This statement alone is why stroke survivors need to be in charge.
EE has yet to be proven effective within the clinical setting. Survivors wouldn't let a minor thing like that prevent creating a protocol on this. What the fuck is the downside?
Abstract
Purpose:
In this study, we explored the experiences of patients who participated
in an enriched task-specific therapy (ETT) program in the chronic phase
after stroke.
Method: Focus group interviews were
conducted with twenty participants with a mean time since stroke of
30 months and mean age 61 years, who completed the ETT program including
task-specific training and environmental enrichment. ETT was delivered
3.5–6 h per day, 5½ days per week for 3 weeks in a climate suitable for
both indoor and outdoor activities. The training consisted of repetitive
mass practice of gradually increasing difficulty. Directly after the
intervention, qualitative interviews were conducted in six focus groups.
The interviews were analysed with qualitative content analysis.
Results: Three main categories describing the informants’ experiences of the ETT program were identified. These categories were; 1.
The program—different and hard – highlighting the participants view of the ETT as strenuous and different in nature; 2.
My body and mind learn to know better
– describing positive changes in participants’ body function and
functional ability as well as behavioural changes experienced throughout
the ETT; and 3.
The need and trust from others – emphasizing the
perceived importance of trust in rehabilitation clinicians and the
support of family and other participants. From these categories, a main
theme emerged:
It’s hard but possible—but not alone!
Conclusion:
A therapy program including task-specific training and environmental
enrichment may provide late-phase stroke survivors with perceived
improvements in functional ability, knowledge insights, perceptions of
rehabilitation needs and enriching emotional impacts.
- Implications for rehabilitation
ETT
is feasible and may lead to perceived improvements in function and a
change of mindset, even in the chronic phase after stroke.
Trust
in the competence of the rehabilitation staff is an important factor in
compliance with the high-intensity training in the ETT program.
Given
the lack of stimulation and socialization among many individuals with
chronic stroke, the social and physical environment are important
components of the ETT program.
Introduction
With
the worldwide declines in the stroke mortality rate over the past two
decades have come increases in the prevalence of stroke survivors and
the global burden of stroke [
1]. A stroke often radically changes the life situation both psychologically and socially as well as physically [
2].
The most promising rehabilitation interventions to regain lost motor
function consist of task-oriented and goal-directed training and include
feedback, repetition, intensity, and specificity [
3,
4].
Many standard treatment methods and innovative rehabilitation
techniques can minimize functional disability after stroke, including
constraint-induced movement therapy, robotic exercise, weight-supported
treadmill training, cardiovascular training, and goal-directed physical
exercise [
5]. However, in growing numbers, stroke survivors are left with persistent impairments [
2], and many lack stimulation, exercise, and socialization [
6].
The stroke rehabilitation field needs to not just select
individualised, patient-centred, evidence-based interventions to improve
function [
7], but also to prevent deterioration of function late after stroke [
8].
One
promising and clinically feasible intervention is enriched
rehabilitation combining environmental enrichment (EE) and task-specific
therapy [
6,
9–11].
In rodent brains, EE that enhances motor, cognitive, sensory and social
stimulation is shown to profoundly affect neuroplasticity [
12,
13].
In a typical EE, animals are housed in conditions chosen to encourage a
variety of activities and stimulations. The combination of treatment
modalities in clinical EE contexts may also be termed multimodal
interventions [
6].
The combination of EE and task-specific reach training has recently
been shown to more effectively restore forelimb function in rats after
stroke, as compared to effective environment enrichment or task specific
reach training alone [
14].
Coupled with previous investigations on animal models, these findings
support the premise that combining EE with task-specific training aid
the stroke recovery process beyond what is possible with either
treatment modality in isolation [
6,
9,
15,
16].
Researchers have learnt from animal models of enrichment and attempts
have been made to translate the EE approach to human stroke
rehabilitation settings [
11,
17,
18].
Even though there is mounting support that various EE approaches and
multimodal interventions could stimulate the recovery process after
stroke [
17,
19],
EE has yet to be proven effective within the clinical setting [
20].
