Why is this research needed?

National Clinical Guidelines for stroke recommend that stroke survivors should be offered rehabilitation for at least 3 hours a day, 5 days a week. What this rehabilitation is can differ a lot from person to person depending on the effects that a stroke has had and what someone's goals for recovery are. For example, some stroke survivors might want to focus entirely on recovering language skills, while others might want a mix of speech and language therapy and physiotherapy.

However, about two in five stroke survivors don't get any rehabilitation after leaving hospital. This might be because of long waiting lists, time limits on how long after stroke the rehabilitation is offered, staffing shortages, or many other reasons.

One way this problem could be solved is through telerehabilitation - rehabilitation delivered at a distance through means like phone calls, video recordings, or emails. This could increase service capacity, reduce costs, and make it easier to personalise therapy and monitor progress. However, telerehabilitation needs to be approached with caution. Most studies in this area are small so it's hard to know whether positive findings would generalise to large groups.

PRACTISE lead researcher Professor Lorna Paul and team member Dr Elaine Coulter founded a Community Interest Company called Giraffe Healthcare. Working with patients with experience of physiotherapy, they co-developed a new telerehabilitation platform that delivers a home-based physiotherapy programme they think could be useful for stroke survivors.

The PRACTISE team now want to test whether the programme works with stroke survivors in Lanarkshire and Tayside in preparation for a larger randomised controlled trial that could help build the evidence base for the programme to be adopted by the NHS.

What are the aims of this research?

The PRACTISE team plan that a participant in the Giraffe Healthcare programme will go through the following steps:

• Collaborating with a physiotherapist to set rehabilitation goals using the Goal setting and Action Planning (G-AP) framework.
• Following a tailored exercise programme that starts with in-person visits from a physiotherapist and progresses to a phone or video call every other week. Throughout, they practice exercises on their own using the telerehabilitation platform and with support from a carer if relevant and record what they've done in an exercise diary.
• Learning about ways to self-manage physiotherapy, like how to deal with difficulties that might make doing exercises harder. This is partly through chats with a physiotherapist and partly through a self-guided workbook.

To begin with, the team will work with stroke survivors and physiotherapists to create the workbook for stroke survivors and a guidance manual for physiotherapists. Once these are ready, they'll trial the programme with around 60 people who've had a stroke within the last few months and have returned home from hospital. They want to understand whether the programme is working for stroke survivors, carers and physiotherapists. This will include exploring whether it might need adapting for some groups of stroke survivors - for example, someone who's also facing thinking and memory difficulties after a stroke might need extra support to do the programme. The overall goal is to understand whether the programme is working well for everyone and whether the PRACTISE team are asking participants the right kinds of questions about their experience of the programme before they move on to a bigger clinical trial.

What is the benefit of this research?

We're in desperate need of ways to ensure that stroke survivors get the recommended amount of physiotherapy after leaving hospital. If PRACTISE and the planned follow-up clinical trial are successful, the Giraffe Healthcare programme could help more stroke survivors to reach their physical rehabilitation goals, live independently, and enjoy life to the fullest. While it's designed for community-based physiotherapy at the moment, the PRACTISE team also hope to adapt it to work for stroke survivors at different points in the recovery pathway, such as transitioning from hospital to home. This would open up the benefits of the programme to even more stroke survivors.

What PSP priorities does this research link to?

From 2019 to 2021, we worked with the James Lind Alliance on the Stroke Priority Setting Partnership (PSP). During the PSP process, we collaborated with people with lived experience of stroke and stroke professionals to find out what they thought were the top priorities in stroke research. From this, we identified the top ten priorities in two areas: prevention, diagnosis and short-term care, and rehabilitation and long-term care.

Now, when researchers apply to us for funding, we require that their work addresses at least one of these priorities, or a priority from the Childhood Neurological Disabilities PSP Top 10 as it relates to childhood stroke.

PRACTISE addresses the following priorities from the Stroke PSP:

• Rehab and long-term care 5: Community stroke services
• Rehab and long-term care 7: Time, place and amount of therapy
• Rehab and long-term care 9: Interventions for strength, fitness, recovery and secondary prevention

Meet the team

PRACTISE is led by Lorna Paul, Professor in Allied Health Science at Glasgow Caledonian University. She is a physiotherapist by training and uses her clinical and research expertise to explore how physical activity can help with managing disease.

“Achieving up to 3 hours of therapy a day Is challenging for anyone. Through the PRACTICE study we aim to support people after stroke who are discharged home from hospital, to take part In more meaningful, goal based therapy using tools like telerehabilitation with the aim of Improving functional outcomes and quality of life after stroke.”

The other members of the team include:

• Keith Jenkinson and Peter White, stroke survivors who use their experience of physical disability and physiotherapy to support the planning and delivery of PRACTISE.
• Dr Elaine Coulter, Lecturer in Physiotherapy at Glasgow Caledonian University. Elaine is an expert in telerehabilitation and will work with Keith, Peter and other people affected by stroke to make sure that PRACTISE reflects their views, priorities and needs.
• Dr Jacqui Morris, Reader in Rehabilitation Research at the University of Dundee. Jacqui leads on delivering the Giraffe Healthcare programme in the Tayside area.
• Dr Lesley Scobbie, Clinical Lecturer at Glasgow Caledonian University and the creator of G-AP, the goal-setting technique that PRACTISE participants use. Lesley developed G-AP during her Stroke Association-funded lectureship.
• Lisa Kidd, Professor of Nursing at Glasgow Caledonian University. Lisa is an expert on self-management after stroke (when a stroke survivor manages the long-term effects of their stroke in their own way) and is also a team member on the Stroke Association-funded TELSTAR project.
• Frederike van Wijck, Professor of Neurological Rehabilitation at Glasgow Caledonian University. Frederike is an expert in complex medical interventions, ways for people to improve their health that require several different stages or components.
• Carol Bugge, Professor of Nursing at Glasgow Caledonian University. Carol is an expert in process evaluation - that is, understanding whether an intervention is working as intended.
• Helen Mason, Professor of Health Economics at Glasgow Caledonian University. Helen uses her expertise to explore whether the Giraffe Healthcare programme is likely to be cost-effective for the NHS.
• Professor Mark Barber, Consultant Physician in Geriatric Medicine in NHS Lanarkshire. Mark is the medical lead for PRACTISE.
• Dr Katie Gallacher, GP and Senior Clinical Research Fellow at the University of Glasgow. Like Lesley, Katie has also been a Stroke Association-funded lecturer. She will use her expertise in primary care to help guide the progress of PRACTISE.
• Graeme MacLennan, Professor of Medical Statistics at the University of Aberdeen. Graeme leads on statistical analysis for PRACTISE.