Nudging stroke survivors toward better self-management: a commentary.

BackgroundExergames are increasingly being used among survivors of stroke with chronic upper extremity (UE) sequelae to continue exercising at home after discharge and maintain activity levels. The use of virtual reality exergames combined with a telerehabilitation app (VirTele) may be an interesting alternative to rehabilitate the UE sequelae in survivors of chronic stroke while allowing for ongoing monitoring with a clinician.ObjectiveThis study aimed to determine the feasibility of using VirTele in survivors of chronic stroke at home and explore the impact of VirTele on UE motor function, quantity and quality of use, quality of life, and motivation in survivors of chronic stroke compared with conventional therapy.MethodsThis study was a 2-arm feasibility clinical trial. Eligible participants were randomly allocated to an experimental group (receiving VirTele for 8 weeks) or a control group (receiving conventional therapy for 8 weeks). Feasibility was measured from the exergame and intervention logs completed by the clinician. Outcome measurements included the Fugl-Meyer Assessment-UE, Motor Activity Log-30, Stroke Impact Scale-16, and Treatment Self-Regulation Questionnaire-15, which were administered to both groups at four time points: time point 1 (T1; before starting the intervention), time point 2 (after the intervention), time point 3 (1 month after the intervention), and time point 4 (T4; 2 months after the intervention).ResultsA total of 11 survivors of stroke were randomized and allocated to an experimental or a control group. At the onset of the COVID-19 pandemic, participants pursued the allocated treatment for 3 months instead of 8 weeks. VirTele intervention dose was captured in terms of time spent on exergames, frequency of use of exergames, total number of successful repetitions, and frequency of videoconference sessions. Technical issues included the loss of passwords, internet issues, updates of the system, and problems with the avatar. Overall, most survivors of stroke found the technology easy to use and useful, except for 9% (1/11) of participants. For the Fugl-Meyer Assessment-UE and Motor Activity Log-30, both groups exhibited an improvement in >50% of the participants, which was maintained over time (from time point 3 to T4). Regarding Stroke Impact Scale-16 scores, the control group reported improvement in activities of daily life (3/5, 60%), hand function (5/5, 100%), and mobility (2/5, 40%), whereas the experimental group reported varied and inconclusive results (from T1 to T4). For the Treatment Self-Regulation Questionnaire-15, 75% (3/4) of the experimental group demonstrated an increase in the autonomous motivation score (from T1 to time point 2), whereas, in the control group, this improvement was observed in only 9% (1/11) of participants.ConclusionsThe VirTele intervention constitutes another therapeutic alternative, in addition to conventional therapy, to deliver an intense personalized rehabilitation program for survivors of chronic stroke with UE sequelae.International Registered Report Identifier (IRRID)RR2-10.2196/14629

Influence of Psychological Disorders on the Functional Outcomes in the Survivors of Ischemic Stroke

The design and usability evaluation of a monitoring and feedback system for stroke survivors

Continued smoking after stroke is associated with a high risk of stroke recurrence and other cardiovascular disease. We sought to comprehensively understand the epidemiology of smoking cessation in stroke survivors in the United States. Furthermore, we compared smoking cessation in stroke and cancer survivors because cancer is another smoking-related condition in which smoking cessation is prioritized. We performed a cross-sectional analysis of data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System, an annual, nationally representative health survey. Using pooled data from 2013 to 2019, we identified stroke and cancer survivors with a history of smoking. We used survey procedures to estimate frequencies and summarize quit ratios with attention to demographic and geographic (state-wise and rural-urban) factors for stroke survivors. The quit ratio is conventionally defined as the proportion of ever smokers who have quit. Then, we used multivariable logistic regression to compare quit ratios in stroke and cancer survivors while adjusting for demographics and smoking-related comorbidities. Among 4 434 604 Americans with a history of stroke and smoking, the median age was 68 years (interquartile range, 59-76), and 45.4% were women. The overall quit ratio was 60.8% (95% CI, 60.1%-61.6%). Quit ratios varied by age group, sex, race and ethnicity, and several geographic factors. There was marked geographic variation in quit ratios, ranging from 48.3% in Kentucky to 71.5% in California. Furthermore, compared with cancer survivors, stroke survivors were less likely to have quit smoking (odds ratio, 0.72 [95% CI, 0.67-0.79]) after accounting for differences in demographics and smoking-related comorbidities. There were considerable demographic and geographic disparities in smoking quit ratios in stroke survivors, who were less likely to have quit smoking than cancer survivors. A targeted initiative is needed to improve smoking cessation for stroke survivors.

