Acceptance and Commitment Therapy for Post-Stroke Adjustment Via Telerehabilitation
Phase: NA
Conditions: Stroke, Psychological Flexibility, Acceptance and Commitment Therapy
Sponsor: University of East Anglia

29.07.2025, Version 3 
IRAS ID: 348067 
 
 
Title: ACT for Post-Stroke Adjustment Via Telerehabilitation 
Date Study Approved by REC: 23rd June 2025 
Protocol Version 3 Date: 29th July 2025 
Protocol Amendment Approval Date: 2nd September 2025 
NCT Number: Pending 
 
 
 

ACT for Post-Stroke Adjustment Via Telerehabilitation 
Aims 
The primary aim is to assess the preliminary efficacy of an adapted eight-week group 
of acceptance and commitment therapy (ACT), developed following Majumdar and Morris’ 
2019 study, that is delivered via telerehabilitation using idiographic methods. 
The second aim is to explore the preliminary feasibility and acceptability of the 
intervention for adult stroke survivors. 
Background 
Stroke 
With more than 1.3 million stroke survivors in the UK, stroke is considered one of the 
UK’s main causes of disability (Stroke Association, 2017). The risk of stroke increases 
exponentially with age (Truelsen et al., 2006), but can have a detrimental impact on an 
individual’s life regardless, affecting social interactions (Vickers, 2010), mood (Hilari, 2011) 
and activities of daily living (Hilari, 2011; Lazar & Boehme, 2017). Changes can be 
unexpected and difficulty adjusting could get in the way of rehabilitation (Mahmoud & Elaziz, 
2016), affecting quality of life (QOL) (Bays, 2001; Jeong et al., 2012). Consequently, stroke 
survivors identify improvements to mental health services as an important research area 
(Weerasekara et al., 2021), and psychological intervention for wellbeing and adjustment is 
within the top 10 priorities for stroke rehabilitation (JLA, n.d.). 
According to NICE (2023) Guidelines for psychological functioning in stroke 
rehabilitation, clinicians should assess changes to the way individuals adjust and cope, 
including monitoring of emotional functioning and behaviour. Specifically, Acceptance and 
commitment therapy (ACT) is recommended for those most at risk of anxiety or depression 
post-stroke (National Clinical Guideline for Stroke, 2023). 
 

Acceptance and Commitment Therapy 
 
ACT is a psychological intervention (Harris, 2019; McHugh, 2011) aiming to alter how 
individuals relate to distress following unexpected changes in circumstance, rather than 
change the distress itself (Hayes et al., 2006). ACT is therefore favoured for promoting 
wellbeing in adults living with long-term health conditions, including brain injury (Sander et 
al., 2021), chronic pain (Hughes et al., 2017), and multiple sclerosis (Han, 2021). 
ACT incorporates the hexaflex model, referring to six core components of 
psychological flexibility (PF; Bond et al., 2015), where PF is the ability to act in line with our 
values (Doorley et al., 2020; Harris, 2019). The components include acceptance, contacting 
the present, values, committed action, self as context and defusion (Bond et al., 2015; 
Harris, 2019), which are grouped into a triflex of being present, opening up, and doing what 
matters (Harris, 2019). 
In ACT, distress is considered normal due to the inevitability of adversity which 
prevents individuals from moving toward their goals and values (Harris, 2019). Cognitive 
therapies, however, argue a need to treat and therefore control distress (Hayes et al., 2006). 
This teaches clients to challenge their thoughts (Graham et al., 2015), undermining stroke 
survivors’ understandably difficult circumstances (Gregg et al., 2007). 
Consequently, ACT is preferred for addressing distress post-stroke because those 
with an acquired brain injury (ABI) must learn to accept their new difficulties/limitations and 
live with some uncertainty as part of moving forward with their life (Kangas & McDonald, 
2011). 
ACT Post-Stroke 
The extent ACT reduces distress post-stroke is not yet known (Graham et al., 2015), 
possibly due to no consensus on the format/length of the intervention. However, many 
studies have started identifying the efficacy of ACT on wellbeing post-stroke and (more 

generally, ABI populations) using numerous methods, including case studies, bibliotherapy, 
and single-case experimental designs (Gladwyn-Khan & Morris, 2023; Graham et al., 2015; 
Niu et al., 2022; Ooi & Steverson, 2023; Rauwenhoff et al., 2023; Sathananthan et al., 
2022). 
Considering current waitlists in healthcare and the cost of implementing interventions 
into the NHS, group-based psychological therapies could be more practical. In 2019, 
Majumdar and Morris conducted a four-week, face-to-face ACT group intervention that was 
adapted for stroke survivors. They found that ACT led to clinically significant improvements 
in depression and increased self-reported ratings of health status and hopefulness, 
compared to controls receiving treatment as usual (Majumdar & Morris, 2019). 
Further research comparing ACT to other psychological interventions (such as 
cognitive behavioural therapy) would be beneficial in establishing its true effectiveness, 
providing a potential topic for systematic review. However, a significant problem with 
research thus far, and in particular Majumdar and Morris’ (2019) study, is the focus on 
wellbeing, QOL and mood, rather than the constructs of ACT (Doorley et al., 2020). While 
important to monitor wellbeing with any psychological intervention and its pertinent links with 
acceptance (Lander, 2009; Simione et al., 2021; Townend et al., 2010), it remains unclear 
whether ACT achieves its primary aim in supporting stroke survivors to accept and adjust to 
their circumstances. 
Consequently, qualitative research using a grounded theory approach with Majumdar 
and Morris’ (2019) participants, found preliminary evidence that ACT helps those 
experiencing psychological distress when adjusting post-stroke (Large et al., 2019). Notably, 
this study also proposed modifications for the four-week intervention to improve accessibility 
which has not yet been assessed experimentally (Large et al., 2019). These modifications 
included extending the intervention from four to eight weeks and is currently being rolled out 
in a stroke healthcare setting in Wales NHS. As an initial monitoring of outcomes in a clinical 

setting, the service uses the Short Warwick Edinburgh Mental Wellbeing Scale to monitor 
overall wellbeing and the UK Social Value Bank (HACT, 2017) to assess cost effectiveness 
of the intervention in regard to its impact on wellbeing and quality of life. 
The literature therefore highlights a need for further research into the efficacy of ACT 
for post-stroke adjustment, including the empirical assessment of the modified ACT 
intervention from Majumdar and Morris’ (2019) study. 
Telerehabilitation 
In addition to the benefits of group-based interventions in the NHS, the delivery of 
post-stroke healthcare via telerehabilitation (rehabilitation using technologies such as 
telephone, videoconferencing and web-based resources (Brennan et al., 2009; Signal et al., 
2020)) is recommended in NICE (2023) Guidelines. Telerehabilitation improves accessibility 
of healthcare for those who cannot travel or access transport (Ostrowska et al., 2021). This 
is important given the risk of stroke increases exponentially with age (Truelsen et al., 2006) 
as older adults are more likely to have disabilities (Coleman, 2023) and/or live in rural or 
coastal areas far from healthcare services (Office for National Statistics, 2022). 
To start assessing the efficacy of ACT via telerehabilitation, Ooi and Steverson 
(2023) conducted a case study, finding that six sessions improved psychological distress, 
depression and PF which was also maintained after six months. Given these findings, and a 
recent Cochrane review emphasising a need for more research into the efficacy of 
psychological therapy via telerehabilitation post-stroke (Laver et al., 2020), it is important to 
further explore the efficacy of ACT-based telerehabilitation for post-stroke adjustment. 
Research Questions 
Is group-based ACT delivered via telerehabilitation efficacious in managing post-
stroke adjustment difficulties? 
Is this intervention feasible and acceptable for adult stroke survivors? 