Aligning the preclinical and clinical approaches will allow research to
fully address gaps in knowledge and facilitate the implementation of EE
to the clinical setting [
20].
In an attempt to translate the EE paradigm into a clinical stroke
setting we designed an exploratory study with the aim to assess the
effectiveness of enriched task-specific therapy (ETT) in individuals
with chronic stroke [
11].
This showed that a therapy program that combines the physical, sensory,
and social stimulation inherent in EE may provide durable benefits
across the wide spectrum of motor deficits and impairments, even years
after stroke [
11].
Qualitative studies are increasingly used in medical and health research [
21], including stroke [
22], and many focus on issues directly relevant to clinical practice [
21].
A qualitative study in an Australian stroke rehabilitation ward
explored the participants’ experience of translating EE to a routine
clinical setting for acute stroke rehabilitation [
23].
Among the qualitative themes to emerge were the perceived benefits of
participation in EE, such as increased opportunities for enhanced motor,
cognitive, and sensory stimulation. Engagement in the EE interrupted
the ongoing cycle of boredom and inactivity experienced by many
participants and increased feelings of personal control. However, the
findings also identified barriers to implementation of the EE, such as
not wanting to make the staff busier [
23].
As interventions move from simple to more complex, evaluation becomes more challenging [
24].
Practitioners, policymakers, and researchers are increasingly
interested in the evaluation of complex interventions consisting of
multiple interacting components [
25].
Moreover, the base of evidence for the effectiveness of an EE paradigm
in clinical stroke rehabilitation needs to be increased. No studies have
been conducted combining environmental enrichment and intense
rehabilitation, why it is important to understand the experience from
participants involved. In this study, an extension of our intervention
study [
11], we used a qualitative research approach to address these issues.
Materials and methods
Study design and participant selection
In
this qualitative study, stroke survivors who had just completed an ETT
program were interviewed in semi-structured focus groups interviews. The
participants were Swedish or Norwegian stroke survivors who had applied
to a Swedish rehabilitation agency that provides rehabilitation
services in Spain. The eligibility criteria are described in
Table 1.
The study aim was narrow, and the combination of participants was
highly specific for the study question. Therefore, we estimated that
15–20 participants in 5–8 groups would be necessary to gather a variety
of experiences and opinions [
26].
Table 1. Eligibility criteria.
Theoretical framework
To
reach a deeper understanding of the participants’ experience of ETT, we
used a qualitative approach and focus group interviews. The
philosophical standpoint was interpretivistic. The position of
interpretivism in relation to ontology and epistemology is, according to
Lincoln and Guba, that the epistemological view of interpretivism is
subjectivism, and the ontological view is relativism, where reality is
subjective and relative [
27]. Using a qualitative approach may lead to new insights and a richer understanding of a phenomenon [
28–30]. When research literature or theory on a topic is limited, as in this study, the inductive approach is desirable [
31].
The inductive approach is a systematic procedure in which an evaluator
or researcher interprets the raw data through detailed reading to derive
codes, categories, (concepts), themes, or a model [
31,
32].
Trustworthiness
To
establish the rigor and trustworthiness of the findings in qualitative
research, the following criteria need to be addressed: credibility,
confirmability, transferability, dependability, and reflexivity [
27].
To increase credibility, we included participants with a broad range
and degree of motor deficits resulting from stroke. Participants with
slight to moderately severe disability and with no to mild aphasia, with
different age and different gender, were included. This contributed to a
wider variation of the opinions and experiences included in the study.
Quotes from the discussions in the interviews are presented verbatim to
further increase credibility and confirmability and to describe the
relevance and bearing of the subcategories and categories. The
transferability and dependability of the study derive from a detailed
description of the study context, the intervention, and the selection
and size of the sample. The reflexivity—an attitude of attending
systematically to the context of knowledge construction, especially to
the effect of the researcher, at every step of the research—was enhanced
by the different backgrounds, professions, and perspectives of the
authors. The retrospective reflexivity refers to the effects of the
study on the researcher, and the impact of this was reduced since the
moderator was not involved in the analyse process of the interviews.
