Perceptions of Post-Stroke Fatigue among Health Care Practitioners: A Qualitative Interview Study.

Background and Objectives: Post-Stroke Fatigue (PSF) is a complex, multidimensional, debilitating condition that affects almost half of all stroke survivors. This study explored the perceptions of physiatrists, physiotherapists, and occupational therapists about PSF and their experiences in managing patients with PSF in Saudi Arabia. Materials and Methods: Qualitative semi-structured interviews were conducted with participants from three different groups: eight physiotherapists (PTs), eight occupational therapists (OTs), and eight physiatrists (DRs). Using purposive sampling, participants with at least one year of experience in the field of PSF management were invited to take part. The data were analysed using inductive thematic analysis. Results: Twenty-four health care participants (eight PTs, eight OTs, eight DRs) were recruited. Five overarching themes encompassing various subthemes and sub-subthemes were generated: 'knowledge about post-stroke fatigue', 'diagnosing post-stroke fatigue', 'treatment approach', 'lack of awareness about post-stroke fatigue', and 'domains to improve'. The data indicated that participants used various strategies to manage PSF, including dietary changes, sleep hygiene, exercise, and energy conservation. Conclusions: Participants acknowledged that they lacked PSF-related management skills, despite possessing adequate knowledge about the management of stroke. Their openness to participating in activities that would improve their ability to diagnose and manage PSF was particularly striking.

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.

Comparing individual and group intervention for psychological adjustment in people with multiple sclerosis: a feasibility randomised controlled trial.

OBJECTIVE: To modify a published group intervention for adjustment to multiple sclerosis (MS) to suit an individual format, and to assess the feasibility of a randomised controlled trial (RCT) to compare individual and group intervention for people with multiple sclerosis and low mood. DESIGN: Feasibility randomised controlled trial. SETTING: Participants were recruited through healthcare professionals at a hospital-based multiple sclerosis service and the MS Society. SUBJECTS: People with multiple sclerosis. INTERVENTIONS: Adjustment to multiple sclerosis in individual or group delivery format. MAIN MEASURES: Participants completed mood and quality of life assessments at baseline and at four-month follow-up. Measures of feasibility included: recruitment rate, acceptability of randomisation and the intervention (content and format), and whether the intervention could be adapted for individual delivery. Participants were screened for inclusion using the General Health Questionnaire-12 and Hospital Anxiety and Depression Scale, and were randomly allocated to receive either individual or group intervention, with the same content. RESULTS: Twenty-one participants were recruited (mean age 48.5 years, SD 10.5) and were randomly allocated to individual (n=11) or group (n=10) intervention. Of those offered individual treatment, nine (82%) completed all six sessions. Of those allocated to group intervention, two (20%) attended all six sessions and three (30%) attended five sessions. There were no statistically significant differences between the groups on the outcome measures of mood and quality of life. CONCLUSIONS: The intervention could be provided on an individual basis and the trial design was feasible. There were lower attendance rates at group sessions compared to individual sessions.

Psychological interventions for mood and cognition after stroke and transient ischaemic attack: A protocol for an umbrella review.

Background: People who have had a stroke or a Transient Ischaemic Attack (TIA) can experience psychological and/or cognitive difficulties. The body of research for psychological and neuropsychological interventions after stroke is growing, however, published systematic reviews vary in scope and methodology, with different types and severity of strokes included, and at times, diverse conclusions drawn about the effectiveness of the interventions evaluated. In this umbrella review, we aim to systematically summarise the existing systematic reviews evaluating psychological interventions for mood and cognition post-stroke/TIA. Methods: We will conduct this umbrella review according to the JBI Manual for Evidence Synthesis. The following databases will be searched from inception: Cochrane Database of Systematic Reviews, Database of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Epistemonikos. Systematic reviews with or without meta-analysis published until the search date will be included. Reviews including psychological interventions addressing mood and/or cognition outcomes for any stroke type or severity will be screened for eligibility. A narrative synthesis, including content analysis, will be used. Each stage of the review will be processed by two independent reviewers and a third reviewer will be considered to resolve disagreements. The methodological quality of the included reviews will be assessed using AMSTAR 2. Discussion: Existing systematic reviews provide varied evidence on the effectiveness of psychological interventions post-stroke/TIA. This umbrella review aims to summarise knowledge and evidence on different types of psychological and neuropsychological interventions targeting mood and cognition. Findings will highlight important knowledge gaps and help prioritise future research questions. Systematic Review Registration: This protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) on November 15, 2022; PROSPERO CRD42022375947.

Psychological support after stroke: unmet needs and workforce requirements of clinical neuropsychological provision for optimal rehabilitation outcomes.

