Long-term psychological outcomes following stroke: the OX-CHRONIC study.

BACKGROUND: Stroke survivors rate longer-term (> 2 years) psychological recovery as their top priority, but data on how frequently psychological consequences occur is lacking. Prevalence of cognitive impairment, depression/anxiety, fatigue, apathy and related psychological outcomes, and whether rates are stable in long-term stroke, is unknown. METHODS: N = 105 long-term stroke survivors (M [SD] age = 72.92 [13.01]; M [SD] acute NIH Stroke Severity Score = 7.39 [6.25]; 59.0% Male; M [SD] years post-stroke = 4.57 [2.12]) were recruited (potential N = 208). Participants completed 3 remote assessments, including a comprehensive set of standardized cognitive neuropsychological tests comprising domains of memory, attention, language, and executive function, and questionnaires on emotional distress, fatigue, apathy and other psychological outcomes. Ninety participants were re-assessed one year later. Stability of outcomes was assessed by Cohen's d effect size estimates and percent Minimal Clinically Important Difference changes between time points. RESULTS: On the Montreal Cognitive Assessment 65.3% scored < 26. On the Oxford Cognitive Screen 45.9% had at least one cognitive impairment. Attention (27.1%) and executive function (40%) were most frequently impaired. 23.5% and 22.5% had elevated depression/anxiety respectively. Fatigue (51.4%) and apathy (40.5%) rates remained high, comparable to estimates in the first-year post-stroke. Attention (d = -0.12; 85.8% stable) and depression (d = 0.09, 77.1% stable) were the most stable outcomes. Following alpha-adjustments, only perceptuomotor abilities (d = 0.69; 40.4% decline) and fatigue (d = -0.33; 45.3% decline) worsened over one year. Cognitive impairment, depression/anxiety, fatigue and apathy all correlated with worse quality of life. CONCLUSION: Nearly half of participants > 2 years post-event exhibited psychological difficulties including domains of cognition, mood, and fatigue, which impact long-term quality of life. Stroke is a chronic condition with highly prevalent psychological needs, which require monitoring and intervention development.

Developing a patient care pathway for emotional support around the point of multiple sclerosis diagnosis: A stakeholder engagement study.

BACKGROUND: Diagnosing multiple sclerosis (MS) can be a lengthy process, which can negatively affect psychological well-being, condition management, and future engagement with health services. Therefore, providing timely and appropriate emotional support may improve adjustment and health outcomes. PURPOSE: To develop a patient care pathway for providing emotional support around the point of diagnosing MS, and to explore potential barriers and facilitators to delivery and implementation. METHODS: Focus groups were conducted with 26 stakeholders, including 16 people living with MS, 5 carers/family members and 5 professionals working with people living with MS (3 MS nurses, 1 psychiatrist, and 1 charity staff member). Discussions were audio-recorded, transcribed verbatim and analyzed using framework analysis. RESULTS: Participants suggested that a patient care pathway should include comprehensive information provision as a part of emotional support at diagnosis, and follow-up sessions with a healthcare professional. Barriers including increasing staff workloads and financial costs to health services were acknowledged, thus participants suggested including peer support workers to deliver additional emotional support. All participants agreed that elements of a care pathway and embedded interventions should be individually tailored, yet provided within a standardized system to ensure accessibility. CONCLUSIONS: A patient care pathway was developed with stakeholders, which included an embedded MS Nurse support intervention supplemented with peer support sessions. Participants suggested that the pathway should be delivered within a standardized system to ensure equity of service provision across the country. PATIENT OR PUBLIC CONTRIBUTION: This research was conceptualized and designed collaboratively with Nottingham Multiple Sclerosis Patient and Public Involvement and Engagement (PPIE) group members. One member is a co-author and was actively involved in every key stage of the research process, including co-design of the pathway and research protocol, data collection (including presenting to participants and moderating group discussions), analysis and write-up. Authors consulted with PPIE members at two meetings (9 and 11 PPIE attendees per meeting) where they gave feedback on the research design, findings and the resulting pathway. People living with MS and carers of people with MS were included in the focus groups as participants.

Psychological interventions for post stroke pain: A systematic review.