Study context
The
participants were interviewed in seven focus groups, each with 3–4
participants, at the rehabilitation facility immediately after the
intervention. Interviews were conducted by a physiotherapist with
experience in stroke rehabilitation who was not a member of the
rehabilitation team and no previous relationship with the participants.
The moderator had little experience from focus group interviews, but was
supervised by a person highly experienced in qualitative research.
Focus group methodology is a social method that allows a group of people
to provide research data through group interactions [
33].
Focus groups are thought to be a useful method to obtain information on
perceptions and experiences of a homogenous group of people related to a
clearly defined topic, and efforts are made to gather information and
different opinions from the group members [
34,
35]. The focus groups were carried out as described by Kreuger and Casey [
36]. Our results are reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [
37].
Interview guide
The interviews were semi-structured and based on an interview guide (
Figure 1).
The questions in the guide provided starting points for the discussion,
during which additional questions were raised. The interviewer did not
steer the conversation if the interviewees themselves raised a topic.
Intervention: enriched task-specific therapy (ETT)
The
ETT was conducted at two rehabilitation facilities in Spain, near
Marbella and Malaga, respectively, where the climate is suitable for
both indoor and outdoor activities. The principles of the multimodal
rehabilitation program were conceived and developed by the medical board
of Neurooptima Forsk Rehab. The ETT was individually tailored and took
place in a group setting. Participants did the exercises in groups of
4–9 in the same room/place. Physical exercise, led by physical
therapists, was scheduled 3.5–6 h per day, 5½ days per week for 3 weeks.
The training consisted of repetitive mass practice of gradually
increasing difficulty. Individuals with hemiplegia used noncompensatory
strategies, such as focusing on not compensating with the nonaffected
side of the body and enforcing use of the affected side [
38].
The program included functional training for transfers and upper/lower
limb (1–3 sessions/day), such as practicing functional use of affected
arm/hand, transfers, balance and gait training. It also consisted of
impairment-based training (1–3 sessions/day) for upper and lower limb
like mobility training, training of isolated movements, stretching and
strength training. It also included lectures (1–3 sessions/week)
designed to widen participants’ knowledge about stroke. Each day
included 30 min of submaximal cardiovascular training on a stationary
bicycle, treadmill, or cross-trainer. Participants with speech
impairments worked with a speech therapist for about 1.5 h a day. The
ETT also included enriching beach or village excursions, accompanied by
rehab personnel to enable goal-directed training in different
environments (a couple of half-day excursions and one full-day
excursion). Beyond scheduled activities, participants were encouraged to
physically engage in the challenging outdoor environment (every day
during, in between and after sessions). The participants also interacted
socially with each other and with accompanying family members at
training, meals, and social events after the scheduled activities [
11].
Data analysis
Content
analysis is, according to Baxter and Krippendorff, suitable for
analysing communication about individuals’ experiences and may better
capture the complexity of interventions [
39,
40].
The data were not analysed until all interviews were done. The
interviews were recorded and transcribed by the moderator and S.V, and
the content was analysed as described [
41].
First, one of the authors (S.V.) listened to each interview several
times to get a general idea of the data content and then scrutinized the
transcript to identify meaning units—one or more sentence or paragraphs
of a narrative—that referred to the participant’s experiences of ETT.
The meaning units were then condensed, interpreted, and coded. Next, the
co-authors read the initial analysis, discussed the condensations and
codes, and modified them as needed. The codes were then analysed and
grouped by the first author into subcategories. After reading the
analysis as a whole, the authors discussed and compared the findings
until agreement was reached. Next, categories were expressed from the
subcategories, and an overall theme was extracted [
41]. The interviews in their original form served as a reference point throughout the analysis.
Ethics
The
study was approved by the Regional Ethical Review Board in Gothenburg,
Sweden (Ref number: 549-12) and conducted in accordance with relevant
ethical guidelines. All participants received detailed study
information, signed a written informed consent form, and were told they
could withdraw from the study at any time. To ensure confidentiality,
the transcripts were coded and the data were presented at the group
level. Some participants took part in the ETT program at their own
expense. Others had the costs covered by the Swedish Social Insurance
Agency, the county council, or employers.