Background: Physical activity is an effective modifiable behavior for preventing recurrent strokes. This study aims to determine the adherence to physical activity recommendations among stroke survivors in the United States. We further compared our findings with the adherence observed among myocardial infarction (MI) survivors. Methods: We utilized data from the 2011-2019 Behavioral Risk Factor Surveillance System, a nationally representative survey. To establish benchmarks, we referenced the physical activity recommendations outlined in 2011, 2014, and 2021 American Heart Association stroke prevention guidelines. Adherence to recommendations was determined by the respondents' self-reported intensity, duration, and frequency of physical activity. Multivariate logistic regression was used to compare adherence in stroke survivors, MI survivors, and healthy adults. Results: Among 48,222 stroke survivors in the United States, the overall adherence rates to 2011, 2014, and 2021 physical activity guidelines were 75.4%, 40.2%, and 69.2%. For independently mobile stroke survivors, the adherence rates increased to 78.1%, 42.1%, and 69.9%. When 2021 recommendations were used as a benchmark, older (≥65) stroke survivors were more likely to adhere to recommendations than younger survivors (71.9%vs.62.3%; p<0.0001). However, when the benchmark was changed to the 2011 and 2014 guidelines, which recommended longer exercise durations, the difference between younger and older stroke survivors dissipated. After adjusting for sociodemographic factors and comorbidities, non-Hispanic Black survivors were less likely to adhere to recommendations (aOR,0.81[95%CI,0.7–0.94]), whereas older and higher educated stroke survivors were more likely to adhere to recommendations. Geographically, stroke belt and non-rural residents were less likely to adhere to recommendations [(63.5%vs.67.9%;p<0.0001), (53.8%vs.58.7%;p<0.0001)]. Stroke and MI survivors were less likely to adhere to the latest recommendations than healthy adults (aOR,0.74[95%CI,0.69-0.8], (aOR,0.24[95%CI,0.22-0.26])). Conclusion: A substantial number of stroke survivors do not meet physical activity recommendations. Tailored interventions should be designed for at-risk populations, e.g., non-Hispanic Black survivors and lower educated stroke survivors.

Physical activity is an effective modifiable behavior for preventing recurrent strokes. This study aims to determine the adherence to physical activity recommendations among stroke survivors in the United States. We further compared our findings with the adherence observed among myocardial infarction (MI) survivors and healthy adults, each assessed against distinct physical activity guidelines specific to their respective populations. We utilized data from the 2011 to 2019 Behavioral Risk Factor Surveillance System, a nationally representative survey. To establish benchmarks for stroke survivors, we referenced 3 different physical activity recommendations outlined in 2011, 2014, and 2021 American Heart Association stroke prevention guidelines. Similarly, for MI survivors and healthy adults, we used the 2011 guidelines for secondary prevention of coronary vascular diseases and the 2020 World Health Organization physical activity guidelines, respectively. Adherence to recommendations was determined by the respondents' self-reported intensity, duration, and frequency of physical activity. Multivariate logistic regression compared adherence in stroke survivors, MI survivors, and healthy adults. Among 48 222 stroke survivors in the United States, the overall adherence rates to 2011, 2014, and 2021 physical activity guidelines were 75.4%, 40.2%, and 69.2%. For independently mobile stroke survivors, the adherence rates increased to 78.1%, 42.1%, and 69.9%. Among MI survivors and healthy adults, the adherence rates were 42.7% and 72%. When 2021 recommendations were used as a benchmark, older (aged ≥65 years) stroke survivors were more likely to adhere to recommendations than younger survivors (71.9% versus 62.3%; P<0.0001). After adjusting for sociodemographic factors and comorbidities, non-Hispanic Black survivors were less likely to adhere to recommendations (adjusted odds ratio, 0.81 [95% CI, 0.7-0.94]), whereas older and higher educated stroke survivors were more likely to adhere to recommendations. Geographically, stroke belt and nonrural residents were less likely to adhere to recommendations ([63.5% versus 67.9%; P<0.0001]; [53.8% versus 58.7%; P<0.0001]). Stroke and MI survivors were less likely to adhere to the latest recommendations than healthy adults (adjusted odds ratio, 0.74 [95% CI, 0.69-0.8]; (adjusted odds ratio, 0.24 [95% CI, 0.22-0.26]). A substantial number of stroke survivors do not meet physical activity recommendations. Tailored interventions should be designed for at-risk populations, for example, non-Hispanic Black survivors and lower educated stroke survivors.

