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.

Barriers and facilitators in providing home-based rehabilitation for stroke survivors with severe disability in the UK: an online focus group study with multidisciplinary rehabilitation teams.

OBJECTIVES: In the UK, over 20% of stroke survivors leave hospital with severe disability. Limited evidence-based clinical guidance is available to support the rehabilitation of these individuals. Our previous research has focused on establishing consensus regarding the core components of home-based rehabilitation for this under investigated group. This study explores the barriers of providing rehabilitation and identifies strategies to overcome them. DESIGN: Three focus group interviews were conducted with n=20. The context coding framework was employed to organise the transcribed data and to facilitate inductive and deductive analysis and synthesis. SETTING: Online, MSTeams, UK. PARTICIPANTS: A purposive sample of 20 National Health Service clinical staff participants, from 3 multidisciplinary teams providing home-based stroke rehabilitation for this population (n=7, 6 and 7). RESULTS: High levels of need were reported across multiple domains for survivors including continence, communication and physical function. Interventions often required multiagency collaboration in order to optimise the available resources and specialist skills. There was lack of clarity regarding who was ultimately responsible for providing components of rehabilitation for stroke survivors with severe disability. Teams provide rehabilitation for this population but are insufficiently commissioned or resourced to fully meet their needs. In-complete and disjointed pathways with resultant healthcare inequalities were commonly reported. Teams used a variety of strategies to overcome these barriers and optimise rehabilitation opportunities. These included upskilling a diverse range of partners to capitalise on the skills and resources across health, social care and voluntary sector boundaries employing multiagency collaboration. Teams established and engaged networks of stakeholders in order to advocate on behalf of stroke survivors. CONCLUSIONS: Collaboration and partnership working is important in the delivery of rehabilitation for stroke survivors with severe disability. Commissioners need to be aware that cross-agency multidisciplinary expertise is required, if rehabilitation opportunities are to be realised and existing health inequalities addressed.

A qualitative study exploring how stroke survivors' expectations and understanding of stroke Early Supported Discharge shaped their experience and engagement with the service.

PURPOSE: To explore how stroke survivors' expectations and understanding of Early Supported Discharge (ESD) helped them make sense of their experiences, and shaped their engagement with the service. METHODS: Data were collected as part of a study of large-scale implementation of stroke ESD: the WISE realist mixed-methods study. Semi-structured interviews were conducted with five purposefully selected stroke survivors from six sites in England implementing stroke ESD (n = 30). Participants were aged 32-88 years (20 males). Interviews were audio recorded, transcribed verbatim and transcripts were analysed using reflexive thematic analysis. RESULTS: Three overarching themes were identified: (1) ESD as a post-stroke recovery tool, (2) desire to recover quickly, (3) psychosocial impact and support. Stroke survivors were uncertain about what to expect when they first entered the service, however, their experience of ESD exceeded their expectations and increased their engagement with the service. Stroke survivors especially valued the goal-oriented approach the team adopted. Rehabilitation at home was perceived as positive and practical, encouraging independence within real-life contexts. Psycho-social support played an important role in the stroke survivors' rehabilitation. CONCLUSIONS: Ensuring stroke survivors are fully informed about ESD and what to expect, optimises engagement with the services, improves experience and could enhance outcomes.IMPLICATIONS FOR REHABILITATIONInforming stroke survivors about what to expect from ESD services could optimise engagement and improve their experience.The provision of personalised and target focussed therapy at home improves stroke survivors' experience and could potentially accelerate recovery.Preparing stroke survivors early for discharge from ESD can reduce anxiety and enhance engagement with the service.

A Qualitative Study Exploring the Lives and Caring Practices of Young Carers of Stroke Survivors.

This study investigated the life transformation of children when a parent returned home from hospital after a stroke. The study explored children's experiences of taking on caring roles in partnership with their well parent and stroke survivors' perceptions of the young carer roles. The study aimed to identify unmet support needs in order to inform future service provision. Semi-structured interviews were conducted separately with stroke survivors (n = 7) (age range 41-60 years, mean 50.6) and their young carers (n = 11) (age range 11-20 years, mean 16). Interviews were audio recorded, transcribed and analysed using reflexive thematic analysis. Three overarching themes were identified: the lives of young carers, impact of stroke, and insulating the family. All the children were providing some level of care. None were in receipt of any formal support. Children moved in and out of the caring role in the absence of an adult, to act as primary carer. Young carers valued the life skills they were gaining but reported gaps in their knowledge and understanding of stroke. The well parent and young carers worked together in a bi-directional partnership to ameliorate the impact of stroke on the family. The study concluded that age appropriate and stroke specific information for children of stroke survivors could enhance agency and optimise positive outcomes of caring.