Results
Between
1 September 2012 and 31 July 2015, seven focus groups were conducted
with 23 participants; however, only six groups were included owing to
technical recording and sound problems in the fifth interview. The
interviews lasted for 29–64 min. Twenty informants were included. The
mean age was 61 years (sd = 13.1; range 25–84 years), and 40% were
women. The mean time since the stroke was 30 months (sd = 34.1). The
modified Rankin Scale (mRS) was used to describe the degree of
disability or dependence in activities of daily living [
42]. The characteristics of the 20 informants are described in
Table 2.
Table 2. Characteristics of the included participants.
The data analyses identified a main theme, three categories and eight subcategories. The findings are presented in
Figure 2.
The program—different and hard!
This
category described the multimodal intervention and the experiences of
participating in this program. These experiences included the demanding
nature of the training, the difference between this intervention with
regard to what rehabilitation they had received before; more
individualized and more intense.
The subcategory
Hard, innovative therapy
describes the strenuous nature of the training. Some participants
thought it might have been the hardest thing they had experienced so
far. Participants also noted that when they managed to perform a task,
the rehabilitation team increased the level of difficulty. One
participant put it like this:
“The philosophy is that the things that
are easy, that you know how to do, those things you don´t have to
practice. But the things that are hard, are the most important to
manage.” [Male, age > mean, mRS > mean, time since stroke < mean]. Another said
“It borders on the impossible, all the time. If something is too easy, they increase…”
[Male, age < mean, mRS < mean, time since stroke > mean].
Additionally, participants noted that the training was versatile and
comprehensive:
“The training was multifaceted. I mean, there are so many different tasks one gets to do during a day. It’s very varied.” [Male, age > mean, mRS < mean, time since stroke < mean].
According
to the participants, the interventions differed considerably from the
rehabilitation they had received at home—an observation captured in the
subcategory
Unlike rehabilitation at home. The
intervention was more fitted and individualized, they noted, than the
rehabilitative interventions at home. One participant stated:
“The
big difference is, I think, that it’s very customized here. Adapted for
each and every one. What you got at home was a standard program. One
should kick a little bit there and pull a little here and then it’s
supposed to be fine. Here it’s totally different for everyone, or
everyone that´s been here.” [Male, age < mean, mRS < mean,
time since stroke > mean]. They appreciated the intense,
noncompensatory training and commented on the novelty of this approach
for them:
“Yes, many new muscles. I feel it, that there are many new
muscles that until now have been weak. My rehabilitation until now has
been weak. I´ve been to both X (hospital) and Y (hospital)1
and this is the first place where they have focused on my weak side. On
all the other places they have only worked on my strong side.” [Female, age < mean, mRS < mean, time since stroke > mean].
The subcategory
The significance of the environment
describes the respondents’ experience of training in an environment
that was different from where they received regular care at home. The
positive experience of being in a warm place with beautiful surroundings
close to the ocean was described:
“This clearly means a lot.
Positive surroundings. I only see the colours, the ocean… Most of us
have been ill for a long time, and have perhaps not experienced many
other things during this time. Maybe you’ve had to give up travelling or
other things that you used to do.” [Female, age < mean,
mRS >> mean, time since stroke < mean]. The groups identified the
environment as a healthy one. One stated:
“And that means a lot because you’ve been in so many unhealthy environments since the stroke.”
[Female, age < mean, mRS < mean, time since stroke < mean].
Some mentioned that they had never imagined being able to experience
certain activities again:
“We went to the beach promenade with a
crutch and wandered out in the water until it reached the knees. I did
never imagine that! An incredibly lovely experience.” [Female, age > mean, mRS < mean, time since stroke > mean].
My body and mind learn to know better
The
respondents described changes in their body function and functional
ability and also behavioural changes experienced throughout the ETT
program. They noted changes in their mindset, the importance of learning
more about stroke, and acknowledging and maintaining motivation in the
rehabilitation process.