Stroke services must detect and manage psychological and neuropsychological problems that occur after stroke, such as cognitive and language impairments, post-stroke apathy, post-stroke emotionalism, depression, anxiety, post-traumatic stress disorder, personality changes and suicidality. Stroke neuropsychology plays a key role in the assessment, understanding and management of these consequences of stroke, as well as contributing to complex case management, staff supervision and training. Where these provisions are absent from the stroke rehabilitation pathway, this significantly limits potential rehabilitation outcomes. To manage the scale of psychological and neuropsychological needs post stroke, clinical guidance recommends the use of a matched care system, in which these needs are triaged and matched with corresponding levels of support. Recent workforce guidelines provide clear professional recommendations for psychological staffing skill mix and threshold requirements for clinical oversight and clinical governance assurances.

The association between the Multiple Sclerosis Screening Questionnaire and objective measures of cognition: a systematic literature review and meta-analysis.

INTRODUCTION: The Multiple Sclerosis Screening Questionnaire (MSNQ) is a self-report measure used to assess cognitive difficulties in people with Multiple Sclerosis (PwMS). The aim of this systematic review was to determine the associations between the MSNQ and: objective measures of cognition, measures of mood, and quality of life measures. METHOD: A comprehensive search was done across three databases (PsycINFO, MEDLINE, and CINAHL). A total of 15 studies, including 1992 participants, were selected for final inclusion. Meta-analyses were conducted to determine the pooled effect size of associations. Where data were not available for meta-analyses, a narrative synthesis approach was taken. RESULTS: Significant, but small (r = -0.17), associations were found between the MSNQ and objective measures of cognition. Significant, moderate associations (r = 0.47) were found between the MSNQ and measures of mood. CONCLUSIONS: The small association between the MSNQ and objective measures of cognition shows that the measures do not converge well. However, their divergence may be important to map the broad construct of "cognitive ability" more fully. Limitations include a lack of reporting of non-significant effect sizes in individual studies. Clinical implications include the potential for the MSNQ to be used beyond being solely a proxy measure for objective cognition. Future research should investigate the associations between the informant version of the MSNQ and objective measures.

Lasting impairments following transient ischemic attack and minor stroke: a systematic review protocol.

Introduction: The focus on medical management and secondary prevention following Transient Ischemic Attack (TIA) and minor stroke is well-established. Evidence is emerging that people with TIA and minor stroke can experience lasting impairments as fatigue, depression, anxiety, cognitive impairment, and communication difficulties. These impairments are often underrecognized and inconsistently treated. Research in this area is developing rapidly and an updated systematic review is required to evaluate new evidence as it emerges. This living systematic review aims to describe the prevalence of lasting impairments and how they affect the lives of people with TIA and minor stroke. Furthermore, we will explore whether there are differences in impairments experienced by people with TIA compared to minor stroke. Methods: Systematic searches of PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Libraries will be undertaken. The protocol will follow the Cochrane living systematic review guideline with an update annually. A team of interdisciplinary reviewers will independently screen search results, identify relevant studies based on the defined criteria, conduct quality assessments, and extract data. This systematic review will include quantitative studies on people with TIA and/or minor stroke that report on outcomes in relation to fatigue, cognitive and communication impairments, depression, anxiety, quality of life, return to work/education, or social participation. Where possible, findings will be grouped for TIA and minor stroke and collated according to the time that follow-up occurred (short-term < 3 months, medium-term 3-12 months, and long-term > 12 months). Sub-group analysis on TIA and minor stroke will be performed based on results from the included studies. Data from individual studies will be pooled to perform meta-analysis where possible. Reporting will follow the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) guideline. Perspectives: This living systematic review will collate the latest knowledge on lasting impairments and how these affect the lives of people with TIA and minor stroke. It will seek to guide and support future research on impairments emphasizing distinctions between TIA and minor stroke. Finally, this evidence will allow healthcare professionals to improve follow-up care for people with TIA and minor stroke by supporting them to identify and address lasting impairments.

The COVID-19 pandemic altered the modality, but not the frequency, of formal cognitive assessment.

PURPOSE: We investigated the impacts of the COVID-19 pandemic on the modality of formal cognitive assessments (in-person versus remote assessments). MATERIALS AND METHODS: We created a web-based survey with 34 items and collected data from 114 respondents from a range of health care professions and settings. We established the proportion of cognitive assessments which were face-to-face or via video or telephone conferencing, both pre- and post-March 2020. Further, we asked respondents about the assessment tools used and perceived barriers, challenges, and facilitators for the remote assessment of cognition. In addition, we asked questions specifically about the use of the Oxford Cognitive Screen. RESULTS: We found that the frequency of assessing cognition was stable compared to pre-pandemic levels. Use of telephone and video conferencing cognitive assessments increased by 10% and 18% respectively. Remote assessment increased accessibility to participants and safety but made observing the subtleties of behaviour during test administration difficult. The respondents called for an increase in the availability of standardised, validated, and normed assessments. CONCLUSIONS: We conclude that the pandemic has not been detrimental to the frequency of cognitive assessments. In addition, a shift in clinical practice to include remote cognitive assessments is clear and wider availability of validated and standardised remote assessments is necessary.IMPLICATIONS FOR REHABILITATIONWe caution the wider use and interpretation of remote formal cognitive assessments due to lack of validated, standardised, and normed assessments in a remote format.Clinicians should seek out the latest validation and normative data papers to ensure they are using the most up to date tests and respective cut offs.Support is needed for individuals who lack knowledge/have anxiety over the use of technology in formal cognitive assessments.

