Enhancing Resilience in Young Stroke Survivors With Res-ET
Condition: Resilience; Stroke
MeSH terms: Stroke
Study type: Interventional

Summary: 
      The proposed pilot study will explore the feasibility and preliminary impacts of a 6-week
      at-home group delivered inspiratory muscle strength training (IMST) exercise intervention on
      resilience in young stroke survivors. Resilience Exercise Training (Res-ET) intervention on
      young stroke survivors will assess feasibility of Res-ET and preliminary changes in
      resilience on young stroke survivors using a quasi-experimental one-group pretest-posttest
      design within the RE-AIM framework. The connection between resilience and exercise has not
      been clearly identified in literature, and there is no literature supporting IMST on
      resilience in young stroke survivors. The Res-ET intervention in young stroke survivors may
      serve as a pragmatic and novel approach to increase resilience while also increasing
      physiological and psychosocial well-being of young stroke survivors.

      Aim 1. Test the feasibility (recruitment, retention, participation, and acceptability) of
      Res-ET intervention in a sample of young stroke survivors having had a stroke between the age
      of 18 - 50, AND who experienced a stroke within the last 6 months to 55 years of age AND have
      been cleared by a physician to participate in IMST exercise.

      Aim 2. Assess the efficacy potential of Res-ET intervention on resilience, and preliminary
      direction and magnitude of psychosocial and physiological outcomes in young stroke survivors
      pre/post Res-ET intervention. Psychosocial outcome measures consist of; positive affect,
      self-efficacy, meaning/purpose, physical function, fatigue, and social satisfaction.
      Physiological outcome measures consist of, pulmonary function, physical activity, biometrics,
      and daily movement.

      Aim 3. Collect qualitative data to assess acceptability and usability of Res-ET. Data will be
      collected through interviews and questionnaires about Res-ET feasibility, perceived utility,
      and satisfaction of the intervention. Perceived changes to resilience, functional
      capacity/movement (ADL's), and well-being will be recorded, transcribed, and thematically
      coded
    

Detailed description: 
      Strokes impact a growing number of younger individuals; it has been reported that
      approximately 10 to15% of all strokes occur in individuals 18 to 50 years of age with
      hospitalization rates almost doubling from 1995 to 2012. Disability or the onset of a chronic
      condition like stroke is often life-altering and this might be exaggerated in persons who
      have a stroke at a younger age at the height of managing family and work responsibilities.
      The FUTURE study reports after a 13.9 year follow up that 44.7% of young stroke patients have
      poor functional outcomes. Young stroke survivors may encounter lifelong challenges impacting
      physical, emotional, visual, and cognitive capabilities. Edwards and colleagues (2019)
      reported young stroke survivors with no early recurrence showed a 7-fold increased hazard
      ratio of long-term risk of adverse outcomes when compared to young healthy controls.
      Post-stroke depression affects approximately one third of all stroke survivors and young
      stroke survivors are nearly three times more likely to have anxiety and depression. Current
      focus in rehabilitation is on acute physical and neurological function and integration, but
      this focus may not necessarily lead to positive long-term outcomes for young stroke
      survivors.

      Resilience is the inherent and acquired ability to recover and sustain a new way of thriving
      after a life altering event or situation. Resilience has been shown to be dependent on
      inherent and acquired factors that have both modifiable and non-modifiable components.
      Understanding the relationship between resilience and disability is still new but it appears
      increased resilience may mitigate secondary symptoms such as pain or fatigue, may predict
      physical functioning, is positively associated to self-efficacy, optimism, and improved
      quality of life. According to Terrill et al.'s (2019) Resilience and Disability model,
      resilience is dependent on intrapersonal, social-environmental, and interpersonal factors
      that dynamically influence an individual's capacity to achieve and maintain quality of life
      and well-being. Interactional aspects of intrapersonal and environmental factors influence
      relationships, systems of support, and combine to create an ecosystem for resilience and
      well-being. Increasing/modifying psychosocial components related to intrapersonal,
      intrapersonal, and environmental factors have been shown to increase resilience such as;
      self-efficacy, positive affect, positive psychological well-being, meaning and purpose, and
      engagement with social environment.

      Exercise may be a potential mechanism for enhancing resilience. For example, Childs and Wit
      (2014) found that regular exercise is associated with psychosocial factors like emotional
      resilience to acute stress in healthy adults and Deuster and Silverman (2013) proposed a
      conceptual model where increased levels of fitness link to increased resilience. Evidence
      also suggests that exercise need not be intensely physically demanding to enhance mental and
      emotional health. The positive effects of low-intensity physical movement programs on
      resilience have not been examined in the young stroke survivors. Exercise has been
      significantly associated with improved self-reported mental health and preliminary findings
      demonstrated exercise improves mental health outcomes after stroke, but empirical studies
      examining these effects are still largely lacking, especially in young stroke survivors who
      are at greater risk of depression and distress.