The subcategory Perceived functional improvement describes the experience of increased functional capacity. For example, “Well,
the thing is that the left hand was more or less dead before. I haven´t
given it a lot of thought, but now I can turn it and put my thumb
against my index finger and stuff like that.” [Male, age > mean,
mRS < mean, time since stroke << mean]. The participants noted
function improvements both in training settings and in daily life
outside the rehabilitation context. One put it like this: “There have
been a lot of things that one hadn’t been able to do upon arrival…that
has gone very well the last week. Maybe not exercises but rather in
practice.” [Male, age < mean, mRS < mean, time since stroke > mean]. Another said: “Well, my goal back then was to learn to walk with a walker, which I think I have succeeded doing quite well.” [Male, age > mean, mRS > mean, time since stroke < mean].
The subcategory Experiences of insights and challenges throughout the program
describes the experience of shaping new attitudes towards exercise,
improvement, and knowledge. They noted the importance of knowing how and why
the rehabilitation was done this way—elements they perceived as
essential in motivating themselves to continue the high-intensity
training. The participants expressed how tough it was to do exercises
that were nearly impossible to accomplish. One participant expressed it
this way: “It has meant a whole lot to gain knowledge also about how
the brain works to keep the motivation and stimulation going and…it is
the effort that counts. It has carried me a lot. Hmm, especially when it
doesn’t work.” [Female, age < mean, mRS < mean, time since
stroke < mean]. The respondents also highlighted the importance of
sustaining the progress they made and viewed future rehabilitative and
daily activities as a challenge. “It became very clear to me that this was only 3 weeks, but there are several more weeks to go…”[Male,
age > mean, mRS > mean, time since stroke < mean]. It became
clear from the interviews that it takes hard work to maintain the
improved functional capacity. “This is not a quick fix, but rather a
struggle. The thing is that you need to get motivated and encouraged to
keep it up. Being damn stubborn. Because if one were to quit now after
all that one has achieved, I think it would disappear quite quickly. [Male, age > mean, mRS < mean, time since stroke > mean].
The need and trust of others
The category Need and trust of others
describes the importance of different external factors identified by
the respondents for a successful rehabilitation. The category highlights
the perceived importance of trust in rehabilitation clinicians and the
support of family and other participants.
To undertake the ETT
program with the intense training included, they had to trust the
competence of the rehabilitation staff, represented in the subcategory Trust in competence of physiotherapists and rehab personnel. One participant put it like this: “And
that doesn’t mean that the exercises was rather demanding and you
thought that…but I knew that she was there (the doctor) and that felt
safe in a way.” [Male, age > mean, mRS > mean, time since
stroke < mean]. The enthusiasm and positive attitude of the rehab
staffs was described as important and motivating: “We have had very enthusiastic physiotherapists. I think that has meant a lot (the others agree). Happy all the time.” [Male, age < mean, mRS < mean, time since stroke < mean].
During
the rehabilitation period, strong connections developed between the
group members. Meeting with others in the same situation was perceived
as both inspiring and comforting, a sentiment captured in the
subcategory The group as a source for motivation and cheerfulness.
The group setting was noted as an important factor in self-motivation,
and following the progress of others was both comforting and pleasing: “And you watch the others and their progress and so, and get inspired by that.”
[Male, age > mean, mRS > mean, time since stroke < mean]. The
group setting was also important for the attitude towards one’s own
impairment, and a source of comfort in challenging moments. One stated: “It
has been a fantastic group of very positive individuals that had very
positive attitudes although they were more severely disabled than me.” [Male, age > mean, mRS > mean, time since stroke < mean]. Another said “And you are sweating and you are crying and you are laughing together, goddammit”
[Male, age > mean, mRS > mean, time since stroke < mean]. The
bonding between group members was evident. One responder put it like
this: “And I had never expected that going away on a training camp
would result in such deep relationships with people that I´d never met
before whom I’d probably would never had met, if I had not been here.” [Male, age > mean, mRS > mean, time since stroke < mean].