Stroke and TIA Survivors' Perceptions of the COVID-19 Vaccine and Influences on Its Uptake: Cross Sectional Survey.

BACKGROUND: People who have experienced a stroke or transient ischaemic attack (TIA) have greater risks of complications from COVID-19. Therefore, vaccine uptake in this vulnerable population is important. To prevent vaccine hesitancy and maximise compliance, we need to better understand individuals' views on the vaccine. OBJECTIVES: We aimed to explore perspectives of the COVID-19 vaccine and influences on its uptake from people who have experienced a stroke or TIA. METHOD: A cross-sectional, electronic survey comprising multiple choice and free text questions. Convenience sampling was used to recruit people who have experienced a stroke/TIA in the UK/Ireland. RESULTS: The survey was completed by 377 stroke/TIA survivors. 87% (328/377) had either received the first vaccine dose or were booked to have it. The vaccine was declined by 2% (7/377) and 3% (11/377) had been offered the vaccine but not yet taken it up. 8% (30/377) had not been offered the vaccine despite being eligible. Some people expressed concerns around the safety of the vaccine (particularly risk of blood clots and stroke) and some were hesitant to have the second vaccine. Societal and personal benefits were motivations for vaccine uptake. There was uncertainty and lack of information about risk of COVID-19 related complications specifically for people who have experienced a stroke or TIA. CONCLUSION: Despite high uptake of the first vaccine, some people with stroke and TIA have legitimate concerns and information needs that should be addressed. Our findings can be used to identify targets for behaviour change to improve vaccine uptake specific to stroke/TIA patients.

A Biopsychosocial Intervention for Stroke Carers (BISC): development and description of the intervention.

OBJECTIVE: Family members of stroke survivors are often not supported for their caring role, with many reporting adjustment difficulties. This paper describes the development and content of a group-based intervention for informal carers of stroke survivors. METHOD: The intervention is based on the theoretical foundation of the biopsychosocial model with the aim to understand and address the physical, psychological and social factors of caring for stroke survivors. Findings from a comprehensive literature review and a qualitative study with carers and stroke professionals were synthesized to guide the intervention development. The Template for Intervention Description and Replication (TIDieR) checklist was used as a framework to describe the intervention. RESULTS: The intervention integrates cognitive-behavioural approaches via the identification of the biopsychosocial (physical, emotional, social) factors that can have an impact on the well-being of carers. It includes education on stroke-specific topics and advice on coping strategies. It consists of six structured two-hour group sessions facilitated in a community setting. It provides information and support on adjusting to the caring role in the first year post-stroke. Intervention materials were designed for addressing carers' specific needs using psychological techniques, such as problem-solving, goal setting and relaxation exercises. CONCLUSION: We have underlined the importance for describing and reporting the process of intervention development for complex interventions in the context of stroke rehabilitation. An intervention addressing the needs of informal stroke carers (Biopsychosocial Intervention for Stroke Carers; BISC) has been developed and described. BISC was further evaluated in a single-centre feasibility randomized controlled trial.

A scoping review of psychoeducational interventions for people after transient ischemic attack and minor stroke.

BACKGROUND: Psychoeducation can provide information and support to cope with the physical and emotional effects of a health condition. This scoping review aimed to identify the evidence regarding psychoeducational interventions for people after a Transient Ischemic Attack (TIA) and minor stroke. METHODS: This review was conducted in accordance with the PRISMA Extension for Scoping Reviews. Three electronic databases (MEDLINE, Embase, PsycINFO) were searched for articles on interventions related to psychoeducational support post-TIA and minor/mild stroke. Search retrieved 3722 articles. Three reviewers independently screened titles, abstracts, full-texts, and extracted data for included studies. Study quality was assessed using the JADAD scale. TIDieR checklist was used to describe interventions. RESULTS: Fifteen RCTs were included. Twelve studies were of high quality (JADAD score ≥2), two were of low quality. A total of 1500 participants were recruited across studies. Definition of TIA and minor stroke was unclear, leading to the exclusion of several studies. Various interventions were included, including education/psychoeducation (n = 4); exercise and lifestyle advice (n = 3); telephone-based education/counseling (n = 3); secondary prevention education (n = 1); motivational interviewing (n = 2); self-management (n = 2). Interventions were inconsistently described, with information missing about who delivered it and tailoring. CONCLUSIONS: Definitions of stroke severity are not adequately reported. There are a variety of interventions including education about a range of stroke-specific topics. Many interventions are not adequately described, thus making it difficult to determine if the aim was to provide information or support post-TIA/minor stroke. There is a need for an in-depth systematic review to develop a clear definition of psychoeducation.