Methods 
Design 
This is a single-case experimental design (SCED) using a small sample size and 
repeated collection of outcome measures (Krasny-Pacini & Evans, 2018). 
In SCEDs, each participant serves as their own control (Tate & Perdices, 2019), but 
to improve validity and reliability, a multiple baseline design (MBD) will be adopted where 
participants are randomly allocated a baseline length before starting the intervention 
(Bouwmeester & Jongerling, 2020). This allows for longitudinal monitoring of stability in 
scores, improving confidence that changes observed are due to ACT and not other factors, 
evidencing “a potential treatment effect” (Slocum et al., 2022, p. 622). 
According to Bouwmeester and Jongerling (2020), the MBD holds more power with 
groups of participants than single cases as outcomes in each phase are averaged. The 
revised “quality rating scale for [the] Risk of Bias in N-of-1 Trials” therefore argues a 
minimum of five datapoints at baseline (Tate et al., 2013, p. 619). This improves monitoring 
of the level, trend, and variability of data, which is important if attrition is high (Kratochwill et 
al., 2010). The baseline length will range from five to seven weeks. 
Attrition is problematic when participant dropout causes less than five datapoints at 
baseline or occurs at a critical timepoint (e.g., during the intervention) (Kratochwill et al., 
2010). Attrition at each stage will be reported in a flow chart, as per the Reporting Standards 
for Research in Psychology (APA, 2008). 
The risk of attrition will be mitigated using a two-phase AB design, whereby A is the 
baseline (control), and B is the intervention (Levin et al., 2021). The longevity of change will 
be monitored three- and six-months post-intervention, reducing study demands compared to 
an ABA design where the second A acts as another control (Kazdin, 2021). Six-month follow-
ups may occur after thesis submission for the purpose of publication if recruitment presents 
a challenge. 

Participants 
Nine adult stroke survivors will be recruited via NHS services (e.g., Early Supported 
Discharge Stroke Teams, IAPT services) and stroke charities. In SCEDs, six participants are 
recommended (Kratochwill et al., 2013), though nine will be recruited to account for attrition, 
with three being assigned to each baseline length (five, six, or seven weeks). 
Inclusion 
Adults (>18 years) will be included if they have: 
• 
Suffered a stroke over three months ago. 
• 
No other neurological illness. 
• 
Not currently receiving any psychological intervention. 
• 
No severe communication difficulties. 
• 
No severe cognitive impairments. 
• 
No current or historical suicidal ideation/self-harming behaviours. 
• 
Not been diagnosed with major long-term health conditions in the last 12 
months (except for stroke or trans-ischaemic attack; TIA). 
• 
Access to a device with a camera, stable internet connection and private space. 
Inclusion criteria ensure any changes are due to the intervention and not other 
factors such as spontaneous recovery from stroke which typically occurs within the first three 
months (Cassidy & Cramer, 2017; Zeiler, 2019); and other rehabilitative or psychological 
programmes. Criteria also ensures the monitoring of post-stroke adjustment rather than 
adjustment to other health conditions. 
Exclusion 
Participants will be excluded if they have: 
• 
Had a TIA without the presence of a stroke. 
• 
No current distress around adjusting to the consequences of stroke. 

• 
  Distress of a severity that it cannot be managed safely in a group therapy 
setting 
Distress will be assessed using the Clinical Outcomes in Routine Evaluation – 10 
(CORE-10) as it is considered valid and reliable in UK primary care populations (Barkham et 
al., 2013). 
Measures 
Outcome measures will be completed weekly, pre- and post-intervention or at three- 
and six-month follow-ups to reduce participant burden associated with frequent 
questionnaire completion. This is important as attrition is more likely amongst stroke 
survivors if studies are time-consuming (Weerasekara et al., 2021). 
Less frequently collected measures were decided based on the secondary gains of 
ACT, the importance for between-study comparisons in assessing intervention efficacy and 
the second aim of feasibility and acceptability. 
While some measures are not validated post-stroke, Bouwmeester and Jongerling 
(2020) suggest that the repeated collection of data in a SCED provides increased reliability 
in the test statistic. 
CompACT-10 
The Comprehensive assessment of Acceptance and Commitment Therapy 
Processes (CompACT) assesses PF (Francis et al., 2016) from the “three dyadic ACT 
processes”: openness to experience (OE), behavioural awareness (BA) and valued action 
(VA) (Golijani-Moghaddam et al., 2023, p. 60). The CompACT-10 (not attached due to 
copyright) has 10 items with acceptable to excellent internal consistency (Cronbach’s alpha, 
α, “total = 0.81, OE = 0.70, BA = 0.79, and VA = 0.75”), test-retest reliability (intraclass 
correlations, ICC, total = 0.83; OE = 0.86; BA = 0.76; VA = 0.89), convergent validity with the 
acceptance and action questionnaire-II (rs = -0.65 and -0.70) and concurrent validity with 

measures of wellbeing (rs = 0.66 and 0.67) amongst UK-representative samples (Golijani-
Moghaddam et al., 2023, p. 64). 
Higher scores indicate greater PF (Golijani-Moghaddam et al., 2023) and will be 
completed weekly during baseline/intervention phases and repeated at follow-up. 
Community Integrated Questionnaire (CIQ) 
The CIQ has 15 items assessing participation in relation to three subscales: 
home/social integration and productivity (Wilier et al., 1994). Each item has a three-point 
scale and is totalled for an overall score, whereby higher scores indicate greater 
independence for activities such as managing finances, housework, 
employment/volunteering and socialising (Dalemans et al., 2010). Data will be collected 
pre/post-intervention and at follow-up. 
The CIQ has high test-retest reliability (ICC = 0.997) amongst geriatric populations 
(Singh & Sharma, 2015) and good internal consistency (α = 0.71 – 0.84) and test-retest 
reliability (ICC = 0.91-0.97) amongst adults with neurological conditions (Turcotte et al., 
2019). The measure has also been extensively used in stroke research (Lee et al., 2015; 
Matos et al., 2020; Sathananthan et al., 2022). 
Clinical Outcomes in Routine Evaluation-10 (CORE-10) 
 
The CORE-10 is a 10-item questionnaire assessing psychological distress that is 
considered valid and reliable in UK primary care populations (Barkham et al., 2013). Each 
item is rated on a 5-point Likert scale from ‘not at all’ to ‘most or all of the time’ and provides 
a total clinical score where higher scores are indicative of more severe psychological 
distress (Barkham et al., 2013). 
 