Chronic pain is prevalent after stroke and has a significant impact on quality of life. Research demonstrates the efficacy of psychological interventions for mixed chronic pain conditions. This review aimed to assess evidence on the effectiveness of psychological interventions for chronic pain in people with stroke. PubMed, PsychINFO, Embase, and CINAHL were searched from inception to 31 January 2021 at all levels of evidence. Psychological interventions assessing chronic pain in adults following stroke as a primary outcome were included. All outcomes related to pain quality were included (e.g., intensity, frequency, duration). Study quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports and Risk of Bias in N-of-1 Trials (RoBiNT) Scale. Three single n case reports were included. A narrative synthesis was performed, indicating that psychological interventions may reduce chronic post-stroke pain; however, overall quality appraisal of the included studies was poor, owing to the low internal validity found in the single-n case report designs. The limited evidence suggests that psychological interventions may have clinical utility in reducing chronic post-stroke pain. However, owing to the paucity and quality of studies found, the results must be treated with caution. More rigorous research is needed.

How do stroke survivors and their caregivers manage post-stroke fatigue? A qualitative study.

OBJECTIVES: The primary objective was to gain insight into the lived experiences of using day-to-day strategies to manage post-stroke fatigue. DESIGN: Qualitative, descriptive study. SETTING: Community telephone interviews. PARTICIPANTS: A purposive sample of 20 stroke survivors with current, or previous, post-stroke fatigue, and 8 caregivers, who provided informal care or support, were recruited. MAIN MEASURES: Semi-structured telephone interviews were undertaken. Data were analysed using a framework approach. RESULTS: Most participants had found their own ways of coping and their personal strategies included acceptance of having fatigue; 'pacing' (spreading activities out and interspersing with rest periods); keeping a diary in order to plan activities and to identify 'trigger' activities which induced fatigue; talking to (and educating) others about having fatigue; using relaxation; and accessing professional advice and support. The burden placed on caregivers was considerable and they often had to oversee the post-stroke fatigue management strategies used. CONCLUSIONS: Post-stroke fatigue is managed in different ways and there was not one particular strategy that seemed effective for everyone. Most people in our study had had to devise their own ways of coping practically. Given the scale of this problem, which profoundly impacts the lives of both stroke survivors and caregivers, the management of post-stroke fatigue merits more attention and evaluation. However, this must be directly informed by those with lived experience.

A pilot economic evaluation of a feasibility trial for SUpporting wellbeing through PEeR-Befriending (SUPERB) for post-stroke aphasia.

OBJECTIVES: To explore the feasibility of a full economic evaluation of usual care plus peer-befriending versus usual care control, and potential cost-effectiveness of peer-befriending for people with aphasia. To report initial costs, ease of instruments' completion and overall data completeness. DESIGN: Pilot economic evaluation within a feasibility randomised controlled trial. SETTING: Community, England. PARTICIPANTS: People with post-stroke aphasia and low levels of psychological distress. INTERVENTION: All participants received usual care; intervention participants received six peer-befriending visits between randomisation and four months. MAIN MEASURES: Costs were collected on the stroke-adapted Client Service Receipt Inventory (CSRI) for health, social care and personal out-of-pocket expenditure arising from care for participants and carers at 4- and 10-months post-randomisation. Health gains and costs were reported using the General Health Questionnaire-12 and the EQ-5D-5L. Mean (CI) differences for costs and health gains were reported and uncertainty represented using non-parametric bootstrapping and cost-effectiveness acceptability curves. RESULTS: 56 participants were randomised. Mean age was 70.1 (SD 13.4). Most (n = 37, 66%) had mild and many (n = 14; 25%) severe aphasia. There was ≥94% completion of CSRI questions. Peer-befriending was higher in intervention arm (p < 0.01) but there were no significant differences in total costs between trial arms. Peer-befriending visits costed on average £57.24 (including training and supervision costs). The probability of peer-befriending being cost-effective ranged 39% to 66%. CONCLUSIONS: Economic data can be collected from participants with post-stroke aphasia, indicating a full economic evaluation within a definitive trial is feasible. A larger study is needed to demonstrate further cost-effectiveness of peer-befriending.

Supporting wellbeing through peer-befriending (SUPERB) for people with aphasia: A feasibility randomised controlled trial.