Another external factor identified by the respondents was The support from family and relatives. Many participants were accompanied by relatives, whose attendance was described as significant. One participant said “It feels good that someone has seen what I have done, bridging over to home, I think…”
[Female, age < mean, mRS < mean, time since stroke < mean].
The presence of family or relatives was described as important as they
could verify the functional achievements and help translate some of the
functional gains to the home environment. “It was important today
when I was accompanied by my wife at the gym and she saw me walk 6 h, no
I mean, 6 min with my walker! That was important for her! Very
important! She had never seen that before.” [Male, age > mean, mRS >mean, time since stroke <<< mean].
Discussion
In
this study, we sought to elucidate the experience of a combination of
environmental enrichment and intense task-specific rehabilitation for
individuals in a chronic phase after stroke. The participants reported
perceptions of improved function, increased knowledge, new insights and
perceptions of rehabilitation needs, as well as enriching emotional
impacts. These results support the efficacy of environmental
modifications that entail complex, multisensory stimulation in producing
functional improvements in a clinical stroke population. Even though
the participants were in the chronic phase of stroke, the effect seemed
prominent, consistent with previous findings [
43,
44].
Our
aim was to translate basic research on environmental enrichment and
intense task-specific training to a clinical chronic stroke setting.
Previous studies of patients in the acute [
45] and subacute [
17]
phase of stroke undergoing inpatient rehabilitation aimed to translate
an EE model to a clinical environment in different ways. Those studies
indicated that as compared to a regular clinical setting, EE may
increase the activity level and the social and cognitive engagement of
individuals in an acute clinical stroke setting [
45],
and in the subacute phase, it has been showed that the individuals
engaged in EE were more likely to do “any activity” compared to
individuals in the control group [
17].
Another EE study in a larger inpatient cohort including chronic stroke
and several other neurological disorders, showed that an EE program can
give significant improvements in functional and cognitive ability [
18].
Few studies have added intense training and training outside the ward
to the EE paradigm before us, and no earlier study have tried to
highlight the experience of this kind of enriched therapy. The findings
of this study might contribute to insights and further knowledge about
how to best implement EE in clinical practice.
In rehabilitation
contexts involving multidisciplinary team care, patient motivation and
engagement seem to be associated with positive outcomes [
2]. Among our study participants, the theme
It’s hard but possible—but not alone!
emerged after the EE program. The participants described physical
improvements both in the training facility and in activities of daily
life, revealing both the perception of enhanced physical performance
capacity and an increased likelihood of further recovery. These insights
most likely contributed to the participants’ perception of their
overall health, since the degree of motor function, balance, walking
capacity, and independence in activities of daily living is important
for the perception of health-related quality of life [
46].
The
experience of multimodal interventions for stroke survivors has been
described in other contexts. For example, in a study of music-and-rhythm
therapy [
47],
the participants came to terms with their changed bodies as a result of
the therapy, leading to feelings of being connected with their bodies.
In our study, both the experience of
perceived physical improvements and a change of mindset in terms of
experiences of insights and challenges was revealed.
Trust in the rehabilitation personnel and the
Hard, innovative therapy were also highlighted as important components. In another study [
43],
a multimodal intervention program with rhythm and music as operating
ingredients contributed to positive experiences in terms of motor
enhancements. The study also showed the importance of social
interactions, challenging exercises, and skilled instructors [
43].
Another recent Swedish study explored chronic stroke survivors’
experiences of another multimodal intervention, horseback riding [
44].
As a result of the therapy, the participants reported increased
self-efficacy and self-esteem as well as perceived improvements in
balance and gait—all of which could be transferred to everyday life [
44].
It remains to be established which component of EE, incorporating a
number of behavioural experiences – or ER - in combination with other
components (exercise, task-specific training), that promote recovery
following stroke [
20].
In our study a combination of physical, social and environmental
content was applied, but which component of the therapy that the
responders experienced as the most beneficial needs to be further
investigated. Additionally, the cognitive component of EE may be further
developed and refined in future programs, to enhance the therapeutic
effectiveness in cognitive domains.