Amongst a post-acute stroke sample, the CORE-10 was considered to have high 
internal consistency (α = 0.80) and test-retest reliability (ICC = 0.81) as well as acceptable 

concurrent validity with measures of depression and anxiety (r = 0.49 – 0.89) (Steverson et 
al., 2024).  
Aside from its validity and reliability, the CORE-10 was chosen due to its wide use in 
research and clinical settings, allowing for between-study comparisons and monitoring of 
wellbeing for early signposting (see ‘Ethics: Risk Management’). This data will be collected 
pre/post-intervention and at follow-up. 
Stroke-Specific Quality of Life (SS-QoL) 
SS-QoL measures health-related QOL amongst stroke survivors (Vincent-Onabajo et 
al., 2016). The 12-item version refers to domains of self-care, mobility/upper extremity, 
language, vision, thinking, work/family/social roles, personality and mood/energy which are 
rated on a five-point scale to generate a mean total score and physical and psychosocial 
sub-scores (Post et al., 2011). The measure has good internal consistency (α = 0.77 - 0.89) 
(Post et al., 2011) and is validated in a bi-ethnic stroke population (Kerber et al., 2013). 
Higher mean scores indicate better QOL (Vincent-Onabajo et al., 2016). Data will be 
collected pre/post-intervention and at follow-up. 
Short Warwick Mental Wellbeing Scale (SWEMWBS) 
 
SWEMWBS is a seven-item questionnaire that monitors mental wellbeing (Stewart-
Brown et al., 2009). Each positively phrased item is ranked on a Likert-scale of one (none of 
the time) to five (all of the time) and totalled to provide an overall score, whereby higher 
scores indicate better mental wellbeing (Stewart-Brown et al., 2009). The scale has been 
validated across clinical (Shah et al., 2021; Vaingankar et al., 2017) and non-clinical 
populations (Ng Fat et al., 2017), and is comparable to the 14-item version (Ng Fat et al., 
2017). SWEMWBS is also considered responsive to change following therapeutic 
intervention at a group and individual level (Shah et al., 2018). 

Beyond assessing mental wellbeing, the scale also assesses cost effectiveness of an 
intervention in regard to its impact on wellbeing and quality of life (HACT, 2017). Therefore, 
data will be collected pre/post-intervention and at follow-up. 
Feasibility and Acceptability 
Immediately after the intervention, participants will complete a questionnaire created 
for the purpose of this study to address the second aim on intervention acceptability. No gold 
standards for satisfaction scales currently exist, but they typically include satisfaction and 
staff skills (Miglietta et al., 2018). 
Feasibility will be assessed using six criteria monitoring attrition, attendance and 
homework completion, as per previous research (Sathananthan et al., 2022). 
Procedure 
 
A poster will be circulated via NHS services and stroke charities, containing a link to 
an online survey (JISC, 2021). Here, participants can view the information sheet, consent 
form, and eligibility questionnaire. A consent to contact form and researcher contact details 
will be available should anyone prefer discussing the study before consenting to participate. 
To ensure accessibility to the study, the consent to contact form can be signed by the 
individual themselves or, if unable to sign (for example, due to physical impairment following 
stroke preventing ability to write, or due to healthcare appointments being held remotely), 
they can provide verbal consent to be contacted by the researcher to their clinician. The 
clinician can then sign the consent to contact form on their behalf. 
 
Those meeting the inclusion criteria will attend a 30-minute video call to confirm 
eligibility, including ability to use videoconferencing platforms as per guidance for remote 
research (McCarthy et al., 2021). Guidance for accessing video calls will be provided. 
 
Once a group is identified, participants will be randomly allocated to a baseline length 
(five, six or seven weeks) and provided a start date. Visual calendars will mark the dates of 

each phase/task. Reminders and links to the questionnaire will also be sent weekly. During 
baseline and intervention phases, the CompACT-10 (Golijani-Moghaddam et al., 2023) will 
be completed weekly. 
The intervention, delivered by the research team, lasts eight weeks. Each session is 
two hours, including breaks. Permission to access the protocol for the modifications to the 
intervention was granted (Large et al., 2019) and has been received. ACT training will be 
sought for the chief investigator prior to the study commencing. 
Participants will have time at the end of each session for group reflections with 
reminders of where to access mental health support. 
Immediately before and after the intervention phase and at three- and six-month 
follow-ups, participants will complete all questionnaires. At six-months, a 30-minute debrief 
will be offered. 
As per the BPS Code of Human Research Ethics (BPS, 2021), all participants will 
receive a £10 gift card as reimbursement for their time. 
For the purposes of this research, the end of the study will be defined as the date of 
the final data collection point from the last participant. This will mark the completion of all 
study-related procedures, including follow-up data collection. The study will be formally 
closed following data verification and any required reporting to the REC and HRA. 
Patient and Public Involvement (PPI) 
Patient and public involvement (PPI) was conducted with two older adults who have 
suffered a stroke. The purpose was to inform accessibility and readability of the research 
poster, information sheet and consent form. They were also asked to complete the 
questionnaires to ascertain how long it takes to complete and how many breaks would be 
required. They were also involved in discussions around the format of the questionnaires 
(online versus paper) and how to best remind participants at each stage of the study. This 

enabled assessment of potential participant burden of the study and for appropriate 
adaptations to be made.  
The first stroke survivor was an older adult, who has been involved in a multitude of 
PPI over the last 20 years. They have supported various healthcare services, universities, 
charities, research groups and ethics committees to develop projects by participating in 
panels and focus groups, commenting on research materials such as advertisements and 
providing feedback on how to adapt procedures/interventions/designs to improve 
accessibility. This individual provided the perspective of a service user having suffered a 
stroke themselves; the perspective of a carer for someone with a physical health diagnosis; 
and the perspective of a healthcare professional who previously worked on a ward with 
patients who had suffered a stroke. This range of perspectives meant valuable insights were 
provided from multiple angles to improve the accessibility of each aspect of the study in the 
design stage. In particular, they offered insights into how we can best recruit via the NHS 
and provided creative suggestions for overcoming any potential barriers raised. 
The second stroke survivor was an older adult who had suffered two strokes 12 
years ago. They presented with mild aphasia and cognitive difficulties, which sometimes 
impacts word finding or problem solving/processing of complex information. This did not 
significantly impact their ability to communicate or understand information, but they did 
require some additional time for processing. Additional processing time is a common feature 
post-stroke, so they were selected to help us ascertain the potential burden the study 
materials may place on participants. This perspective was critical given the study does not 
plan to exclude those with mild language or cognitive difficulties. Below is a summary of the 
changes made following PPI. 
Recruitment and Eligibility 
 
For the poster, the feedback suggested that it was difficult to process due to being 
quite busy with no clear order of how to read the boxes. Therefore, the font within the main 

body was made bolder, the spacing and arrangement of boxes was improved (increasing 
blank space) and steps (1, 2, 3 etc.) were added to improve readability. Some of the 
language was simplified, including the description of background research and combining 
the two aims into one. There were suggestions of making the benefits to the study clearer, 
though this was not amended to manage expectations of the study. The possible benefits to 
taking part are included in the information sheet, alongside the potential risks, which 
provides a more balanced overview so the individual can feel confident they are making a 
fully informed decision. 
 
