More blame the survivor for not recovering. What the fuck good does perserverance do when there are NO PROTOCOLS TO FOLLOW TO RECOVER? What is really needed is research on why the stroke medical world has no perserverance to actually solve stroke! With exact protocols including number of repetitions survivors would perservere even if it called for 10 million reps. Solve the correct problem, lack of protocols. If you don't understand that, get the hell out of stroke.
Perseverance with technology-facilitated home-based upper limb practice after stroke: a systematic mixed studies review
Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 43 (2021)
Abstract
Background
Technology is being increasingly investigated as an option to allow stroke survivors to exploit their full potential for recovery by facilitating home-based upper limb practice. This review seeks to explore the factors that influence perseverance with technology-facilitated home-based upper limb practice after stroke.
Methods
A systematic mixed studies review with sequential exploratory synthesis was undertaken. Studies investigating adult stroke survivors with upper limb disability undertaking technology-facilitated home-based upper limb practice administered ≥ 3 times/week over a period of ≥ 4 weeks were included. Qualitative outcomes were stroke survivors’ and family members’ perceptions of their experience utilising technology to facilitate home-based upper limb practice. Quantitative outcomes were adherence and dropouts, as surrogate measures of perseverance. The Mixed Methods Appraisal Tool was used to assess quality of included studies.
Results
Forty-two studies were included. Six studies were qualitative and of high quality; 28 studies were quantitative and eight were mixed methods studies, all moderate to low quality. A conceptual framework of perseverance with three stages was formed: (1) getting in the game; (2) sticking with it, and; (3) continuing or moving on. Conditions perceived to influence perseverance, and factors mediating these conditions were identified at each stage. Adherence with prescribed dose ranged from 13 to 140%. Participants were found to be less likely to adhere when prescribed sessions were more frequent (6–7 days/week) or of longer duration (≥ 12 weeks).
Conclusion
From the mixed methods findings, we propose a framework for perseverance with technology-facilitated home-based upper limb practice. The framework offers opportunities for clinicians and researchers to design strategies targeting factors that influence perseverance with practice, in both the clinical prescription of practice and technology design. To confirm the clinical utility of this framework, further research is required to explore perseverance and the factors influencing perseverance.
Registration: PROSPERO CRD42017072799—https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=72799
Introduction
Upper limb (UL) recovery after stroke is a long and often arduous journey. High doses of task-specific therapy have been suggested to enhance neuroplasticity, motor relearning and recovery [1, 2]. Yet, the specific dose and timing of UL practice required to maximise functional recovery remains unclear [3]. Stroke survivors in the inpatient setting have been observed to complete on average 18 min per day of UL therapy, which is considered insufficient for functional recovery [4]. In turn, up to 65% of stroke survivors have a non-functional UL six months after stroke [5]; extending their UL recovery journey beyond the inpatient rehabilitation phase and into the home.
Upper limb home exercise programs (HEP) are commonly provided to stroke survivors in an effort to increase practice and enhance recovery [6]. Dose and content of UL HEP are variable, ranging from a structured one-size-fits-all program, to an individualised program specific to the needs and goals of the stroke survivor [6]. Adherence to HEP after stroke has been attributed to family support, confidence in therapist knowledge and experience, and goal oriented practice with an accountability strategy [7,8,9]. Non-adherence with HEP after stroke has been attributed to fatigue, depression and diminished motivation, musculoskeletal issues, and lack of time due to competing commitments [8, 9]. Additionally, some stroke survivors have found that traditional HEP are not enjoyable, too difficult or insufficiently challenging, and thus of minimal functional benefit [8,9,10]. Evidently, practicing intensely in the home over a long period of time is challenging for stroke survivors. Therefore, options that enable stroke survivors to continue with home-based practice in the long term need to be considered.
Technology offers an increasing number of options to facilitate independent, intensive and task-specific UL practice in the home [11]. Upper limb rehabilitation technology typically allows stroke survivors to play motion-based games on an interactive platform that offers feedback on performance and results [11]. Practice is monitored and progressed either in person or online by a therapist [11]. Some technologies also provide mechanical assistance to make practice possible [11]. Unfortunately, adherence with technology-facilitated practice is variable, and has been reported to be lower than that of more traditional methods due to decreased task specificity and engagement with the technology [6]. Recommendations for technology design focus on engagement, including personalisation of games and sufficient variability and challenge, as well as user-friendliness and contextual applicability to the home environment [11]. To date however, within efficacy studies of technology-facilitated interventions, there has been limited exploration of how these design factors influence stroke survivors’ ability to persevere with practice.
Perseverance is a dynamic behaviour that has been defined as “persistence in doing something despite difficulty or delay in achieving success” [12] and is known to be influenced by multiple factors[13, 14]. Perseverance is thought to play a vital role in disciplines where significant amounts of practice over years are required to achieve expert skill [14,15,16]. Accordingly, perseverance is required by stroke survivors to recover UL skill through high dose practice, over a long period of time, to promote the neuroplasticity required for recovery [1, 2]. The added challenge for stroke survivors is that they must persevere in the presence of physical and cognitive impairments, and independently within their home environment. While technology offers a unique opportunity to enhance independent home-based UL practice, the factors that influence stroke survivors’ ability to persevere with technology-facilitated practice are yet to be explored in detail. Therefore, the question to be answered in this systematic mixed studies review was: What are the factors that influence perseverance with technology-facilitated home-based UL practice after stroke?
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