BackgroundThe South African health system has policies and strategies to ensure effective rehabilitation and reintegration of individuals who have survived a cerebrovascular accident into their respective communities. However, implementation of such guidelines remains an issue.AimThis study sought to explore cerebrovascular accident (CVA) survivors’ experiences of community integration.SettingThe study was located in a peri-urban community within the KwaZulu-Natal Province, South Africa.MethodsAn explorative qualitative study with eight purposively selected CVA survivors was conducted via semi-structured individual interviews. Data were audio-recorded and manually transcribed prior to thematic analysis. Trustworthiness of the study was maintained by strategies such as analyst triangulation, an audit trail and use of thick descriptions. Ethical principles of autonomy, informed consent, confidentiality and privacy were also maintained in the study.ResultsSix themes emerged that highlighted (1) loss of autonomy and roles, (2) barriers to community reintegration, (3) social isolation of participants, (4) finding internal strength, (5) enablers of community reintegration including the positive influence of support and the benefits derived from rehabilitation and (6) recommendations for rehabilitation.ConclusionThe study revealed both positive and negative influences that impact CVA survivors’ ability to effectively reintegrate into their respective communities following a CVA. Recommendations include the need for education and awareness around access to rehabilitation services for CVA survivors, advice on how to improve CVA survivors’ ability to mobilise in the community and make environmental adaption to facilitate universal access, provision of home programmes and caregiver training for continuity of care and for inclusion of home-based rehabilitation into current models of care.

The incidence of stroke in children is low, and pediatric stroke rehabilitation services are less developed than adult ones. Survivors of pediatric stroke have a long poststroke life expectancy and therefore have the potential to experience impairments from their stroke for many years. However, there are relatively few studies characterizing these impairments and what factors facilitate or counteract recovery. This study aims to characterize the main barriers to and facilitators of recovery from pediatric stroke. A secondary aim was to explore whether these factors last into adulthood, whether they change, or if new factors impacting recovery emerge in adulthood. We performed a qualitative thematic analysis based on posts from a population of participants from a UK-based online stroke community, active between 2004 and 2011. The analysis focused on users who talked about their experiences with pediatric stroke, as identified by a previous study. The posts were read by 3 authors, and factors influencing recovery from pediatric stroke were mapped into 4 areas: medical, physical, emotional, and social. Factors influencing recovery were divided into short-term and long-term factors. There were 425 posts relating to 52 survivors of pediatric stroke. Some survivors of stroke posted for themselves, while others were talked about by a third party (mostly parents; 31/35, 89% mothers). In total, 79% (41/52) of survivors of stroke were aged ≤18 years and 21% (11/52) were aged >18 years at the time of posting. Medical factors included comorbidities as a barrier to recovery. Medical interventions, such as speech and language therapy and physiotherapy, were also deemed useful. Exercise, particularly swimming, was deemed a facilitator. Among physical factors, fatigue and chronic pain could persist decades after a stroke, with both reported as a barrier to feeling fully recovered. Tiredness could worsen existing stroke-related impairments. Other long-standing impairments were memory loss, confusion, and dizziness. Among emotional factors, fear and uncertainty were short-term barriers, while positivity was a major facilitator in both short- and long-term recovery. Anxiety, grief, and behavioral problems hindered recovery. The social barriers were loneliness, exclusion, and hidden disabilities not being acknowledged by third parties. A good support network and third-party support facilitated recovery. Educational services were important in reintegrating survivors into society. Participants reported that worrying about losing financial support, such as disability allowances, and difficulties in obtaining travel insurance and driving licenses impacted recovery. The lived experience of survivors of pediatric stroke includes long-term hidden disabilities and barriers to rehabilitation. These are present in different settings, such as health care, schools, workplaces, and driving centers. Greater awareness of these issues by relevant professional groups may help ameliorate them.

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5 Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery. Because there remains a …