For the information sheet and consent form, feedback overall was positive whereby 
comments referred to the layout, design and wording being clear. Within the information 
sheet, a description of what OneDrive is was added as suggested and the explanation of 
what research has shown was improved for coherence. Within the consent form, a line was 
added for participants to consent to the research team contacting them via the details 
provided as this was previously missed. 
There were some suggestions to alter some of the wording within the information 
sheet. This included changing “you will” to “I need you to”. These changes were considered 
but not applied to reduce the likelihood of those reading feeling pressured into taking part. It 
was felt that “you will” conveys that there is structure to the study and may reduce the 
potential impact of demand characteristics by not applying too much emphasis onto each 
component. Moreover, depending on the sentence, the gunning-fog index of the text 
increased if the change was made, so this was avoided to ensure the information is 
simplified for accessibility and reducing the potential for distress when reading. 
 
 The eligibility questionnaire also received comments that it was easy to read and 
follow with a clear layout. Suggestions were made around reminding participants of why we 
are asking for specific personal details (e.g. NOK), so this has been made more explicit. 
There were some questions around whether the distress scale referred to post-stroke 

distress or distress more generally, so this has also been made more explicit at the time the 
question is asked. 
Video Call Instructions 
PPI agreed these were clear and helpful and that it was well set out and logical. It 
was suggested that those unfamiliar with Teams may find it harder to follow, so we discussed 
alternative support that could be provided and agreed that talking to the participant via 
telephone as they are logging into a videocall can be provided prior to the study. It is hoped 
this will improve accessibility to the study. 
Questionnaire Completion   
PPI suggested the questionnaires should be conducted online rather than in paper 
format. Given the group therapy will be held online, they said it can likely be assumed the 
individual can use the basic functions of a device to do the questionnaire online. Additionally, 
it was agreed that paper surveys would increase burden placed on participants, whereby 
paper copies may get lost in the post or at home; they would need to be posted back, and 
not all stroke survivors are independent or able to get out easily; and surveys may not be 
completed at the right time. Therefore, online surveys were considered more practical and 
accessible to a wider population. 
The platform chosen for the online survey (JISC) was one that allows participants to 
pause and return to. This means they do not need to complete the survey in one sitting. If 
they need breaks, this can be done easily, and they will not lose their answers. 
To assess the potential for participant burden, PPI were asked to time how long it 
takes to complete each questionnaire, including recording any breaks they required. The 10-
item questionnaire took one person 2 minutes and another 45 minutes. The 48- item 
questionnaire took both individuals 5-10 minutes to complete. This led to discussions around 
the impact of fatigue and distraction post-stroke so information at the start of every 
questionnaire has been added to encourage participants to complete at a time when they 

are less tired/distracted and to seek support if required. My contact details have also been 
added to every page of the questionnaire so that if the individual requires support in 
completing the questionnaire, they can easily get in contact to discuss. It is hoped this will 
improve participant’s experience of the study by making it easier to complete. 
In regard to the feedback questionnaire, PPI found the questionnaire easy to 
understand and follow. It was suggested that greater emphasis on how the feedback will be 
used will improve the detail in responses. There was a suggestion that discussing the 
feedback with each participant may help to make it feel more personable and as though their 
individual comments are heard. We discussed the potential challenges of this, whereby 
some participants may not feel able to provide honest feedback if asked directly. The 
anonymity of the online questionnaire may help participants feel confident to provide 
critiques and suggestions for improvements. Therefore, it was agreed that giving participants 
the option to discuss the feedback with the research team directly was the next best solution. 
For this reason, this has been explicitly mentioned at the start of the questionnaire. 
The final component PPI were asked to consider was how and when reminders to 
complete the questionnaire should be sent. It became clear that how people are reminded 
can come down to a matter of preference. However, PPI suggested that text messages are 
often more likely to be seen sooner than emails. For this reason, participants will be 
reminded via text (from a work phone) and via email. Links to the questionnaires will be 
provided in both messages, so that they can be accessed however the participant prefers. 
Discussions from PPI indicated that a reminder the day before and on the day would be 
most beneficial, given they must be completed within a certain timeframe. There were also 
suggestions around sending an additional reminder at 5pm on the day the questionnaire is 
due if the participant has not completed the questionnaire. To monitor who has completed 
the questionnaires, a box for participants to provide their initials has been added to the start 
of every questionnaire (except the feedback questionnaire). It is important the feedback 
questionnaire is anonymous, so participants feel able to disclose honest opinions on their 

experiences of the therapy. In assigning initials to each questionnaire, it will also be possible 
to monitor psychological risk throughout the study to ensure participant safety. 
Ethics 
NHS Research Ethics Committee approval will be sought. 
Informed Consent 
All recruiting avenues will have access to the poster, information sheet, 
inclusion/exclusion criteria and consent forms, outlining the study’s purpose, possible 
benefits/risks and handling of data. Documentation produced is informed by the Health 
Research Authority Guidelines (HRA, 2020). 
Full written informed consent is required to access the eligibility questionnaire and 
individuals will be reminded of their right to withdraw at any time without explanation, as per 
BPS (2021) Ethical Guidelines. To improve accessibility, a consent to contact form is 
available (which can be signed by the individual themselves or by their clinician on their 
behalf following verbal consent to be contacted) and researchers can be contacted directly 
prior to consenting to participate. 
Mental Capacity 
All participants must have capacity to consent to participating. In accordance with the 
Mental Capacity Act 2005 (Department of Constitutional Affairs, 2007), capacity will be 
assumed unless proven otherwise. Appropriate steps will be taken to support individuals to 
make and communicate their decision. If lacking capacity to consent to participating, 
individuals will be excluded as this may impact their ability to engage. 
During the study, capacity to consent to participating will be assumed when 
questionnaires are completed (NHS, 2021). Capacity will be monitored throughout the 
intervention and if no longer stands, participants will be removed from the study given the 
possibility of discussing personal and/or sensitive topics with people they do not know. 

Confidentiality, Anonymity and Data Protection 
All information collected will be on a needs-to-know basis, in accordance with GDPR 
safeguards (ICO, 2020). Reasons for collecting personal information will be provided when 
requested. Data will be stored in a password protected file saved on University of East 
Anglia’s OneDrive which is only accessible by the research team. All personal and 
identifiable information will be stored separately to questionnaire responses. 
Participants will not be pressured into sharing personal details. Information shared 
during the intervention will be of their own volition, not discussed with others and 
anonymised in the final report with pseudonyms and all identifiable information removed. 
While participants will be reminded of confidentiality at the start of each group, the 
sharing of information outside the group cannot be monitored. Participants will be informed 
of this risk prior to consenting to participate. 
During the intervention, participants will be asked to join the videoconference 
platform from a safe/private space (McCarthy et al., 2021) and encouraged against using 
their full name for confidentiality reasons. 
In accordance with the BPS (2021) Code of Human Research Ethics, confidentiality 
will be breached if participants are at risk of physical or psychological harm, including 
contacting their next of kin (NOK), GP, or emergency services. Participants will be informed 
of this prior to consenting to participate. 
Coercion and Deception 
Individuals will not be pressured into participating. All aims of the study will be 
provided prior to consenting. Participants will be reminded of their right to withdraw without 
explanation at the start of each questionnaire and intervention session. 
Participant Distress and Burden 