Supported self-management in community stroke rehabilitation: what is it and how does it work? A protocol for a realist evaluation study.

INTRODUCTION: A growing evidence base demonstrates the effectiveness of supported self-management in stroke for stroke survivors and their families. However, there is significant variation in its implementation in community stroke care and little understanding about how supported self-management works and is delivered across different settings, models used and contexts of community stroke rehabilitation. METHODS AND ANALYSIS: Using a mixed method, realist approach across two phases, this protocol describes a study on community-based supported self-management. The aim is to identify the mechanisms and outcomes of supported self-management in stroke and to understand how supported self-management is implemented in different contexts of community stroke rehabilitation. Phase 1 involves (1) a realist synthesis, (2) a scoping and mapping of current community rehabilitation settings and (3) a Q-methodology study to develop initial programme theories about how community-based supported self-management works, for whom and in what contexts. Phase 2 involves realist informed interviews/focus groups with stroke survivors, community rehabilitation practitioners and team managers from across Scotland to test and refine programme theories and an explanatory model for how supported self-management works across different contexts of community-based stroke rehabilitation. ETHICS AND DISSEMINATION: Ethical approval and R&D approvals have been granted from East of Scotland Research Ethics Committee (REC reference number: 19/ES/0055) and participating NHS boards. An understanding of how, for whom and in what contexts community-based supported self-management works will help to strengthen its delivery in practice. Such an understanding will enable the design of context-specific recommendations for policy and practice that genuinely reflect the challenges in implementing supported self-management in community stroke care. Results will be disseminated to clinical partners working in community stroke rehabilitation, stroke survivors and families and to policymakers and third sector partners involved in the provision of long-term support for people affected by stroke. PROSPERO REGISTRATION NUMBER: CRD42020166208.

Evaluating stroke early supported discharge using cost-consequence analysis.

PURPOSE: To evaluate different stroke early supported discharge (ESD) services in different geographical settings using cost-consequence analysis (CCA), which presents information about costs and outcomes in the form of a balance sheet. ESD is a multidisciplinary service intervention that facilitates discharge from hospital and includes delivery of stroke specialist rehabilitation at home. MATERIALS AND METHODS: Data were collected from six purposively sampled services across the Midlands, East and North of England. All services, rural and urban, provided stroke rehabilitation to patients in their own homes. Cost data included direct and overhead costs of service provision and staff travel. Consequence data included service level adherence to an expert consensus regarding the specification of ESD service provision. RESULTS: We observed that the most rural services had the highest service cost per patient. The main costs associated with running each ESD service were staff costs. In terms of the consequences, there was a positive association between service costs per patient and greater adherence to meeting the evidence-based ESD service specification agreed by an expert panel. CONCLUSIONS: This study found that rural services were associated with higher costs per patient, which in turn were associated with greater adherence to the expert consensus regarding ESD service specification. We suggest additional resources and costs are required in order for rural services to meet evidence-based criteria.Implications for rehabilitationThe main costs of an early supported discharge (ESD) service for stroke survivors were staff costs and these were positively associated with greater levels of rurality.Greater costs were associated with greater adherence to ESD core components, which has been previously found to enhance the effectiveness of ESD service provision.The cost-consequence analysis provides a descriptive summary for decision-makers about the costs of delivering ESD, suggesting additional resources and costs are required in order for rural services to meet evidence-based criteria.

Nominal group technique to establish the core components of home-based rehabilitation for survivors of stroke with severe disability.

In the UK, over 20% of patients leaving hospital after a stroke will be severely disabled. Despite this, limited clinical guidance is available to teams tasked with providing support for this complex population at home. Additionally, many areas across the UK are not commissioned to treat this patient cohort, leaving them with no specialist support on discharge. OBJECTIVES: To establish core components of home-based rehabilitation for survivors of stroke with severe disability, based on expert panel consensus. SETTING: Virtual nominal group technique (vNGT) across the UK. PARTICIPANTS: Experts in the field of stroke rehabilitation (n=14) including researchers, clinicians and those with lived experience. METHODS: Two vNGT were completed using a freely available online platform, Microsoft Teams. The technique's five stages were completed virtually; introduction, silent idea generation, round robin, clarifications and scoring. Statements were analysed for consensus, those achieving consensus underwent content analysis to form rich overarching consensus statements. RESULTS: A combined total of 421 statements achieved positive consensus (>75% in agreement), which formed 11 overarching consensus statements. These outline key components of home-based rehabilitation for survivors of stroke with severe disability including the structure and members of the team, as well as the skills and knowledge required. CONCLUSION: The consensus statements highlight the complexity of managing patients with severe stroke disability following discharge from hospital. This study has the potential to support the provision of services for this patient group, providing a benchmark for commissioners and clinicians as well as setting expectations for stroke survivors and their carers. What remains unknown is how many services currently offer this service to patients with severe disability.