Stroke is highly debilitating and requires long-term care. Informal caregivers of stroke survivors play important roles in stroke rehabilitation. Caring for stroke survivors can negatively affect the caregivers' well-being and may adversely impact on their caregiving quality and subsequently on stroke survivors' well-being. There seems to be a dearth of research on the relationships between caregivers' and stroke survivors' well-being. This study was designed to determine the relationships among informal caregivers' burden and quality of life (QOL) and stroke survivors' QOL and community reintegration. This ethically certified cross-sectional survey involved 82 stroke survivors (mean age=60.48±11.13years) and their 82 primary caregivers (mean age=36.13±13.69years) consecutively recruited from seven conveniently sampled tertiary hospitals in Nigeria. Caregivers Strain Index, Igbo-culture adapted Maleka Stroke Community Reintegration Measure and Short-Form 36-item Health Survey questionnaires were used to assess the caregivers' burden, survivors' community reintegration and QOL (of survivors and caregivers), respectively. Data were analysed using descriptive statistics, Spearman rank, Mann-Whitney U and Kruskal-Wallis tests at alpha level of 0.05. The mean stroke survivors' community reintegration and QOL were 34.05±21.54% and 34.93±16±49%, respectively. The mean caregivers' QOL and burden scores were 74.49±12.61% and 9.13±3.18, respectively. About 80.5% of the caregivers experienced significant burden. Stroke survivors' QOL and community reintegration, and caregivers' QOL and burden significantly correlated with one another (p<0.05). Poststroke duration, survivor-caregiver cohabitation duration, survivors' community-dwelling duration and daily care-giving hours significantly correlated with each of stroke survivors' community reintegration and QOL, and caregivers' burden and QOL (p<0.05). Stroke survivors' community reintegration and QOL were poor while caregivers' had moderate QOL and high prevalence of significant burden. Significant correlations exist between caregivers' well-being and stroke survivors' QOL and community reintegration. Interventions targeted at reducing caregivers' burden may help improve both caregivers and survivors' well-being.

Community walking is a multifactorial task and an important functional goal for stroke survivors. Measuring community walking is challenging because there is not a good understanding of what is considered successful community walking or how this could be measured. Physiotherapists currently use a range of measures to assess community walking. Furthermore, the factors contributing to community walking that are captured by these measures are not yet well understood. This thesis, comprising two studies, explores these gaps. The first study is a qualitative exploration of physiotherapists’ perspectives of community walking measurement in stroke survivors. Physiotherapists experienced in stroke rehabilitation were recruited to participate in focus groups. Semi-structured interviews were utilised to explore physiotherapists’ perspectives on measuring community walking in stroke survivors. Interviews were transcribed verbatim and thematically analysed. Four themes were identified: successful community walking is goal-dependent, physiotherapists lack consistency in measurement of community walking, current measures don’t reflect actual community walking, and measures of community walking should be multifactorial. Physiotherapists perceived that stroke survivors’ goals related to community walking played an important role in achieving success in community walking. However, for physiotherapists, successful community walking implied stroke survivors satisfying specific criteria for gait speed, distance walked and ability to dual- task while walking. There appeared to be a range of ways in which physiotherapists measure community walking. For example, physiotherapists working in in-patient rehabilitation used more functional measurement such as observing the task of walking and commenting on assistance required. Whereas physiotherapists working in outpatient and community rehabilitation more objectively inferred community walking using measures including Berg Balance Scale, Dynamic Gait Index, 10-Meter Timed Walk and 6-Minute Walk Test. Even when using specific measures, physiotherapists reported using different values or cut-off scores as representative of stroke survivors’ community walking. Physiotherapists reported that stroke survivors’ goals were taken into account when selecting a measure. Physiotherapists noted that current measures of community walking were performed in a clinical setting, not necessarily involving situations reflective of community walking. Physiotherapists identified a range of factors that were important to be included in a measure of community walking including stroke survivors’ satisfaction and confidence in activities related to community walking. Physiotherapists’ evaluation of walking in an environment reflecting community walking, dual tasking, dynamic balance ability and stroke survivors’ safety awareness were suggested to be included in a measure of community walking. The second study, a systematic review, identified current measures of community walking and explored the content of these measures within the International Classification of Functioning, Disability and Health (ICF) framework. Search strategies were conducted in databases of CINAHL, EMBASE, PubMed, Scopus and Web of Science. Twenty measurement tools were identified from 27 studies included in the final synthesis. The identified measures of community walking were categorised as instrumented measures, patient-reported measures and therapist- reported measures. Content covered by the identified measures was then analysed within the ICF framework using an established ICF linking process. Across all measures, 169 ICF categories were linked. The majority were linked with Activity and Participation component (88%), with remaining categories linked with Environmental factors (10%) and Body functions (2%). All measures covered Activity and Participation, in which mobility categories were the most commonly linked and included walking on different surfaces, climbing, and walking around obstacles. Environmental categories were covered by half of the identified measures and included use of assistive devices for indoor and outdoor mobility and products and technology for gaining access to facilities inside buildings. Three of the identified measures covered Body functions and included categories of confidence and proprioception. Measures of community walking for stroke survivors illustrated diversity in the content covered, with most measures covering activity of walking. None of the measure comprehensively covered factors associated with community walking. Findings from Study 1 and Study 2 highlight that there is a lack of a comprehensive measurement tool of community walking in stroke survivors, as no single tool measures all of the important factors contributing to community walking. Community walking is mostly inferred based on some components of these measurement tools. Physiotherapists take into account stroke survivors’ goals when selecting a measure of community walking, at the same time relying on measures that they think best represent community walking.