Questionnaires will be as short as possible and PPI will inform the accessibility of all 
supporting documents, reducing the potential for distress/burden from the point of 
advertisement and throughout. 
While there is preliminary evidence of ACT improving mood post-stroke (Graham et 
al., 2015; Majumdar & Morris, 2019; Ooi & Steverson, 2023; Rauwenhoff et al., 2023; 
Sathananthan et al., 2022), potential risks will be highlighted during recruitment to improve 
feelings of preparedness and reduce the likelihood of distress. 
  Criteria of no severe cognitive impairments or communication difficulties will ensure 
participants can engage with the demands of the study, keeping distress and burden to a 
minimum. Excluding those without access to a private space during the intervention will 
reduce the likelihood of conversations being heard by those not participating and the 
associated distress this may cause for both participants and bystanders. 
To minimise distress and burden during questionnaire completion and the 
intervention, breaks will be provided/encouraged. Group rules will encourage participants to 
be mindful of the sensitive nature of topics discussed and therefore how much they share 
with the group about their personal experiences. 
Risk Management 
Prior to consenting to participate, contact details for mental health 
services/charities/helplines will be provided at the end of the information sheet. This 
information will be re-sent with the questionnaires, during each session and at follow-up. 
When assessing eligibility, individuals will be excluded if they have a history of 
complex mental health difficulties to ensure participants can engage with the content of the 
questionnaires and intervention. This will reduce the likelihood of sensitive topics of suicide 
in the group setting, further reducing the potential for participant distress. 

As discussed under ‘Confidentiality, Anonymity and Data Protection’, participants 
must provide contact details for their NOK and GP at the time of consenting to participate to 
ensure appropriate steps can be taken if concerns for their wellbeing arise. If risk is identified 
during the intervention, as well as contacting the above, the individual(s) will be asked to 
stay on the call to discuss a safety plan. A risk management protocol will be followed. 
Debriefing 
Participants will have space for reflection in each group session. If risk is 
identified/disclosed in a session, participants will receive a 1:1 debrief with signposting as 
appropriate. 
A 1:1 debrief will be given to all participants on study completion, outlining the 
aims/background, procedures taken place and why, and how to seek psychological support. 
Analysis 
Multiple methods of analysis are chosen to improve understanding and confidence in 
the results (Lane & Gast, 2014). These are outlined below. 
Effect Size 
Effect sizes estimate “the magnitude of a relationship”, irrespective of sample size 
(Tarlow & Penland, 2016, p. 228). To assess this, the percentage of non-overlapping data 
(PND) and percentage of data exceeding the median (PEM) are recommended for SCED’s 
with datasets smaller than 20 (Lenz, 2013). 
The PND assesses the degree of change between baseline and intervention phases 
(Lenz, 2013) and can be easily interpreted due to its visual displays (Ma, 2006). It can be 
liable to Type II errors due to its focus on single data points (Ma, 2006; Tarlow & Penland, 
2016), so Lane and Gast (2014) advise against using the PND alone. 

To overcome this, Ma (2006) suggests using PEM which assesses the direction and 
magnitude of change. Scores range from zero to one (Ma, 2006), and while liable to Type I 
errors, is recommended in datasets that have outliers and/or variability (Lenz, 2013).  
Due to their respective limitations, both the PND and PEM will be conducted to 
improve the validity and reliability of the analysis. 
Visual Analysis (VA) 
According to Kennedy (2005), VA is key for a SCED to demonstrate and interpret the 
effect of an intervention. It enables evaluation of the trend, level and stability of data (Lane & 
Gast, 2014).  
Two types of VA will be conducted: a within-condition analysis assessing the pattern 
of data within each phase (Lane & Gast, 2014) and a between-condition analysis comparing 
data between each phase (Kennedy, 2005). 
It is recommended that between-condition VA compares median rather than mean 
scores to minimise the influence of outliers (Lane & Gast, 2014). However, neither VA should 
be utilised in isolation (Lane & Gast, 2014) emphasising the importance of both for this 
project. 
Reliable Change Index (RCI) 
 
It is recommended that VA should be supported by statistical data analyses where 
possible (Bouwmeester & Jongerling, 2020; Morley & Adams, 1991). Therefore, RCI will be 
conducted to understand whether the change observed is significant and reliably exceeds 
what is expected from measurement error alone (Blampied, 2022; Jacobson & Truax, 1991).  
Analyses will monitor changes between pre- and post-intervention scores and will be 
presented in a modified Brinley (scatter) plot (Blampied, 2022). Recommendations proposed 
by McAleavey (2024) will be considered. 
 

References 
APA. (2008). Reporting standards for research in psychology: Why do we need them? What 
might they be? The American Psychologist, 63(9), 839.  
Association, S. (2017). State of the Nation: Stroke Statistics. https://www.stroke.org.uk/ 
stroke /statistics 
Barkham, M., Bewick, B., Mullin, T., Gilbody, S., Connell, J., Cahill, J., Mellor-Clark, J., 
Richards, D., Unsworth, G., & Evans, C. (2013). The CORE‐10: A short measure of 
psychological distress for routine use in the psychological therapies. Counselling and 
Psychotherapy Research, 13(1), 3-13.  
Bays, C. L. (2001). Quality of life of stroke survivors: a research synthesis. Journal of 
Neuroscience Nursing, 33(6), 310-316.  
Blampied, N. M. (2022). Reliable change and the reliable change index: still useful after all 
these years? The Cognitive Behaviour Therapist, 15, e50. https://doi.org/10.1017 
/S1754470 X22000484 
Bond, F. W., Lloyd, J., Flaxman, P. E., & Archer, R. (2015). Psychological flexibility and ACT 
at work. The Wiley handbook of contextual behavioral science, 459-482. 
https://doi.org/10.1002/9781118489857.ch22 
Bouwmeester, S., & Jongerling, J. (2020). Power of a randomization test in a single case 
multiple baseline AB design. PloS one, 15(2), e0228355. https://doi.org/10.1371/ 
journal.pone.0228355 
BPS. (2021, 5th April 2021). BPS Code of Human Research Ethics. The British 
Psychological Society. https://www.bps.org.uk/guideline/bps-code-human-research-
ethics 
Brennan, D. M., Mawson, S., & Brownsell, S. (2009). Telerehabilitation: enabling the remote 
delivery of healthcare, rehabilitation, and self management. In Advanced 
technologies in rehabilitation (pp. 231-248). IOS Press. https://doi.org/10.3233/978-1-
60750-018-6-231 