OBJECTIVE: To determine the feasibility and acceptability of peer-befriending, for people with aphasia. DESIGN: Single-blind, parallel-group feasibility randomised controlled trial comparing usual care to usual care + peer-befriending. PARTICIPANTS AND SETTING: People with aphasia post-stroke and low levels of distress, recruited from 5 NHS Hospitals and linked community services; their significant others; and 10 befrienders recruited from community. INTERVENTION: Six 1-hour peer-befriending visits over three months. MAIN MEASURES: Feasibility parameters included proportion eligible of those screened; proportion consented; missing data; consent and attrition rates. Acceptability was explored through qualitative interviews. Outcomes for participants and significant others were measured at baseline, 4- and 10-months; for peer-befrienders before training and after one/two cycles of befriending. RESULTS: Of 738 patients identified, 75 were eligible of 89 fully screened (84%), 62 consented (83% of eligible) and 56 randomised. Attrition was 16%. Adherence was high (93% attended ⩾2 sessions, 81% all six). The difference at 10 months on the GHQ-12 was 1.23 points on average lower/better in the intervention arm (95% CI 0.17, -2.63). There was an 88% decrease in the odds of GHQ-12 caseness (95% CI 0.01, 1.01). Fourty-eight significant others and 10 peer-befrienders took part. Procedures and outcome measures were acceptable. Serious adverse events were few (n = 10, none for significant others and peer-befrienders) and unrelated. CONCLUSIONS: SUPERB peer-befriending for people with aphasia post-stroke experiencing low levels of distress was feasible. There was preliminary evidence of benefit in terms of depression. Peer-befriending is a suitable intervention to explore further in a definitive trial.Clinical trial registration-URL: http://www.clinicaltrials.gov Unique identifier: NCT02947776Subject terms: Translational research, mental health, rehabilitation, quality and outcomes, stroke.

'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.

"Now I Am Myself": Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial.

Aphasia, a language disability, can profoundly affect a person's mood and identity. The experiences of participants who received Solution-Focused Brief Therapy, a psychological intervention, were explored in the Solution-Focused brief therapy In poststroke Aphasia (SOFIA) Trial. Thirty participants with chronic aphasia, 14 with severe aphasia, participated in in-depth interviews that were analyzed using framework analysis. Two overarching themes emerged: valued therapy components (exploring hopes, noticing achievements, companionship, sharing feelings, and relationship with therapist) and perceptions of progress (mood, identity, communication, relationships, and independence). Participants were categorized into four groups: (a) "changed," where therapy had a meaningful impact on a person's life; (b) "connected," where therapy was valued primarily for companionship; (c) "complemental," where therapy complemented a participant's upward trajectory; and (d) "discordant," where therapy misaligned with participants' preference for impairment-based language work. This study suggests that it is feasible to adapt a psychological therapy for people with aphasia, who perceive it as valuable.

Assessing Self-Reported Mood in Aphasia Following Stroke: Challenges, Innovations and Future Directions.

Assessment of mood is critical in determining rehabilitation outcomes for stroke and other acquired brain injury, yet a common consequence of such injuries is aphasia, where language is impaired. Consequently, the use of language-based measures in this population is often not possible. Following a critical review of the neuropsychological aspects of self-reported mood, this paper evaluates the problems in reporting mood after stroke due to aphasia, and discusses implications for the design of adapted instruments. The paper then appraises the construction and psychometric properties of existing, adapted self-report measures developed to try and address these problems, and evaluates their utility and limitations. This includes a focus on the recently validated tablet-based Dynamic Visual Analog Mood Scales (D-VAMS), which uses innovative non-verbal assessment methods based on facial expression modulated via a slider control on a touchscreen interface. Currently, most studies evaluating recovery interventions simply omit individuals with aphasia because of the difficulty of assessing mood and quality of life in this population. However, adapted scales such as the D-VAMS appear to represent an important step forward in assessing mood in people with language impairments, with the use of interactive modulated imagery having wider applications for nonverbal communication as well as the quantification of subjective phenomena.

Biopsychosocial intervention for stroke carers (BISC): results of a feasibility randomised controlled trial and nested qualitative interview study.