Review question/objectives This systematic review will be undertaken to answer the following review question: ‘What is the effectiveness of computer-based interventions in enhancing outcomes of stroke survivors?’ The primary objectives of this systematic review are: To present the best available research evidence pertaining to the effectiveness of computer-based interventions in optimising stroke survivors' physical and psychosocial outcomes. To determine the effectiveness of computer-based interventions in improving knowledge and self-care self-efficacy among stroke survivors. The secondary objectives are: To determine the effectiveness of computer-based interventions in enhancing stroke survivors' satisfaction with care provided. To determine the effectiveness of computer-based interventions in reducing health services utilisation among stroke survivors. The specific review questions to be addressed are: What is the effectiveness of computer-based interventions in enhancing stroke survivors' physical outcomes (for example, functional ability) and psychosocial outcomes (including depression, self-esteem, social participation, and quality of life)? What is the effectiveness of computer-based interventions in improving knowledge and self-care self-efficacy among stroke survivors? What is the effectiveness of computer-based interventions in enhancing stroke survivors' satisfaction with care provided? What is the effectiveness of computer-based interventions in reducing stroke survivors' health services utilisation? What is the effectiveness of different formats of computer-based interventions (for example: delivered via DVD/CD-ROM, internet-based, or computer programmes) on outcomes for stroke survivors? What is the effectiveness of computer-based interventions compared with usual care (for example: education using leaflet, group education, one-to-one teaching, face-to-face education led by lay leaders) on outcomes for stroke survivors? Background Stroke is the second leading cause of death globally.1 According to the World Health Organization, stroke accounts for about 5.7 million deaths worldwide, which constitutes 9.9% of all deaths in 2005.1 Although the mortality rate declined from 44.8% to 14.7% from 1997 to 2007, there are still about 795,000 people who experience a new or recurrent stroke each year.2 The number of people affected by stroke is estimated to continue to surge as the population ages.3 Stroke is also one of the leading causes of disability. Survivors of stroke are often left with different degrees of limitation in physical functioning such as hemiplegia.4 Negative consequences such as depression, restricted social functioning or loss of productivity may also result during the rehabilitation or recovery phases that lead to compromised quality of life.5–7 Post-stroke recovery is often long-term and multi-faceted, comprising physical, psychological and social aspects.8,9 Difficulties in managing their conditions post-stroke, such as coping with physical disabilities, psychosocial adaptation, community reintegration, adherence to medication and lifestyle changes, were often encountered by stroke survivors especially after being discharged to the community when healthcare professionals were not always immediately available.10–13 Provision of adequate information to stroke survivors is crucial during stroke rehabilitation and recovery. Effective information provision is not only associated with improvement in stroke knowledge and depressive moods, and increased patient satisfaction, but also better management of stroke survivors' conditions in daily life.14,15 The types of information that the stroke survivors regarded as important include medical issues, consequences of stroke, experiences of other stroke survivors, home recovery, sexuality and recreation.16 National guidelines recommended that the information offered should be individualised using appropriate communication formats, and be available at different stages of the recovery process. Opportunities for clarification or regular reinforcement of the information provided would be an advantage.14,17 However, despite numerous educational programmes or strategies examined to deliver information to stroke survivors, a systematic review evaluating the effectiveness of different information provision found that the use of booklets, leaflets or information packs were not associated with improvement in stroke survivors' knowledge of stroke, mood changes, perceived health status or quality of life.18 The time spent on providing information to stroke survivors was as low as 17.5% of the total amount of time the healthcare professionals spent on communication with the patients. Patients with aphasia in particular were offered the information in comparatively shorter time and with fewer topics.18 Furthermore, barriers to effective information provision to enhance stroke outcomes include limited availability of the information or information not being tailored to meet the patients' needs.17 Newer and innovative methods to deliver information to stroke survivors are warranted to enhance its accessibility and effectiveness on improving stroke care outcomes. Computer-based interventions, delivered via DVD/CD-ROM, internet-based, or computer programmes, have well-known advantages in providing an individualised learning environment with 24-hour convenient access to information. Features including graphics, audios, and videos can be incorporated to enhance the quality of educational materials, and to facilitate learning and promote understanding. Furthermore, they are characterised by enabling users to repeat, interrupt and resume their learning at will without being limited by other learners' learning pace.19 Computer-based interventions have been widely adopted as a useful adjunct to conventional health education for chronic diseases such as diabetes mellitus, resulting in positive outcomes.20 A review of the literature indicates that the application of computer-based interventions for stroke survivors is receiving increasing attention in recent years. A pilot study of seven stroke survivors and carers reported that a newly developed website focusing on stroke rehabilitation was easy to use and valuable in content. The participants suggested using larger fonts and darker colours for easier viewing.21 A randomised controlled trial evaluated the effectiveness of providing 133 stroke patients with computer-generated tailored written information.22 The results showed that the stroke patients were not only satisfied with the content and presentation of the information, but also found the tailored information more effective in fulfilling their information needs. However, no effect was found on their knowledge about stroke, self-efficacy, depression, or perceived health status.22 On the contrary, another randomised controlled trial which examined the use of an individualised computer program to deliver health education for 65 patients with transient ischaemic attack and minor stroke found no long term effects on