Effect of stroke early supported discharge on length of hospital stay: analysis from a national stroke registry.

OBJECTIVE: The first observational study to investigate the impact of early supported discharge (ESD) on length of hospital stay in real-world conditions. DESIGN: Using historical prospective Sentinel Stroke National Audit Programme (SSNAP) data (1 January 2013-31 December 2016) and multilevel modelling, cross-sectional (2015-2016; 30 791 patients nested within 55 hospitals) and repeated cross-sectional (2013-2014 vs 2015-2016; 49 266 patients nested within 41 hospitals) analyses were undertaken. SETTING: Hospitals were sampled across a large geographical area of England covering the West and East Midlands, the East of England and the North of England. PARTICIPANTS: Stroke patients whose data were entered into the SSNAP database by hospital teams. INTERVENTIONS: Receiving ESD along the patient care pathway. PRIMARY AND SECONDARY OUTCOME MEASURES: Length of hospital stay. RESULTS: When adjusted for important case-mix variables, patients who received ESD on their stroke care pathway spent longer in hospital, compared with those who did not receive ESD. The percentage increase was 15.8% (95% CI 12.3% to 19.4%) for the 2015-2016 cross-sectional analysis and 18.8% (95% CI 13.9% to 24.0%) for the 2013-2014 versus 2015-2016 repeated cross-sectional analysis. On average, the increased length of hospital stay was approximately 1 day. CONCLUSIONS: This study has shown that by comparing ESD and non-ESD patient groups matched for important patient characteristics, receiving ESD resulted in a 1-day increase in length of hospital stay. The large reduction in length of hospital stay overall, since original trials were conducted, may explain why a reduction was not observed. The longer term benefits of accessing ESD need to be investigated further. TRIAL REGISTRATION NUMBER: http://www.isrctn.com/ISRCTN15568163.

Effectiveness of Stroke Early Supported Discharge: Analysis From a National Stroke Registry.

BACKGROUND: Implementation of stroke early supported discharge (ESD) services has been recommended in many countries' clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale. METHODS AND RESULTS: Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016-December 31, 2016), measures of ESD effectiveness were "days to ESD" (number of days from hospital discharge to first ESD contact; n=6222), "rehabilitation intensity" (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%-49%] and increased treatment intensity by 2% [95% CI, 0.3%-4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale. CONCLUSIONS: This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/; Unique identifier: ISRCTN15568163.

Biomarkers of Stroke Recovery: Consensus-Based Core Recommendations from the Stroke Recovery and Rehabilitation Roundtable.

The most difficult clinical questions in stroke rehabilitation are "What is this patient's potential for recovery?" and "What is the best rehabilitation strategy for this person, given her/his clinical profile?" Without answers to these questions, clinicians struggle to make decisions regarding the content and focus of therapy, and researchers design studies that inadvertently mix participants who have a high likelihood of responding with those who do not. Developing and implementing biomarkers that distinguish patient subgroups will help address these issues and unravel the factors important to the recovery process. The goal of the present paper is to provide a consensus statement regarding the current state of the evidence for stroke recovery biomarkers. Biomarkers of motor, somatosensory, cognitive and language domains across the recovery timeline post-stroke are considered; with focus on brain structure and function, and exclusion of blood markers and genetics. We provide evidence for biomarkers that are considered ready to be included in clinical trials, as well as others that are promising but not ready and so represent a developmental priority. We conclude with an example that illustrates the utility of biomarkers in recovery and rehabilitation research, demonstrating how the inclusion of a biomarker may enhance future clinical trials. In this way, we propose a way forward for when and where we can include biomarkers to advance the efficacy of the practice of, and research into, rehabilitation and recovery after stroke.

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.

Biomarkers of stroke recovery: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable.