Cassidy, J. M., & Cramer, S. C. (2017). Spontaneous and therapeutic-induced mechanisms 
of functional recovery after stroke. Translational stroke research, 8, 33-46. 
https://doi.org/10.1007/s12975-016-0467-5 
Coleman, C. (2023). Health care in rural areas. House of Lords Library. 
https://lordslibrary.parliament.uk/health-care-in-rural-areas/ 
Dalemans, R. J., de Witte, L. P., Beurskens, A. J., van den Heuvel, W. J., & Wade, D. T. 
(2010). Psychometric properties of the community integration questionnaire adjusted 
for people with aphasia. Archives of physical medicine and rehabilitation, 91(3), 395-
399. https://doi.org/10.1016/j.apmr.2009.10.021 
Department for Constitutional Affairs. (2007). Mental Capacity Act 2005: Code of Practice. 
TSO, 1-301. https://assets.publishing.service.gov.uk/media/5f6cc6138fa8f541f67 
63295/Mental-capacity-act-code-of-practice.pdf 
Doorley, J. D., Goodman, F. R., Kelso, K. C., & Kashdan, T. B. (2020). Psychological 
flexibility: What we know, what we do not know, and what we think we know. Social 
and Personality Psychology Compass, 14(12), 1-11. 
https://doi.org/10.1111/spc3.12566 
Francis, A. W., Dawson, D. L., & Golijani-Moghaddam, N. (2016). The development and 
validation of the Comprehensive assessment of Acceptance and Commitment 
Therapy processes (CompACT). Journal of Contextual Behavioral Science, 5(3), 
134-145. https://doi.org/10.1016/j.jcbs.2016.05.003 
Frude, N. (n.d.). ACTivate Your Life: Free Online Self-Help Course. Public Health Wales. 
https://phw.nhs.wales/services-and-teams/activate-your-life/ 
Gillespie, D. C., & Cadden, A. P. (2013). The Distress Management System for Stroke 
(DMSS): An approach for screening and initial intervention for post-stroke 
psychological distress. Journal of Nursing Education and Practice, 3(10), 150. 
https://doi.org/10.5430/jnep.v3n10p150 
Gladwyn-Khan, M., & Morris, R. (2023). The efficacy of therapist-supported acceptance and 
commitment therapy-based bibliotherapy for psychological distress after stroke: a 

single-case multiple-baseline study. Behavioural and cognitive psychotherapy, 51(1), 
87-104. https://doi.org/10.1017/S135246582200042X 
Golijani-Moghaddam, N., Morris, J. L., Bayliss, K., & Dawson, D. L. (2023). The CompACT-
10: Development and validation of a comprehensive assessment of acceptance and 
commitment therapy processes short-form in representative UK samples. Journal of 
Contextual Behavioral Science, 29, 59-66. https://doi.org/10.1016/j.jcbs.2023.06.003 
Graham, C. D., Gillanders, D., Stuart, S., & Gouick, J. (2015). An acceptance and 
commitment therapy (ACT)–based intervention for an adult experiencing post-stroke 
anxiety and medically unexplained symptoms. Clinical Case Studies, 14(2), 83-97. 
https://doi.org/10.1177/1534650114539386  
Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving 
diabetes self-management through acceptance, mindfulness, and values: a 
randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2), 
336. https://psycnet.apa.org/doi/10.1037/0022-006X.75.2.336 
HACT. (2017). Valuing improvements in mental health. HACT. https://socialvalueuk.org/wp-
content/uploads/2017/10/HACT-WEMWBS-Report-8pp_PRINT.pdf 
Han, A. (2021). Mindfulness-and acceptance-based interventions for symptom reduction in 
individuals with multiple sclerosis: a systematic review and meta-analysis. Archives 
of physical medicine and rehabilitation, 102(10), 2022-2031. e2024. 
https://doi.org/10.1016/j.apmr.2021.03.011 
Harris, R. (2019). ACT made simple: An easy-to-read primer on acceptance and 
commitment therapy. New Harbinger Publications.  
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and 
commitment therapy: Model, processes and outcomes. Behaviour research and 
therapy, 44(1), 1-25. https://doi.org/10.1016/j.brat.2005.06.006 
Hilari, K. (2011). The impact of stroke: are people with aphasia different to those without? 
Disability and Rehabilitation, 33(3), 211-218. https://doi.org/10.3109/09638288. 
2010.508829  

HRA. (2020). Consent and Participant Information Guidance. https://www.hra-
decisiontools.org.uk/consent/index.html 
Hughes, L. S., Clark, J., Colclough, J. A., Dale, E., & McMillan, D. (2017). Acceptance and 
commitment therapy (ACT) for chronic pain. The Clinical journal of pain, 33(6), 552-
568. https://doi.org/10.1097/AJP.0000000000000425 
ICO, I. C. s. O. (2020, 25th October 2020). GDPR and Research - An Overview for 
Researchers. UK Research and Innovation. https://www.ukri.org/wp-
content/uploads/2020/10/UKRI-020920-GDPR-FAQs.pdf 
Jacobson, N., S, & Truax, P. (1991). Clinical significance: A statistical approach to defining 
meaningful change in psychotherapy research. Journal of Consulting and Clinical 
Psychology, 59(1), 12-19. https://doi.org/10.1037/0022-006X.59.1.12 
Jeong, B.-O., Kang, H.-J., Bae, K.-Y., Kim, S.-W., Kim, J.-M., Shin, I.-S., Kim, J.-T., Park, M.-
S., Cho, K.-H., & Yoon, J.-S. (2012). Determinants of quality of life in the acute stage 
following stroke. Psychiatry Investigation, 9(2), 127. 
https://doi.org/10.4306%2Fpi.2012.9.2.127 
JISC. (2021). JISC Online Surveys Survey Builder. https://www.jisc.ac.uk/ 
JLA. (n.d.). Stroke Rehabilitation and Long-term Care Top 10 Priorities. James Lind Alliance 
Priority Setting Partnerships. https://www.jla.nihr.ac.uk/priority-setting-
partnerships/stroke/stroke-rehabilitation-and-long-term-care-top-10-priorities.htm 
Kangas, M., & McDonald, S. (2011). Is it time to act? The potential of acceptance and 
commitment therapy for psychological problems following acquired brain injury. 
Neuropsychological Rehabilitation, 21(2), 250-276. 
https://doi.org/10.1080/09602011.2010.540920 
Kazdin, A. E. (2021). Single‐case experimental designs: Characteristics, changes, and 
challenges. Journal of the Experimental Analysis of Behavior, 115(1), 56-85. 
https://doi.org/10.1002/jeab.638 
Kennedy, C. H. (2005). Single-case designs for educational research (Vol. 1). Pearson/A & B 
Boston.  

Kerber, K. A., Brown, D. L., Skolarus, L. E., Morgenstern, L. B., Smith, M. A., Garcia, N. M., 
& Lisabeth, L. D. (2013). Validation of the 12-item stroke-specific quality of life scale 
in a biethnic stroke population. Journal of Stroke and Cerebrovascular Diseases, 
22(8), 1270-1272. https://doi.org/10.1016/j.jstrokecerebrovasdis.2012.08.011 
Krasny-Pacini, A., & Evans, J. (2018). Single-case experimental designs to assess 
intervention effectiveness in rehabilitation: A practical guide. Annals of physical and 
rehabilitation medicine, 61(3), 164-179. https://doi.org/10.1016/j.rehab.2017.12.002 
Kratochwill, T. R., Hitchcock, J., Horner, R. H., Levin, J. R., Odom, S. L., Rindskopf, D. M., & 
Shadish, W. R. (2010). Single-case designs technical documentation. What works 
clearinghouse.  
Kratochwill, T. R., Hitchcock, J. H., Horner, R. H., Levin, J. R., Odom, S. L., Rindskopf, D. M., 
& Shadish, W. R. (2013). Single-case intervention research design standards. 
Remedial and Special Education, 34(1), 26-38. 
https://doi.org/10.1177/0741932512452794 
Lander, Z. L. (2009). A qualitative analysis of the phenomena stroke survivors associate with 
post-stroke anxiety. [Doctoral thesis, University of Leicester].  
Lane, J. D., & Gast, D. L. (2014). Visual analysis in single case experimental design studies: 
Brief review and guidelines. Neuropsychological Rehabilitation, 24(3-4), 445-463. 
https://doi.org/10.1080/09602011.2013.815636 
Large, R., Samuel, V., & Morris, R. (2019). A changed reality: Experience of an acceptance 
and commitment therapy (ACT) group after stroke. Neuropsychological 
Rehabilitation. https://doi.org/10.1080/09602011.2019.1589531  
Laver, K. E., Adey‐Wakeling, Z., Crotty, M., Lannin, N. A., George, S., & Sherrington, C. 
(2020). Telerehabilitation services for stroke. Cochrane Database of Systematic 
Reviews(1). https://doi.org/10.1002/14651858.CD010255.pub3 
Lazar, R. M., & Boehme, A. K. (2017). Aphasia as a predictor of stroke outcome. Current 
neurology and neuroscience reports, 17(11), 1-5. https://doi.org/10.1007/s11910-017-
0797-z  