OBJECTIVE: To determine the feasibility of recruiting to and delivering a biopsychosocial intervention for carers of stroke survivors. DESIGN: Feasibility randomised controlled study with nested qualitative interview study. SETTING: The intervention was delivered in the community in either a group or one-to-one format. SUBJECTS: Carers and stroke survivors within one year of stroke onset. INTERVENTIONS: A carer targeted intervention delivered by a research psychologist in six structured two-hour sessions or usual care control. The intervention combined education about the biological, psychological and social effects of stroke with strategies and techniques focussing on adjustment to stroke and caregiving. Stroke survivors in both groups received baseline and follow-up assessment but no intervention. MAIN OUTCOME: Recruitment rate, study attrition, fidelity of intervention delivery, acceptability and sensitivity of outcome measures used (health related quality of life, anxiety and depression and carer burden six months after randomisation). RESULTS: Of the 257 carers approached, 41 consented. Six withdrew before randomisation. Eighteen participants were randomised to receive the intervention and 17 to usual care. Attendance at sessions was greater when treated one-to-one. Feedback interviews suggested that participants found the intervention acceptable and peer support particularly helpful in normalising their feelings. Thirty participants were assessed at follow-up with improvements from baseline on all health measures for both groups. CONCLUSIONS: Our results suggest that a biopsychosocial intervention was acceptable to carers and can be delivered in group and one-to-one formats. Timing of approach and mode of intervention delivery is critical and requires tailoring to the carers individual needs.

Effects of care assistant communication style on communicative behaviours of residents with dementia: a systematic multiple case study.

OBJECTIVES: To determine whether varying the communication style of care assistants, encouraging them to use direct instructions and allowing more time for residents' responses influenced the communicative behaviour of care home residents living with dementia. DESIGN: This study used a multiple systematic case study design. Participants were video-recorded during morning care routines in three communication conditions: usual communication, direct instructions and pacing (allowing more time for resident responses). Each dyad acted as its own control. SETTING: The study took place in a residential care home in the East Midlands, UK. PARTICIPANTS: Three dyads (person with dementia/care worker) MEASURES: The level of compliance with instructions was measured. Validated measures were used to rate positive communicative behaviour (engagement with care tasks, eye contact and initiation of interaction) and negative communicative behaviour (e.g. shouting and kicking). RESULTS: Care assistants were able to employ direct instructions after brief training. The use of direct instructions was positively correlated with positive communicative behaviour from residents (p < 0.05). The pacing condition was not employed adequately to evaluate effectiveness. Negative communicative behaviour (resistiveness to care) was rare. CONCLUSION: The use of direct instructions by care assistants holds promise for effective communication with people with dementia and warrants further investigation in larger samples and in varied contexts.

Assessment of mood in aphasia following stroke: validation of the Dynamic Visual Analogue Mood Scales (D-VAMS).

OBJECTIVES: To validate a non-verbal self-report measure of mood - the Dynamic Visual Analogue Mood Scales (D-VAMS) - against the Hospital Anxiety and Depression Scale (HADS) and assess its suitability as an outcome measure or screening measure for depressed mood following stroke. DESIGN: Cross-sectional observational cohort study. PARTICIPANTS: Forty-six stroke survivors (24% with aphasia) recruited from online, from stroke clubs and via an NHS rehabilitation service. METHODS: A set of seven bipolar scales was developed enabling users to report mood by modifying facial expression images using a slider. Participants completed a tablet/computer task, reporting their mood on these scales mixed randomly with versions which used only words. The HADS was then completed, followed by a repeat run of the two versions in a different, random sequence. RESULTS: Exploratory factor analysis identified one factor consistent with pleasantness of mood accounting for 80% of the variance. Internal consistency of D-VAMS was high ( α = 0.95), and there was a high correlation between face-only D-VAMS scores and HADS total scores ( r = -0.80, P < 0.001), as well as HADS-D/HADS-A subscale scores ( r = -0.73, P < 0.001; r = -0.71, P < 0.001). D-VAMS showed good sensitivity and specificity against HADS, with means of 85%/77% (sensitivity/specificity) against the HADS-D and 80%/77% against the HADS-A across nine cut-offs. CONCLUSION: D-VAMS is a valid and reliable measure likely suitable for assessment of depressed mood in aphasia following stroke. Though D-VAMS performed well as a screening measure in this study sample, further study is needed in the acute stage post-stroke.

Examining the relationship between fatigue and cognition after stroke: A systematic review.