Frequency of anxiety after stroke: An updated systematic review and meta-analysis of observational studies.

BACKGROUND: Anxiety is a common and distressing problem after stroke. AIMS: To undertake an updated systematic review and meta-analysis of observational studies of anxiety after stroke and integrate the findings with those reported previously. SUMMARY OF REVIEW: Multiple databases were searched in May 2018 and 53 new studies were included following dual independent sifting and data extraction. These were combined with 44 previous studies to form a combined data set of 97 studies, comprising 22,262 participants. Studies using interview methods were of higher quality. Rates of anxiety by interview were 18.7% (95% confidence interval 12.5, 24.9%) and 24.2% (95% confidence interval 21.5, 26.9%) by rating scale. Rates of anxiety did not lower meaningfully up to 24 months after stroke. Eight different anxiety subtypes were also reported. CONCLUSIONS: This review confirms that anxiety occurs in around one in four patients (by rating scale) and one in five patients (by interview). More research on anxiety subtypes is needed for an informed understanding of its effects and the development of interventions.

The use of carer perspectives and expert consensus to define key components of a biopsychosocial support intervention for stroke carers.

Objective: To identify the key components of a biopsychosocial support intervention to improve mental wellbeing for informal stroke carers within the first year post-stroke based on the combined perspectives of experts in the field of psychological care after stroke and informal stroke carers themselves. Methods: After reviewing the existing literature a cross-sectional mixed-methods design was adopted comprising 1) focus groups with informal stroke carers about their psychological support needs, and 2) nominal group technique with academic and clinical stroke care experts to reach consensus on intervention priorities. Transcripts were thematically analyzed and combined with the ranked priorities from the nominal group to identify key components for intervention content. Results: Key themes for informal stroke carers were associated with: 1) changes in relationships, roles, and dynamics; 2) emotional impact and acceptance; 3) drawing on inner resources; 4) looking for information, solutions, and explanations; 5) support from others. The expert nominal group placed priority on eight ranked areas: 1) acknowledging "normal" emotions; 2) education about the effects of a stroke; 3) reactions to loss and adjustment; 4) recognizing signs and symptoms of not coping; 5) knowing how and when to access practical and emotional support; 6) strategies for taking care of own health; 7) dealing with difficult emotions; and 8) problem solving skills. Conclusions: Themes from the informal carer focus groups, and ranked priority areas will inform the development of a biopsychosocial support intervention for stroke carers to be tested in a feasibility randomized controlled trial.

Biopsychosocial Intervention for Stroke Carers (BISC): protocol for a feasibility randomised controlled trial (RCT).

INTRODUCTION: Reducing length of hospital stay for stroke survivors often creates a shift in the responsibility of care towards informal carers. Adjustment to the caregiving process is experienced by many carers as overwhelming, complex and demanding and can have a detrimental impact on mental and physical health and well-being. National policy guidelines recommend that carers' needs are considered and addressed; despite this, few interventions have been developed and empirically evaluated. We developed a biopsychosocial intervention in collaboration with carers of stroke survivors. Our aim is to determine whether the intervention can be delivered in a group setting and evaluated using a randomised controlled trial (RCT). METHODS AND ANALYSIS: Feasibility RCT and nested qualitative interview study. We aim to recruit up to 40 stroke carers within 1 year of the stroke onset. Carers are randomised to usual care or usual care plus biopsychosocial intervention. Each intervention group will consist of five stroke carers. The intervention will focus on: psychoeducation, psychological adjustment to stroke, strategies for reducing unwanted negative thoughts and emotions and problem-solving strategies. The main outcome is the feasibility of conducting an RCT. Carer outcomes at 6 months include: anxiety and depression, quality of life and carer strain. Data are also collected from stroke survivors at baseline and 6 months including: level of disability, anxiety and depression, and quality of life. ETHICS AND DISSEMINATION: Favourable ethical opinion was provided by East Midlands - Nottingham2 Research Ethics Committee (14/EMI/1264). This study will determine whether delivery of the biopsychosocial intervention is feasible and acceptable to stroke carers within a group format. It will also determine whether it is feasible to evaluate the effects of the biopsychosocial intervention in an RCT. We will disseminate our findings through peer-reviewed publications and presentations at national and international conferences. TRIAL REGISTRATION NUMBER: ISRCTN15643456; Pre-results.