Lee, H., Lee, Y., Choi, H., & Pyun, S.-B. (2015). Community integration and quality of life in 
aphasia after stroke. Yonsei medical journal, 56(6), 1694. 
https://doi.org/10.3349%2Fymj.2015.56.6.1694 
Lenz, A. S. (2013). Calculating effect size in single-case research: A comparison of 
nonoverlap methods. Measurement and Evaluation in Counseling and Development, 
46(1), 64-73. https://doi.org/10.1177/0748175612456401 
Levin, J. R., Ferron, J. M., & Gafurov, B. S. (2021). Investigation of single-case multiple-
baseline randomization tests of trend and variability. Educational Psychology Review, 
33, 713-737. https://doi.org/10.1007/s10648-020-09549-7 
Ma, H.-H. (2006). An alternative method for quantitative synthesis of single-subject 
researches: Percentage of data points exceeding the median. Behavior modification, 
30(5), 598-617. https://doi.org/10.1177/0145445504272974 
Mahmoud, S., & Elaziz, N. A. (2016). Impact of stroke on life satisfaction and psychological 
adjustment among stroke patients during rehabilitation. Life Sci J, 13(3), 7-17. 
https://doi.org/10.7537/marslsj13031602 
Majumdar, S., & Morris, R. (2019). Brief group‐based acceptance and commitment therapy 
for stroke survivors. British Journal of Clinical Psychology, 58(1), 70-90. 
https://doi.org/10.1111/bjc.12198 
Matos, I., Fernandes, A., Maso, I., Oliveira-Filho, J., de Jesus, P. A., Fraga-Maia, H., & Pinto, 
E. B. (2020). Investigating predictors of community integration in individuals after 
stroke in a residential setting: a longitutinal study. PloS one, 15(5), e0233015. 
https://doi.org/10.1371/journal.pone.0233015 
McAleavey, A. A. (2024). When (not) to rely on the reliable change index: A critical appraisal 
and alternatives to consider in clinical psychology. Clinical Psychology: Science and 
Practice. https://psycnet.apa.org/doi/10.1037/cps0000203 
McCarthy, L., Teague, B., Rowe, K., Janes, K., Rhodes, T., Hackmann, C., Samad, L., & 
Wilson, J. (2021). Practice-informed guidance for undertaking remotely delivered 

mental health research. Nurse Researcher, 29(2). https://doi.org/10.7748/nr.2021 
.e1770 
McHugh, L. (2011). A new approach in psychotherapy: ACT (acceptance and commitment 
therapy). The World Journal of Biological Psychiatry, 12(sup1), 76-79. 
https://doi.org/10.3109/15622975.2011.603225 
Miglietta, E., Belessiotis-Richards, C., Ruggeri, M., & Priebe, S. (2018). Scales for assessing 
patient satisfaction with mental health care: a systematic review. Journal of 
psychiatric research, 100, 33-46. https://doi.org/10.1016/j.jpsychires.2018.02.014 
Morley, S., & Adams, M. (1991). Graphical analysis of single‐case time series data. British 
Journal of Clinical Psychology, 30(2), 97-115. https://doi.org/10.1111/j.2044-
8260.1991.tb00926.x 
National Clinical Guideline for Stroke. (2023). National Clinical Guideline for Stroke for the 
UK and Ireland. Intercollegiate Stroke Working Party. 
https://www.strokeguideline.org/ 
Ng Fat, L., Scholes, S., Boniface, S., Mindell, J., & Stewart-Brown, S. (2017). Evaluating and 
establishing national norms for mental wellbeing using the short Warwick–Edinburgh 
Mental Well-being Scale (SWEMWBS): findings from the Health Survey for England. 
Quality of Life Research, 26, 1129-1144. https://doi.org/10.1007/s11136-016-1454-8 
NHS. (2021, 12th October 2021). Mental Capacity Act. Health Research Authority. 
https://www.hra.nhs.uk/planning-and-improving-research/policies-standards-
legislation/mental-capacity-act/ 
NICE. (2023). Stroke Rehabilitation in Adults. National Institute for Health and Care 
Excellence.https://www.nice.org.uk/guidance/ng236/chapter/Recommendations#psyc
hological-functioning 
Niu, Y., Sheng, S., Chen, Y., Ding, J., Li, H., Shi, S., Wu, J., & Ye, D. (2022). The efficacy of 
group acceptance and commitment therapy for preventing post-stroke depression: a 
randomized controlled trial. Journal of Stroke and Cerebrovascular Diseases, 31(2), 
106225. https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106225 

Office for National Statistics. (2022). Voices of our ageing population: Living longer lives. 
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/a
geing/articles/voicesofourageingpopulation/livinglongerlives#:~:text=Across%20Engla
nd%20and%20Wales%2C%202021,aged%2065%20years%20and%20over. 
Ooi, J., & Steverson, T. (2023). Acceptance and commitment therapy (ACT) for post-stroke 
adjustment difficulties via telerehabilitation in a working-age man. The Cognitive 
Behaviour Therapist, 16, e31. https://doi.org/10.1017/S1754470X23000260 
Ostrowska, P. M., Śliwiński, M., Studnicki, R., & Hansdorfer-Korzon, R. (2021). 
Telerehabilitation of post-stroke patients as a therapeutic solution in the era of the 
COVID-19 pandemic. Healthcare, 9(6). https://doi.org/10.3390/healthcare9060654  
Post, M. W., Boosman, H., Van Zandvoort, M. M., Passier, P. E., Rinkel, G. J., & Visser-
Meily, J. M. (2011). Development and validation of a short version of the Stroke 
Specific Quality of Life Scale. Journal of Neurology, Neurosurgery & Psychiatry, 
82(3), 283-286. https://doi.org/10.1136/jnnp.2009.196394 
Rauwenhoff, J. C., Bol, Y., Peeters, F., van den Hout, A. J., Geusgens, C. A., & van Heugten, 
C. M. (2023). Acceptance and commitment therapy for individuals with depressive 
and anxiety symptoms following acquired brain injury: A non-concurrent multiple 
baseline design across four cases. Neuropsychological Rehabilitation, 33(6), 1018-
1048. https://doi.org/10.1080/09602011.2022.2053169 
Sander, A. M., Clark, A. N., Arciniegas, D. B., Tran, K., Leon-Novelo, L., Ngan, E., Bogaards, 
J., Sherer, M., & Walser, R. (2021). A randomized controlled trial of acceptance and 
commitment therapy for psychological distress among persons with traumatic brain 
injury. Neuropsychological Rehabilitation, 31(7), 1105-1129. 
https://doi.org/10.1080/09602011.2020.1762670 
Sathananthan, N., Dimech-Betancourt, B., Morris, E., Vicendese, D., Knox, L., Gillanders, 
D., Das Nair, R., & Wong, D. (2022). A single-case experimental evaluation of a new 
group-based intervention to enhance adjustment to life with acquired brain injury: 