Many stroke survivors experience fatigue, which is associated with a variety of factors including cognitive impairment. A few studies have examined the relationship between fatigue and cognition and have obtained conflicting results. The aim of the current study was to review the literature on the relationship between fatigue and cognition post-stroke. The following databases were searched: EMBASE (1980-February, 2014), PsycInfo (1806-February, 2014), CINAHL (1937-February, 2014), MEDLINE (1946-February, 2014), Ethos (1600-February, 2014) and DART (1999-February, 2014). Reference lists of relevant papers were screened and the citation indices of the included papers were searched using Web of Science. Studies were considered if they were on adult stroke patients and assessed the following: fatigue with quantitative measurements (≥ 3 response categories), cognition using objective measurements, and the relationship between fatigue and cognition. Overall, 413 papers were identified, of which 11 were included. Four studies found significant correlations between fatigue and memory, attention, speed of information processing and reading speed (r = -.36 to .46) whereas seven studies did not. Most studies had limitations; quality scores ranged from 9 to 14 on the Critical Appraisal Skills Programme Checklists. There was insufficient evidence to support or refute a relationship between fatigue and cognition post-stroke. More robust studies are needed.

The facilitators of communication with people with dementia in a care setting: an interview study with healthcare workers.

OBJECTIVES: to describe the views of healthcare workers on the facilitators of communication with people with dementia in a care setting. DESIGN: thematic analysis of semi-structured interviews. SETTING: all participants were interviewed in their place of work. PARTICIPANTS: sixteen healthcare workers whose daily work involves interacting with people with dementia. RESULTS: four overarching categories of themes were identified from the interviews that impact on communication: the attributes of a care worker, communication strategies used, organisational factors and the physical characteristics of the care environment. CONCLUSION: many strategies used by healthcare workers to facilitate communication have not yet been studied in the research literature. Participants' views on training should be incorporated into future dementia training programmes.

Cross-Cultural Validation and Psychometric Properties of the Arabic Brief Religious Coping Scale (A-BRCS).

The aim of this study was to translate and validate the psychometric properties of an Arabic Brief Religious Coping Scale. A descriptive correlational design was used to conduct the study among participants of 403 Iraqi secondary school students. The A-BRCS and both the subscales, positive and negative, had Cronbach's alphas of .70, .86 and .82, respectively. All inter-item and item-to-total correlations for each subscale were above the recommended criteria of .30. Factor loadings of the positive subscale using oblique (oblimin) and orthogonal (varimax) rotations ranged from .72 to .86 and from .71 to .86, respectively. Factor loadings of the negative subscale using oblimin and varimax rotations ranged from .64 to .83 and from .63 to .83, respectively. The A-BRCS was found to be a valid and reliable instrument to measure religious coping among Iraqi secondary school students.

Cost analysis of the Communication and Low Mood (CALM) randomised trial of behavioural therapy for stroke patients with aphasia.

OBJECTIVE: To evaluate the cost effectiveness of a behavioural therapy intervention shown to be clinically effective in comparison with usual care for stroke patients with aphasia. DESIGN: Randomised controlled trial with comparison of costs and calculation of incremental cost effectiveness ratio. SETTING: Community. PARTICIPANTS: Participants identified as having low mood on either the Visual Analog Mood Scale sad item (≥50) or Stroke Aphasic Depression Questionnaire Hospital version 21 (SADQH21) (≥6) were recruited. INTERVENTIONS: Participants were randomly allocated to behavioural therapy or usual care using internet-based randomisation generated in advance of the study by a clinical trials unit. MAIN MEASURES: Outcomes were assessed at six months after randomisation, blind to group allocation. The costs were assessed from a service use questionnaire. Effectiveness was defined as the change in SADQH21 scores and a cost-effectiveness analysis was performed comparing the behavioural group with the usual care control group. The cost analysis was undertaken from the perspective of the UK NHS and Social Services. RESULTS: The greatest difference was in home help costs where there was a saving of £56.20 in the intervention group compared to an increase of £61.40 in the control group. At six months the SADQH21 score for the intervention group was 17.3 compared to the control group value of 20.4. This resulted in a mean increase of 0.7 in the control group, compared to a mean significant different decrease of 6 in the intervention group (P = 0.003). The Incremental Cost-Effectiveness Ratio indicated that the cost per point reduction on the SADQH21 was £263. CONCLUSION: Overall the behavioural therapy was found to improve mood and resulted in some encouraging savings in resource utilisation over the six months follow-up.

Go to the hospital or stay at home? A qualitative study of expected hospital decision making among older African Americans with advanced heart failure.

To address the need for more information concerning hospital decision making, we conducted in-depth interviews among African Americans with heart failure and their family caregivers (n = 11 dyads). Using a case scenario, we asked participants about their anticipated hospitalization decisions. Most patients indicated that they would seek care to avoid further deterioration or death from their worsening condition. Many family caregivers anticipated having an active influence on hospitalization decisions. Findings suggest that social workers should encourage the development of adequate home-based services, recognize diverse communication styles, and use this information to facilitate medical decision making by these patients and their caregivers.