enhancing knowledge of stroke.23 Stroke survivors may have limitations in physical functioning such as hemiplegia or aphasia. With the advent of information technology, modifications or alternatives in computer access such as voice control have been successful in facilitating stroke survivors' use of computers.24 It is clear from the literature that computer-based interventions are potentially beneficial to stroke survivors. A preliminary search of the Joanna Briggs Institute Library of Systematic Reviews, JBI COnNECT+, Cochrane Library, Medline, CINAHL, and DARE and PROSPERO databases indicate that there are no systematic review reports on this topic either published or underway. This systematic review will be undertaken to evaluate the effectiveness of computer-based interventions in enhancing stroke survivors' physical and psychosocial outcomes, improving knowledge and self-care self-efficacy, enhancing satisfaction with care, and reducing health services utilisation. Significance of the review Effective provision of information and care to stroke survivors is crucial to enhance the outcomes of stroke recovery. The results of this systematic review will provide vital information to clinicians and stakeholders to assist with decision-making about the use of computer-based interventions in clinical and community settings. Inclusion criteria Types of participants This review will consider studies that included adults aged 18 years or above who had had a first-ever or recurrent stroke, or are stroke survivors in the acute, rehabilitation or community settings, regardless of gender or ethnicity. The standard WHO stroke definition will be followed, that is, ‘a focal neurological impairment of sudden onset, and lasting more than 24 hours, and of presumed vascular origin’.25 (p.1-4) There are three major stroke subgroups, namely, ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage.25 We will exclude studies with participants who have transient ischaemic attack, subdural haemorrhage and epidural haemorrhage, as these are excluded from the standard WHO stroke definition. Types of interventions This review will consider computer-based interventions for adult stroke survivors. For the purpose of this review, the computer applications employed in the computer-based interventions include the use of DVD, CD-ROM, website, telehealth/telemedicine/telenursing/telecare, or other computer programme. The formats of information delivery in terms of texts, graphics, videos, discussion forums, interactive games or other means delivered via the computer applications will be included. Computer-based interventions delivered by healthcare professionals, trained voluntary stroke survivors, peers, or volunteers will be included. Types of comparisons Foreseen comparisons include: Comparison between computer-based interventions vs. usual care. For example, computer-based interventions vs. education using leaflet vs. group education vs. one-to-one teaching vs. face-to-face education led by lay leaders vs. other educational interventions for stroke survivors. Comparison between different formats of computer-based interventions. For example, interventions delivered via DVD vs CD-ROM vs website vs telehealth/telemedicine/telenursing/telecare vs computer programme. Types of outcomes This review will consider studies that include the following outcome measures: The primary outcomes of interest will include: Physical outcome: Functional ability is operationally defined as the degree of independence of a patient has in performing the various self-care and mobility activities of daily living tasks.26 Outcome measures include Barthel Index, Modified Barthel Index, and Functional Independence Measure. Psychosocial outcomes: Depression is operationally defined as having depressive symptoms of dysphoric mood, withdrawal, apathy, lack of vigour, hopelessness, cognitive impairment, and anxiety,27 Outcome measures include self-reported measures such as Geriatric Depression Scales (GDS-30, GDS-SF and GDS-4), Hospital and Depression Scale, and Center for Epidemiologic Studies Depression Scale. Self-esteem is operationally defined as self perceived worthiness or inadequacy, confidence about the appearance and body image, as well as the evaluation people make about their relationships with others in the various roles in their lives.28 Outcome measures include, but are not limited to, State Self-Esteem Scale and Rosenberg Self-Esteem Scale. Social participation is operationally defined as the level of participation in society that is possible when there is disability resulting from a health condition.29 Outcome measures include Frenchay Activities Index and London Handicap Scale. Quality of life would be assessed using generic or disease-specific quality of life instruments such as Stroke-Specific Quality of Life Scale (SS-QoL, and SS-QoL-12). Knowledge of stroke care. This would be measured by using knowledge tests assessing knowledge of risk factors, symptoms, treatments, information resources, and self-care management, and self-care behaviours. Self-care self-efficacy is operationally defined as stroke survivors' self-efficacy in performing self-care tasks during stroke recovery. Outcome measure includes Stroke Self-Care Self-Efficacy Questionnaire. The secondary outcomes of interest will include: User satisfaction, which is defined as the satisfaction of users with the computer-based interventions in terms of their usefulness, acceptability, ease of use, and their level of confidence in using the computer-based interventions. This would be assessed by using self-reported measures such as Computer Use Satisfaction Scale. Health services utilisation will be determined by number of emergency department visits, unplanned visits of an urgent nature to a hospital, and hospital re-admissions. Types of studies All randomised controlled trials (RCTs) comparing the effectiveness of computer-based interventions for stroke survivors will be considered for inclusion in this review. In the absence of RCTs or where insufficient RCTs were identified, other research designs including quasi-experimental, non-randomised controlled trials, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies will be included. Exclusion criteria Studies will be excluded from the review if they: Were single case reports, narrative reports, literature reviews, systematic reviews, clinical guidelines, protocols, editorials, or expert opinion articles; Involved caregivers in the delivery of computer-based interventions, where data on caregivers was not reported separately from data on stroke survivors. Search strategy The search strategy will aim to obtain both published and unpublished studies in English and Chinese using a three-step approach. Firstly, the electronic databases will be searched to identify key words used in the titles and abstracts. Secondly, a more extensive search of the databases from inception to October 2012 using the detailed search strategies will be performed to identify potential articles for inclusion into the review. The