VaLiANT (valued living after neurological trauma). Neuropsychological Rehabilitation, 
32(8), 2170-2202. https://doi.org/10.1080/09602011.2021.1971094 
Shah, N., Cader, M., Andrews, B., McCabe, R., & Stewart-Brown, S. L. (2021). Short  
Warwick-Edinburgh Mental Well-being Scale (SWEMWBS): performance in a clinical 
sample in relation to PHQ-9 and GAD-7. Health and quality of life outcomes, 19, 1-9. 
https://doi.org/10.1186/s12955-021-01882-x 
Shah, N., Cader, M., Andrews, W. P., Wijesekera, D., & Stewart-Brown, S. L. (2018). 
Responsiveness of the short Warwick Edinburgh mental well-being scale 
(SWEMWBS): evaluation a clinical sample. Health and quality of life outcomes, 16, 1-
7. https://doi.org/10.1186/s12955-018-1060-2 
Signal, N., Martin, T., Leys, A., Maloney, R., & Bright, F. (2020). Implementation of 
telerehabilitation in response to COVID-19: lessons learnt from neurorehabilitation 
clinical practice and education. New Zealand Journal of Physiotherapy, 48(3), 117-
126. https://doi.org/10.15619/NZJP/48.3.03 
Simione, L., Raffone, A., & Mirolli, M. (2021). Acceptance, and not its interaction with 
attention monitoring, increases psychological well-being: Testing the monitor and 
acceptance theory of mindfulness. Mindfulness, 12, 1398-1411. 
https://doi.org/10.1007/s12671-021-01607-7 
Singh, U., & Sharma, V. (2015). Validity and reliability of community integration questionnaire 
in elderly. International Journal of Health and Rehabilitation Sciences, 4(1), 1-9.  
Slocum, T. A., Pinkelman, S. E., Joslyn, P. R., & Nichols, B. (2022). Threats to internal 
validity in multiple-baseline design variations. Perspectives on Behavior Science, 
45(3), 619-638. https://doi.org/10.1007/s40614-022-00326-1 
Steverson, T., Marsden, J., & Blake, J. (2024). The reliability, validity and clinical utility of the 
Clinical Outcomes in Routine Evaluation–ten-item version (CORE-10) in post-acute 
patients with stroke. Clinical rehabilitation, 38(7), 944-954.  

Stewart-Brown, S., Tennant, A., Tennant, R., Platt, S., Parkinson, J., & Weich, S. (2009). 
Internal construct validity of the Warwick-Edinburgh mental well-being scale 
(WEMWBS): a Rasch analysis using data from the Scottish health education 
population survey. Health and quality of life outcomes, 7, 1-8. 
https://doi.org/10.1186/1477-7525-7-15 
Tarlow, K. R., & Penland, A. (2016). Outcome assessment and inference with the percentage 
of nonoverlapping data (PND) single-case statistic. Practice Innovations, 1(4), 221. 
https://psycnet.apa.org/doi/10.1037/pri0000029 
Tate, R., & Perdices, M. (2019). Single-case experimental designs for clinical research and 
neurorehabilitation settings: Planning, conduct, analysis and reporting. Routledge.  
Tate, R. L., Perdices, M., Rosenkoetter, U., Wakim, D., Godbee, K., Togher, L., & McDonald, 
S. (2013). Revision of a method quality rating scale for single-case experimental 
designs and n-of-1 trials: The 15-item Risk of Bias in N-of-1 Trials (RoBiNT) Scale. 
Neuropsychological Rehabilitation, 23(5), 619-638. 
https://doi.org/10.1080/09602011.2013.824383 
Townend, E., Tinson, D., Kwan, J., & Sharpe, M. (2010). ‘Feeling sad and useless’: an 
investigation into personal acceptance of disability and its association with 
depression following stroke. Clinical rehabilitation, 24(6), 555-564. 
https://doi.org/10.1177/0269215509358934 
Truelsen, T., Piechowski-Jozwiak, B., Bonita, R., Mathers, C., Bogousslavsky, J., & Boysen, 
G. (2006). Stroke incidence and prevalence in Europe: a review of available data. 
European journal of neurology, 13(6), 581-598. https://doi.org/10.1111/j.1468-
1331.2006.01138.x  
Turcotte, S., Beaudoin, M., Vallée, C., Vincent, C., & Routhier, F. (2019). Psychometric 
properties of the Community Integration Questionnaire: a systematic review of five 
populations. Clinical rehabilitation, 33(11), 1775-1787. 
https://doi.org/10.1177/0269215519867998 

Vaingankar, J. A., Abdin, E., Chong, S. A., Sambasivam, R., Seow, E., Jeyagurunathan, A., 
Picco, L., Stewart-Brown, S., & Subramaniam, M. (2017). Psychometric properties of 
the short Warwick Edinburgh mental well-being scale (SWEMWBS) in service users 
with schizophrenia, depression and anxiety spectrum disorders. Health and quality of 
life outcomes, 15, 1-11. https://doi.org/10.1186/s12955-017-0728-3 
Vickers, C. P. (2010). Social networks after the onset of aphasia: The impact of aphasia 
group attendance. Aphasiology, 24(6-8), 902-913. https://doi.org/10.1080/ 
02687030903438532 
Vincent-Onabajo, G. O., Muhammad, M. M., Ali, M. U., Masta, M. A., & Aliyu, H. N. (2016). 
Social support after stroke: Influence of source of support on stroke survivors’ health-
related quality of life. International Neuropsychiatric Disease Journal, 5(1), 1-9. 
https://doi.org/10.9734/INDJ/2016/20240 
Weerasekara, I., Baye, J., Burke, M., Crowfoot, G., Mason, G., Peak, R., Simpson, D., 
Walker, F. R., Nilsson, M., & Pollack, M. (2021). What do stroke survivors’ value 
about participating in research and what are the most important research problems 
related to stroke or transient ischemic attack (TIA)? A survey. BMC Medical Research 
Methodology, 21, 1-10. https://doi.org/10.1186/s12874-021-01390-y 
Wilier, B., Ottenbacher, K. J., & Coad, M. L. (1994). The community integration 
questionnaire: a comparative examination. American journal of physical medicine & 
rehabilitation, 73(2), 103-111.  
Zeiler, S. R. (2019). Should we care about early post-stroke rehabilitation? Not yet, but soon. 
Current neurology and neuroscience reports, 19, 1-9. https://doi.org/10.1007/s11910-
019-0927-x