiding obstacles approaching from different directions and reorienting toward the final target. METHODS: Stroke participants with VSN (VSN+) and without VSN (VSN-) walked in a virtual environment avoiding obstacles that approached contralesionally, head-on or ipsilesionally. Measures of obstacle avoidance (onset-of-heading change, maximum mediolateral deviation) and target alignment (heading and head-rotation errors with respect to target) were compared across groups and obstacle directions. RESULTS: In total, 26 participants with right-hemisphere stroke participated (13 VSN+ and 13 VSN-; 24 males; mean age 60.3 years, range 48 to 72 years). A larger proportion of VSN+ (75%) than VSN- (38%) participants collided with contralesional and head-on obstacles. For VSN- participants, deviating to the same side as the obstacle was a safe strategy to avoid diagonal obstacles and deviating to the opposite-side led to occasional collisions. VSN+ participants deviated ipsilesionally, displaying same-side and opposite-side strategies for ipsilesional and contralesional obstacles, respectively. Overall, VSN+ participants showed greater distances at onset-of-heading change, smaller maximum mediolateral deviation and larger errors in target alignment as compared with VSN- participants. CONCLUSION: The ipsilesional bias arising from VSN influences the modulation of heading in response to obstacles and, along with the adoption of the "riskier" strategies, contribute to the higher number colliders and poor goal-directed walking abilities in stroke survivors with VSN. Future research should focus on developing assessment and training tools for complex locomotor tasks such as obstacle avoidance in this population.

Dual tasking negatively impacts obstacle avoidance abilities in post-stroke individuals with visuospatial neglect: Task complexity matters!

BACKGROUND: Persons with perceptual-attentional deficits due to visuospatial neglect (VSN) after a stroke are at a risk of collisions while walking in the presence of moving obstacles. The attentional burden of performing a dual-task may further compromise their obstacle avoidance performance, putting them at a greater risk of collisions. OBJECTIVE: The objective of this study was to compare the ability of persons with (VSN+) and without VSN (VSN-) to dual task while negotiating moving obstacles. METHODS: Twenty-six stroke survivors (13 VSN+, 13 VSN-) were assessed on their ability to (a) negotiate moving obstacles while walking (locomotor single task); (b) perform a pitch-discrimination task (cognitive single task) and (c) simultaneously perform the walking and cognitive tasks (dual task). We compared the groups on locomotor (collision rates, minimum distance from obstacle and onset of strategies) and cognitive (error rates) outcomes. RESULTS: For both single and dual task walking, VSN+ individuals showed higher collision rates compared to VSN- individuals. Dual tasking caused deterioration of locomotor (more collisions, delayed onset and smaller minimum distances) and cognitive performances (higher error rate) in VSN+ individuals. Contrastingly, VSN- individuals maintained collision rates, increased minimum distance, but showed more cognitive errors, prioritizing their locomotor performance. CONCLUSION: Individuals with VSN demonstrate cognitive-locomotor interference under dual task conditions, which could severely compromise safety when ambulating in community environments and may explain the poor recovery of independent community ambulation in these individuals.

Virtual reality-based navigation task to reveal obstacle avoidance performance in individuals with visuospatial neglect.

Persons with post-stroke visuospatial neglect (VSN) often collide with moving obstacles while walking. It is not well understood whether the collisions occur as a result of attentional-perceptual deficits caused by VSN or due to post-stroke locomotor deficits. We assessed individuals with VSN on a seated, joystick-driven obstacle avoidance task, thus eliminating the influence of locomotion. Twelve participants with VSN were tested on obstacle detection and obstacle avoidance tasks in a virtual environment that included three obstacles approaching head-on or 30 (°) contralesionally/ipsilesionally. Our results indicate that in the detection task, the contralesional and head-on obstacles were detected at closer proximities compared to the ipsilesional obstacle. For the avoidance task collisions were observed only for the contralesional and head-on obstacle approaches. For the contralesional obstacle approach, participants initiated their avoidance strategies at smaller distances from the obstacle and maintained smaller minimum distances from the obstacles. The distance at detection showed a negative association with the distance at the onset of avoidance strategy for all three obstacle approaches. We conclusion the observation of collisions with contralesional and head-on obstacles, in the absence of locomotor burden, provides evidence that attentional-perceptual deficits due to VSN, independent of post-stroke locomotor deficits, alter obstacle avoidance abilities.

Perceptual and locomotor factors affect obstacle avoidance in persons with visuospatial neglect.

BACKGROUND: For safe ambulation in the community, detection and avoidance of static and moving obstacles is necessary. Such abilities may be compromised by the presence of visuospatial neglect (VSN), especially when the obstacles are present in the neglected, i.e. contralesional field. METHODS: Twelve participants with VSN were tested in a virtual environment (VE) for their ability to a) detect moving obstacles (perceptuo-motor task) using a joystick with their non-paretic hand, and b) avoid collision (locomotor task) with moving obstacles while walking in the VE. The responses of the participants to obstacles approaching on the contralesional side and from head-on were compared to those during ipsilesional approaches. RESULTS: Up to 67 percent of participants (8 out of 12) collided with either contralesional or head-on obstacles or both. Delay in detection (perceptuo-motor task) and execution of avoidance strategies, and smaller distances from obstacles (locomotor task) were observed for colliders compared to non-colliders. Participants' performance on the locomotor task was not explained by clinical measures of VSN but slower walkers displayed fewer collisions. CONCLUSION: Persons with VSN are at the risk of colliding with dynamic obstacles approaching from the contralesional side and from head-on. Locomotor-specific assessments of navigational abilities are needed to appreciate the recovery achieved or challenges faced by persons with VSN.