search strategies will include the keywords, index terms and matched subject headings that are specific to each database. Thirdly, a hand searching of other sources of studies will be performed to identify studies or additional relevant source materials that are not located through the search strategies. It will include a manual search of relevant conference proceedings and journals, including Stroke, Disability and Rehabilitation, International Journal of Stroke, and Neurorehabilitation and Neural Repair. Postgraduate and doctoral dissertations will be searched for additional literature. An online search of databases and websites such as Google Scholar will also be performed to identify research studies relevant to the field of interest. Furthermore, the reference lists and bibliographies of all retrieved articles from all types of search will be screened to reveal additional relevant studies. The databases to be searched include: Articles published in English The electronic bibliographic databases to be searched will include: MEDLINE, CINAHL PLUS, EMBASE, Cochrane Central Register of Controlled Trials, All EBM Reviews, EBSCOhost, Health and Medical Complete, Health Sciences, ProQuest Dissertations & Theses, ISI Web of Science, Academic OneFile, Bandolier - Evidence Based Health Care, SCOPUS, Scirus.com, BioMed Central, and Centre for Reviews and Dissemination (CRD). Articles published in Chinese Electronic databases to be searched for primary publications written in Chinese will include: WanFang Data, China Journal Net, Chinese Biomedical Literature Database, Chinese Medical Current Contents, Hong Kong Index to Chinese Periodical Literature, Chinese Electronic Periodical Services, Chinese Electronic Theses & Dissertations Service, and Taiwan Electronic Periodical Services. The Chinese search terms will be based on the terminology used in Taiwan and China. Grey literature The databases to be searched for grey literature or unpublished studies will include: Dissertation Abstracts International, Digital Dissertations, Index to Theses, MEDNAR, Althealth Watch, Netting the Evidence, Lancashire Care Library and Information Service, Grey Literature Report (via The New York Academy of Medicine), National Library of Medicine Gateway, The Networked Digital Library of Theses and Dissertations, Academic Archive On-line, and Agency for Healthcare Research and Quality. The initial keywords to be searched will include: stroke* or cerebro vascular accident* or cva or apople* computer* or CD* or DVD* or online* or website* or web* or tele* educat* or information* or knowledge* recover* or rehabilitat* or communit* or home* Assessment of eligibility Two reviewers will independently assess the identified studies from the search for relevance to the review based on the title and abstract. The assessment will be performed using the inclusion and exclusion criteria regarding the types of studies, participants, interventions and outcome measures of the studies (Appendix I). If a research study is considered relevant and eligible for inclusion into the review, its full text will be retrieved. If the title or abstract of a study is inconclusive, the full text will also be retrieved for further assessment. Disagreement between reviewers will be resolved via discussion. The details of eligible studies will be stored in a bibliographic software package (RefWorks). In case of duplication publications, all available data will be evaluated by comparing the authors' names, settings, participants, interventions, outcomes, data and duration of the studies. Duplicated studies will be included only once. Assessment of methodological quality The methodological quality of eligible studies will be assessed independently by two reviewers using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) critical appraisal instruments for randomised and pseudo-randomised trials (Appendix II), comparable cohort/case control studies (Appendix III), and descriptive/case series studies (Appendix IV). Kappa statistics tests will be performed to assess agreement between reviewers. Any disagreements that arise between the reviewers will be resolved by discussion. Data collection Details of the included studies will be extracted and summarised independently by one reviewer using the standardised data extraction instrument from JBI-MAStARI (Appendix V). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. A second reviewer will independently check for its accuracy. Discrepancies between the reviewers will be resolved by discussion. Data synthesis The included studies will be categorised according to the types of interventions investigated, namely CD-ROMs, DVDs, websites, telehealth or computer programmes. In order to minimize the risk of errors during data entry, all results will be subject to double data entry. Analysis of outcomes will be made using intention-to-treat results where possible. For continuous data that are collected using the same scale, the mean difference and 95% confidence interval will be calculated for each included study and used as the summary measure of effect; while for continuous data collected using different scales, the standardised mean differences and their 95% confidence interval will be calculated. For dichotomous data, relative risks, odd ratios and their 95% confidence interval will be calculated and used as a summary measure of effect. The studies will be assessed for clinical heterogeneity by considering the settings, populations, interventions and outcomes. If appropriate, quantitative results of comparable studies will be pooled in statistical meta-analysis using the JBI-MAStARI. Clinical heterogeneity of the studies will be assessed by considering the settings, formats of computer-based interventions and outcomes. The statistical heterogeneity of the combined studies will be tested using the I2.I2 describes the percentage of total variation across a study that is due to heterogeneity rather than chance. A fixed effects model will be applied for pooling if there is no clinical or statistical heterogeneity; while a random effects model will be used in the absence of clinical heterogeneity but with the presence of statistical heterogeneity. If statistical pooling of results of the included studies is not appropriate or possible, the findings will be summarised in narrative form including tables and figures to aid in data presentation where appropriate. In addition, subgroup analyses will be conducted to evaluate effectiveness in the following comparisons: Computer-based interventions versus usual care; Computer-based interventions versus no intervention; Computer-based interventions in different formats. Sensitivity analyses assessing the impact of studies with high risk of bias will be performed for addressing heterogeneity. Publication bias will be evaluated graphically using a funnel plot if there are a sufficient number of included studies. Conflict of interests The reviewers of this systematic review do not have any type of conflict of interest. Acknowledgements None.