The most difficult clinical questions in stroke rehabilitation are "What is this patient's potential for recovery?" and "What is the best rehabilitation strategy for this person, given her/his clinical profile?" Without answers to these questions, clinicians struggle to make decisions regarding the content and focus of therapy, and researchers design studies that inadvertently mix participants who have a high likelihood of responding with those who do not. Developing and implementing biomarkers that distinguish patient subgroups will help address these issues and unravel the factors important to the recovery process. The goal of the present paper is to provide a consensus statement regarding the current state of the evidence for stroke recovery biomarkers. Biomarkers of motor, somatosensory, cognitive and language domains across the recovery timeline post-stroke are considered; with focus on brain structure and function, and exclusion of blood markers and genetics. We provide evidence for biomarkers that are considered ready to be included in clinical trials, as well as others that are promising but not ready and so represent a developmental priority. We conclude with an example that illustrates the utility of biomarkers in recovery and rehabilitation research, demonstrating how the inclusion of a biomarker may enhance future clinical trials. In this way, we propose a way forward for when and where we can include biomarkers to advance the efficacy of the practice of, and research into, rehabilitation and recovery after stroke.

Is Stroke Early Supported Discharge still effective in practice? A prospective comparative study.

OBJECTIVE: Randomised controlled trials have shown the benefits of Early Supported Discharge (ESD) of stroke survivors. Our aim was to evaluate whether ESD is still beneficial when operating in the complex context of frontline healthcare provision. DESIGN: We conducted a cohort study with quasi experimental design. A total of 293 stroke survivors (transfer independently or with assistance of one, identified rehabilitation goals) within two naturally formed groups were recruited from two acute stroke units: 'ESD' n=135 and 'Non ESD' n=158 and 84 caregivers. The 'ESD' group accessed either of two ESD services operating in Nottinghamshire, UK. The 'Non ESD' group experienced standard practices for discharge and onward referral. Outcome measures (primary: Barthel Index) were administered at baseline, 6 weeks, 6 months and 12 months. RESULTS: The ESD group had a significantly shorter length of hospital stay (P=0.029) and reported significantly higher levels of satisfaction with services received (P<0.001). Following adjustment for age differences at baseline, participants in the ESD group (n=71) had significantly higher odds (compared to the Non ESD group, n=85) of being in the ⩾90 Barthel Index category at 6 weeks (OR = 1.557, 95% CI 2.579 to 8.733), 6 months (OR = 1.541, 95% CI 2.617 to 8.340) and 12 months (OR 0.837, 95% CI 1.306 to 4.087) respectively in relation to baseline. Carers of patients accessing ESD services showed significant improvement in mental health scores (P<0.01). CONCLUSION: The health benefits of ESD are still evident when evidence based models of these services are implemented in practice.

Implementing evidence-based stroke Early Supported Discharge services: a qualitative study of challenges, facilitators and impact.

OBJECTIVES: To explore the perspectives of healthcare professionals and commissioners working with a stroke Early Supported Discharge service in relation to: (1) the factors that facilitate or impede the implementation of the service, and (2) the impact of the service. DESIGN: Cross-sectional qualitative study using semi-structured interviews. Data were analysed by two researchers using a thematic analysis approach. SETTING: Two Early Supported Discharge services in Nottinghamshire. PARTICIPANTS: Purposive sampling identified 35 key informants including practitioners, managers and commissioners. RESULTS: The identified facilitators to the implementation of evidence-based services were: (1) the adaptability of the intervention to the healthcare context, (2) the role of rehabilitation assistants and (3) cross-service working arrangements. Perceived challenges included: (1) lack of clarity regarding the referral decision making process, (2) delays in securing social care input and (3) lack of appropriate follow-on services in the region. Most respondents perceived the impact of the services to be: (1) reducing in-hospital stay, (2) aiding the seamless transfer of care from hospital to the community and (3) providing intensive stroke specific therapy. Commissioners called for greater evidence of service impact and clarity regarding where it fits into the stroke pathway. CONCLUSIONS: Early Supported Discharge services were perceived as successful in providing home-based, stroke specific rehabilitation. Teams would benefit from capitalising on identified facilitators and developing strategies to address the challenges. The remit and impact of the services should be clear and demonstrable, with teams strengthening links with other health and social care providers.

A qualitative study exploring patients' and carers' experiences of Early Supported Discharge services after stroke.

OBJECTIVE: To investigate patients' and carers' experiences of Early Supported Discharge services and inform future Early Supported Discharge service development and provision. DESIGN AND SUBJECTS: Semi-structured interviews were completed with 27 stroke patients and 15 carers in the Nottinghamshire region who met evidence-based Early Supported Discharge service eligibility criteria. Participants were either receiving Early Supported Discharge or conventional services. SETTING: Community stroke services in Nottinghamshire, UK. RESULTS: A thematic analysis process was applied to identify similarities and differences across datasets. Themes specific to participants receiving Early Supported Discharge services were: the home-based form of rehabilitation; speed of response; intensity and duration of therapy; respite time for the carer; rehabilitation exercises and provision of technical equipment; disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Participants receiving Early Supported Discharge or conventional community services experienced difficulties related to: limited support in dealing with carer strain; lack of education and training of carers; inadequate provision and delivery of stroke-related information; disjointed transition between Early Supported Discharge and ongoing rehabilitation services. CONCLUSIONS: Accelerated hospital discharge and home-based rehabilitation was perceived positively by service users. The study findings highlight the need for Early Supported Discharge teams to address information and support needs of patients and carers and to monitor their impact on carers in addition to patients, using robust outcome measures.

