How does context influence arm use after stroke? A qualitative content analysis among rural community-dwelling stroke survivors.

OBJECTIVE: To explore the personal and environmental contextual factors that influence use of affected arm for function among stroke survivors. METHODS: We conducted a qualitative phenomenological study using an interpretivist paradigm among 23 stroke survivors in their late sub-acute and chronic stages and their relatives living in the rural regions of India using maximum variation sampling. Semi-structured interviews were conducted to identify personal and environmental contextual factors relevant to arm use. Their current level of arm use, motor and functional ability were evaluated using Motor Activity Log, AbilHand and Lawton Instrumental Activities of Daily Living scales and the scores were categorized in order to describe and compare the participant's characteristics before analyzing each interview. Differences among the contextual factors of participants with high and low levels of functional arm use and exercise using paretic limb were analyzed using qualitative content analysis. RESULTS: Study participants followed active exercises or passive interventions to improve their arm. Their immediate social environment influenced these decisions. Lack of awareness on how to self-engage or scale down their physical environment to match their abilities demoted active functional task performance. Ability to perceive small gains in arm function helped them sustain their efforts. CONCLUSION: Context influences arm use. Addressing contextual determinants influencing arm use such as facilitating understanding about the need for active functional task engagement; identifying and addressing factors moderating motivation to sustain functional task practice and enriching objects to match their movement abilities can increase arm use and promote upper limb recovery.

Effectiveness of a multifactorial context-enhancing functional therapy to promote functional arm use and recovery of stroke survivors: study protocol for a clinical trial.

INTRODUCTION: After a stroke, 55% of survivors do not regain the ability to completely use their arm in daily life functioning. Currently, evidence-based guidelines recommend functional training for improving the affected hand after stroke. However, promoting an optimal quantity and quality of functional training is influenced by personal and environmental contextual factors. Studies that comprehensively target multiple factors regulating arm use are limited. This study compares the effects of functional training to multifactorial context-enhancing functional training program for improving functional arm use and recovery after stroke. METHODS AND ANALYSIS: This is a protocol for an observer-blinded, two parallel groups, randomised controlled trial. A total of 126 community-dwelling subacute and chronic stroke survivors will be included in the study. A tailor-made multifactorial context-enhancing intervention-incorporating education, environmental enrichment and behaviour change techniques to reinforce functional training will be provided to the experimental group. The functional training group will be provided with functional exercises. The intervention will be delivered for 2 months. The primary outcomes of functional arm use and recovery will be measured using Motor Activity Log, Goal Attainment Scale and Rating of Everyday Arm-use in the Community and Home scale. The secondary outcomes of arm motor impairment and function will be measured using Fugl-Meyer upper limb score, Action Research Arm Test, ABILHAND questionnaire and Stroke Impact Scale. These will be measured at three points in time: before, after 2 months and after 1-month follow-up. The outcome measures will be analysed using one-way analysis of variance and regression analysis will be performed to identify factors limiting optimal task practice. ETHICS AND DISSEMINATION: The study has been approved by the Institutional Ethics Committee of Kasturba Hospital, Manipal, India. Participants will sign a written informed consent prior to participation. The results will be published on completion of the trial and communicated to community-dwelling stroke survivors. TRIAL REGISTRATION NUMBER: CTRI/2017/10/010108.

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. AIMS AND OBJECTIVES: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. METHODS: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. RESULTS: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. CONCLUSION: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.