The category
Perceived functional improvement
described the experience of functional improvement as a result of the
ETT program. In a study of the experience of rehabilitation late after
stroke, patients appreciated physiotherapy, as it was believed to
generate functional improvement [
48].
That study also revealed that patients considered the therapists to be
sources of advice and information, as well as contributors to faith and
hope. In our study, the competencies of the physiotherapists and rehab
personnel was described as comforting.
The ETT intervention had
physical, social, and environmental content and was individually
tailored, and the activities were conducted at the limit of each
patient’s ability. A systematic review of the experience of physical
rehabilitation for stroke survivors have reported negative experiences
of disempowerment, boredom, frustration, no reflections of personal
goals in therapy. In that study, they also found that the rehabilitation
could be improved by increasing activity both within formal therapy and
in free time [
49].
In our study, the participants found the intensity and duration of the
therapy sessions to be challenging, and sometimes close to the limit of
what they perceived was possible. Nevertheless, they felt confidence in
the intensity of the program and trusted the rehab personnel. The
perception that gains in functional capacity resulted from their hard
work motivated the participants to continue the high-intensity program.
The interviews revealed disappointment with regard to the rehabilitation
that participants’ had received at home: “
Why haven’t I received this earlier?” Evidently, the ETT program met patient needs that are not usually addressed by traditional interventions.
Given the lack of stimulation, and socialization among many individuals with chronic stroke [
6],
we believe the social and physical environment are important components
of the ETT program. Our results also highlight two key elements of the
program:
The group as a source for motivation and cheerfulness and
The significance of the environment.
The use of the outdoor environment using community activities might be a
beneficial way to enhance the transition from inpatient to home in
order to get the participant to reintegrate back into community
activities. A previous study [
23]
explored the experience of access to EE in stroke survivors undergoing
rehabilitation. In their study, the participants’ reported increased
social interaction. In our study, a very strong connection between
participants and identification with other group members was revealed.
Even though the content of ETT was individually tailored, the therapy
took place in a group setting, and the small group size may have
contributed to the familiar atmosphere described by responders.
Methodological considerations
Although
this study has implications for our understanding of the effectiveness
of enriched rehabilitation, the results must be considered within the
context of limitations that may have been present. The interviews were
conducted on the last day of the ETT program. Had we interviewed the
participants some weeks later, we could have explored perceptions
concerning the effects of the program on their choice of activities,
life situation, and relationships with people in the home environment.
Unfortunately, reassessment in Sweden was impractical because of the
large geographical spread of the participants. In addition, since all
participants chose themselves to apply to the ETT program, and payment
for the intervention differed (the Swedish social insurance system,
employer, partly self-paid), the results might have been influenced by
the participants’ own expectations. A limitation in this study is that
we did not measure whether the ETT resulted in welcome side-effects such
as reductions in health care utilization, medication intake or falls.
Future studies should explore the cost benefit of enriching intense
post-stroke therapies. The credibility of the data was supported by
enrolling individuals with a wide variety of disabilities after stroke,
including mild aphasia. The interviews were done in small groups of 3–4
participants. The moderator did strive to gather reports from all
respondents. Yet, it might have been difficult for some individuals to
make their opinion clear in the group setting. The fact that some of the
participants had aphasia or a cognitive decline made the interviews
heterogeneous. In a previous study by Dalemans et al. [
50],
it was shown that aphasia severity has a unique contribution to social
participation, next to other factors like age, gender and functional
performance. By combining individuals with mild aphasia with those
without aphasia, we might have unintentionally stifled some of the
participants’ voices. Some of the discussions became somewhat
incoherent; sometimes, when a participant stated something, another
respondent would follow in a focus area unrelated to the first
statement. However, all comments concerning the experience of ETT were
included in the analysis. The quotes in the results came both from
single statements supported by the rest of the group or from discussions
where different statements described the same experience.
In
conclusion, a therapy program that combines the physical, sensory, and
social stimulation combined with an environmental enrichment may affect
the experience of improved function and lead to different emotional
impacts and insights in the chronic phase after stroke.