Orthotist involvement in early gait rehabilitation after stroke: A cross-sectional survey of orthotists in the United Kingdom.

BACKGROUND: The role of the orthotist in early gait rehabilitation after stroke in the United Kingdom is currently poorly understood. OBJECTIVES: The objective of this study was to capture current opinion and practice of orthotists on their role in early stroke gait rehabilitation in the United Kingdom. METHODS: An anonymous web-based cross-sectional survey was developed and distributed to Health and Care Professions Council-registered orthotists by the mailing list of the British Association of Prosthetists and Orthotists professional body in the United Kingdom. Survey items were multiple-choice, Likert scale, or open-ended questions to explore the experiences and opinions of orthotists in early poststroke gait rehabilitation. RESULTS: Responses were received from 56 participants. Orthotists reported having regular contact with patients who had a stroke within their usual clinical caseload. Multidisciplinary care was not typical with 46% respondents "rarely" seeing patients who had a stroke in joint assessment with another clinician. Confidence in managing lower limb gait difficulties was high, with 89% of orthotists feeling able to recommend a lower limb orthotic treatment. Ninety-eight percent (n = 55) of respondents agreed that orthotic assessment should be an essential element of gait re-education after stroke; however, orthotists reported limited involvement within early stroke rehabilitation. CONCLUSION: UK orthotists surveyed in this study report that orthotic treatment is an important aspect of early gait rehabilitation after stroke. Respondents report barriers to multidisciplinary working, which may affect outcomes in this patient group.

Developing consensus-based clinical competencies to guide stroke clinicians in the implementation of psychological care in aphasia rehabilitation.

Background People with aphasia experience depression and anxiety associated with negative outcomes across a range of time post-stroke. Stroke clinicians are well-positioned to facilitate low-intensity psychotherapeutic interventions after aphasia (e.g. mood screening, behavioural activation, problem-solving therapy, relaxation therapy); however, they self-report a lack of knowledge, skills and confidence to do so. The Theoretical Domains Framework (TDF) provides a lens through which to view and target clinician behaviours and training needs in this area of practice. The aim of this study was to develop and gain consensus on items for a rating scale of clinical competencies in facilitating individual-based, low-intensity psychotherapeutic interventions for people with aphasia. Methods An e-Delphi methodology using focus groups and survey rounds was used to gain consensus on clinical competencies considered important. Results Eight stroke clinicians (speech pathologists and psychologists), two people with aphasia and three family members participated in one of four focus groups. Four themes were derived from the data: (1) Communication support, (2) Assessment and therapy structure, (3) Interpersonal skills, and (4) Needs of the significant other (family or friend). Themes informed an initial list of 23 self-rated and observer-rated competency items. Following two rounds of e-Delphi surveys, 11 stroke clinicians (six speech pathologists and five psychologists) reached consensus (80-100%) for 19 competencies. Conclusions The Psychological Care in Aphasia Rehabilitation Competency scale offers a preliminary list of items to guide and train clinicians to implement low-intensity psychotherapeutic interventions for people with aphasia.

Investigating the Implementation of Community-Based Stroke Telerehabilitation in England; A Realist Synthesis Study Protocol.

Telerehabilitation (TR) shows promise as a method of remote service delivery, yet there is little guidance to inform implementation in the context of the National Health Service (NHS) in England. This paper presents the protocol for a realist synthesis study aiming to investigate how TR can be implemented to support the provision of high-quality, equitable community-based stroke rehabilitation, and under what conditions. Using a realist approach, we will synthesise information from (1) an evidence review, (2) qualitative interviews with clinicians (n ≤ 30), and patient-family carer dyads (n ≤ 60) from three purposively selected community stroke rehabilitation services in England. Working groups including rehabilitation professionals, service-users and policy-makers will co-develop actionable recommendations. Insights from the review and the interviews will be synthesised to test and refine programme theories that explain how TR works and for whom in clinical practice, and draw key messages for service implementation. This protocol highlights the need to improve our understanding of TR implementation in the context of multidisciplinary, community-based stroke service provision. We suggest the use of a realist methodology and co-production to inform evidence-based recommendations that consider the needs and priorities of clinicians and people affected by stroke.