      Exercise is a commonly prescribed treatment post-stroke, and benefits derived through
      exercise may parallel those identified in the Resilience and Disability model. Exercise
      interventions have the potential to positively influence multiple psychological, physical,
      and psychosocial domains after stroke. Exercise is typically defined as any bodily movement
      produced by skeletal muscles that results in energy expenditure, and is planned, structured,
      and repetitive with a final or an intermediate objective of improvement or maintenance of
      physical fitness. There is strong evidence that exercise after stroke can improve
      cardiovascular fitness, walking ability, and upper-extremity muscle strength. There is also
      evidence that exercise has positive effects on depression and cognition in adults without
      stroke, and preliminary findings demonstrate that exercise may confer similar effects after
      stroke. Although the benefits of regular exercise are well established there is reported low
      patient adherence and motivation for implementation among stroke survivors.

      Inspiratory muscle strength training (IMST) consists of performing repeated inspirations
      against resistance with unopposed expirations and uses the diaphragm and accessory muscles to
      repeatedly inhale against resistance. IMST is performed using either a constant resistance or
      a pressure-threshold device. Airflow through pressure-threshold devices is regulated by a
      valve that fully occludes airflow until a prescribed threshold is exceeded, at which point
      the valve opens to allow airflow. IMST requires the user to develop inspiratory pressures
      that are significantly greater than those produced during tidal breathing and may be similar
      to inspiratory pressures produced during high intensity aerobic exercise. Although IMST is
      not new, novel insights on potential mechanisms for physiological adaptation are promising.
      IMST has been shown to increase respiratory muscle strength, decrease blood pressure,
      increase endothelial function, reduce systemic inflammation, reduce heart rate at rest,
      improve heart rate variability, and during exercise, improve exercise capacity and endurance.
      IMST has been shown to lead to physiological adaptation in a wide range of populations and
      has been identified effective in stroke survivors. In a recent systematic review on
      respiratory muscle training, Pozuelo-Carrascosa et al. identified multiple studies that
      demonstrated increases in pulmonary function, maximal inspiratory pressure, and walking
      ability. IMST exercise prescription for frequency and intensity on stroke populations are
      still being explored and have been used in a wide range of frequencies ranging from 3 times
      p/week up to 7 times p/week and intensities usually expressed in a percentage of maximal
      inspiratory pressure (MIP) ranging from 30% of MIP to 75% of MIP, for durations usually
      expressed in number of breaths or time under tension 5 min (30 breaths) p/session to 60 min
      (100+ breaths) p/session. IMST has the potential to enhance physical health and resilience in
      young stroke survivors.

      INNOVATION

      The feasibility of a remote-home-group delivered Resilience Exercise Training (Res-ET)
      intervention on young stroke survivors is a novel approach to address the current gaps in
      post-stroke care. The psychosocial factors of resilience have been identified and assessed,
      but the relationship between exercise training and resilience in young stroke survivors has
      not yet been explored. Although IMST has been shown to improve certain physiological
      outcomes, its effects on psychosocial outcomes, such as resilience and resilience-related
      factors, are less well known. Furthermore, IMST and resilience have not been studied in the
      context of young stroke survivor's wellbeing. Remote-home-group delivered exercise training
      has the potential to effectively increase Res-ET access to a broad demographic covering a
      wide geographic area. Stroke rehabilitation program Interventions performed in the community
      may have a favorable effect on the prevention of recurrent stroke and cardiovascular events.
      Sarfo and colleagues (2018) performed a systematic review on tele-rehabilitation after stroke
      and found equal or better salutary effects on motor, higher cortical, and mood disorders
      compared to conventional in-person therapy. A recent feasibility study utilized remote
      technology (iGetBetter) for at-home self-management on patients with congestive heart failure
      and had a 95% completion and 80% engagement throughout the study, concluding the remote
      monitoring program leveraging commonly used mobile and portable consumer devices feasible for
      their fairly young patient populations with a mean age of 53. High levels of social support
      have been associated with faster and more extensive recovery after stroke. Group delivered
      Res-ET intervention may potentially increase social-environmental factors relating to
      engagement, adherence, and motivation for young stroke survivors. The Res-ET intervention
      centered in RE-AIM framework may serve as a pragmatic approach in community-based
      rehabilitation to increase resilience while engaging and supporting young stroke survivors
      through group delivered IMST exercise training. Therefore, this intervention will fill a
      crucial gap and potentially highlight a key strategy for enhancing resilience and wellbeing
      in the community for this highly vulnerable young stroke survivor population.
    

Intervention name(s): Res-ET intervention
Intervention type(s): Other
Intervention description(s): Remote IMST delivery on Resilience
Intervention model: Single Group Assignment
Intervention model description: The proposed feasibility study is a rolling enrollment mixed-methods, one-group quasi-experimental design.
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: IMST; Young Stroke Survivor; Resilience; At-home program