The implementation of evidence-based rehabilitation services for stroke survivors living in the community: the results of a Delphi consensus process.

BACKGROUND: Recovery from stroke requires the provision of specialist rehabilitative care, yet there is a lack of research evidence on optimal methods of delivery and inequitable service provision across countries. Following consensus on Early Supported Discharge, our aim was to define core components of evidence-based community stroke services. DESIGN: We used a modified Delphi approach with a purposive sample of 26 UK-based expert panellists (10 academics, 15 stroke service leads or commissioners, one stroke survivor). Statements based on research literature and policy documents were generated by an independent, mixed academic and service improvement team of nine. In three rounds of consultation panellists indicated their level of agreement with statements. Free text comments were analysed thematically. RESULTS: Consensus of opinion (>70% agreement) was obtained on 76 of 80 statements. Panellists agreed that stroke specialist care tailored to clinical need should be provided following discharge from hospital. Flexible care pathways should be commissioned and provided through strategic and collaborative leadership across health and social care. Teams need to deliver stroke specialist rehabilitation, handing over responsibility to non-specialist services when patient rehabilitation goals have been met. Lack of consensus on whether to provide services exclusively for stroke patients and the need of support for carers highlights areas for further research. CONCLUSIONS: Consensus on the provision of evidence-based community stroke rehabilitation has been reached. Commissioning services with a clearly defined remit, which can deliver tailored care to individual stroke patients, is a challenge that needs further exploration.

From what we know to what we do: translating stroke rehabilitation research into practice.

Despite the recent advances in stroke rehabilitation research, the translation of research evidence into practice remains a challenge. The purpose of this article is to communicate practical experience and describe research methodologies used to promote change and implementation of stroke rehabilitation research in three international settings. In England, the development of an evidence-based consensus document, combined with qualitative and quantitative methods, was used to promote practice change in community-based stroke services. The Canadian research program involved synthesis of evidence, creation of user friendly information, and development of multimodal knowledge transfer strategies to promote change at an individual clinician level. Australian researchers followed a multistep process, involving audit and feedback, identification of barriers, and tailored education to improve implementation of one clinical guideline recommendation. Reducing the evidence-practice gap requires the development of active management strategies. This article highlights the importance of close collaboration between stakeholders - both in terms of the transfer of evidence into clinical practice and for optimizing future Phase IV implementation research endeavours.

The DRESS trial: a feasibility randomized controlled trial of a neuropsychological approach to dressing therapy for stroke inpatients.

OBJECTIVE: To investigate two approaches to treating patients with persistent dressing problems and cognitive difficulties following stroke. DESIGN: Pilot randomized controlled trial. SETTING: Inpatient stroke rehabilitation service. SUBJECTS: Seventy consecutive stroke patients with persistent dressing problems and accompanying cognitive difficulties at two weeks after their stroke. INTERVENTIONS: Patients were randomly allocated to six weeks of either a systematic neuropsychological approach, based on analysis of dressing problems and further cognitive testing, or to the control group who received conventional (functional) dressing practice. Both groups received treatment three times a week in accordance with two separately prepared manuals. MAIN MEASURES: Nottingham Stroke Dressing Assessment (NSDA), Line Cancellation, 10-hole peg transfer test, Object Decision, Gesture Imitation. Patients were assessed at six weeks after randomization by an independent assessor masked to group allocation. RESULTS: Both neuropsychological and functional groups improved performance on the NSDA over the treatment period (31% and 22%, respectively) but there was no significant difference between groups at six weeks. However, the neuropsychological group showed a significantly greater improvement on a line cancellation test of visual neglect (t(62) = 2.1, P < 0.05) and a planned subanalysis for those with right hemisphere damage showed a trend towards better dressing outcome (P = 0.07, one-tailed). CONCLUSIONS: Results demonstrate the potential benefits of a systematic neuropsychological approach to dressing therapy, particularly for patients with right hemisphere damage. This study suggests the need for a phase III study evaluating the efficacy of a systematic neuropsychological approach in treating dressing difficulties, targeting patients with right hemisphere stroke and visuospatial impairments.