Theoretical and practical considerations to inform the self-management of physical stroke rehabilitation

Aim: This study aimed to develop a new stroke exercise manual to promote self-managed rehabilitation with the support of available ‎information and communication technology and a new theoretical foundation for ‎functional ‎physical stroke recovery in the community.‎ ‎ Background: Stroke is the biggest single cause of major disability worldwide and is the single largest cause of adult disability in England. Functional physical recovery continues over a long period of time after stroke, thus, continuous support is essential. Limited resources make it difficult to provide long-term face-to-face services. Hence, there is a need to develop alternative approaches to enable stroke survivors to self-manage their own exercises over the long-term; such as self-managed exercise manual and the use of available information and communication technologies (ICTs). Although the use of physical exercises, self-management concepts and ICTs are shown to be promising for stroke rehabilitation, little was known about integrating them along with educational and technology related theories to empower stroke survivors to manage their own exercise for their continued physical functional rehabilitation in the community. Methodology & Methods: This is a mixed methods research consisting of 3 parts. The overall design of this research was based on the user-centred design principle and the model of evidence-based clinical decisions. The first part is the foundation phase in which literature related to physical functional stroke rehabilitation, stroke self-management and the use of ICTs for stroke rehabilitation were reviewed. The second part is phase 1 in which semi-structured interviews were conducted with community-dwelling stroke survivors with physical disabilities, their carers, and physiotherapists and occupational therapists who were purposively recruited to identify the components required to develop the manual. It was verified and refined with the interviewees using surveys. The third part is phase 2 in which a survey was conducted with another group of therapists to evaluate the acceptability, suitability, feasibility and safety of using the manual from a professional perspective. Content thematic analysis was used to analyse qualitative data collected from the interviews and questionnaires. Descriptive statistical analysis was used to analyse quantitative data collected in the surveys. A mixed methods matrix was used to integrate and interpret both qualitative and quantitative data. Findings: In foundation phase, seven types of exercise were identified from the current evidence for physical functional stroke rehabilitation which were included into the design of the new manual in this research project. In phase 1, eight themes were generated from the interviews with 18 stroke survivors and 8 of their carers. Six themes were identified from 7 therapists. Findings were used to support a new theoretical foundation called the “gear model” which consists of self-efficacy theory, adult learning theory (andragogy), self-regulated learning, motor learning theory and technology acceptance model to suggest an integrated conceptual support to the design of the manual. A refinement study was conducted with 15 interviewed stroke survivors and 6 therapists. The results indicate that the manual is understandable and usable. It was evaluated with another group of 7 therapists in phase 2. The results of the evaluation show that the manual is considered to be acceptable, suitable, feasible and safe to be used from a professional perspective. A conceptual framework was established using the themes and selected theories to propose a way to use the manual in clinical practice. Conclusion: A new stroke exercise manual has been developed to suggest an alternative approach for stroke survivors to manage their own exercise for rehabilitation. Both theoretical and practical considerations were involved in the development process of the manual. Further research is required to examine the impact and value of the manual for stroke rehabilitation. This research has contributed the following new knowledge to the field of community stroke rehabilitation: 1. Integrated theoretical foundation for the self-management of stroke exercises with the support of using available ICTs called “Gear Model” 2. Knowledge about using ICTs that stroke survivors have and wish to use for support 3. Process and components required to individualise a stroke exercise manual with the support of available ICTs to promote self-managed physical functional rehabilitation in the community