Symptoms of depression and active smoking among survivors of stroke and myocardial infarction: An NHANES analysis

How to Address Physical Activity Participation After Stroke in Research and Clinical Practice.

Caring for stroke survivors can affect the caregiver's life, especially with the increment of patients' dependency level. This led to depression, anxiety, and stress in the caregiver, impacting their quality of life (QoL). This study aims to model relationships between caregivers' factors and stroke survivors' factors with caregivers' QoLand to estimate the mediation effects of caregivers' depression, anxiety, and stress in the relationships between stroke survivors' dependency level and caregivers' QoL. Methods: Data from a cross-sectional study with a sample size of 250 subjects was analyzed. Linear regression was done to model the relationship between stroke survivors' factors and caregivers' factors with caregivers' QoL. Hayes's PROCESS macro model 4 for bootstrapping indirect effects was used to estimate the mediation effects of depression, anxiety, and stress in the relationship between stroke survivors' dependency level and caregivers' QoL. Stroke survivors' dependency levels that were measured by the Modified Barthel Index score (b=0.14; 95% CI: 0.07, 0.20), caregivers' depression score (b=-0.81; 95% CI: -1.44, -0.20), and caregivers' anxiety score (b=-0.73; 95% CI: -1.34, -0.12) were found to be associated with caregivers' QoL. Caregivers' depression score (effect=0.02; 95% CI for bootstrapping: 0.01, 0.04) and caregivers' anxiety score (effect=0.01; 95% CI for bootstrapping: 0.01, 0.04) were found as partial mediators in the relationship between stroke survivors' dependency level and caregivers' QoL. Stroke survivors' dependency level and caregivers' depression and anxiety significantly impact caregivers' QoL, with the latter factors partially mediating this relationship. Interventions such as providing caregivers with psychological support, stress management programs, and training in caregiving skills could help mitigate these impacts and improve caregivers' QoL.