PLOS ONE
STUDY PROTOCOL
Nurse-led telerehabilitation intervention to
improve stroke efficacy: Protocol for a pilot
randomized feasibility trial
Stephanopoulos Kofi Junior Osei 1ID *, Emmanuella Adomako – Bempah2, Adelaide
Appiah Yeboah3, Lawrence Akuamoah Owiredu2, Lillian Akorfa Ohene1
1 School of Nursing & Midwifery, University of Ghana, Accra, Ghana, 2 37 Military Hospital, Accra, Ghana,
3 University of Ghana Hospital, Accra, Ghana
a1111111111 * stephanpaosei@gmail.com
a1111111111
a1111111111
a1111111111
a1111111111 Abstract
Background
OPEN ACCESS The prevalence of stroke continues to rise in low-middle income countries. The continual
Citation: Osei SKJ, Adomako – Bempah E, Yeboah rise in stroke cases and increasing prevalence on post-acute needs represent a crucial call
AA, Owiredu LA, Ohene LA (2023) Nurse-led for increased accessibility and utilization of rehabilitation services.
telerehabilitation intervention to improve stroke
efficacy: Protocol for a pilot randomized feasibility
trial. PLoS ONE 18(6): e0280973. https://doi.org/ Aim
10.1371/journal.pone.0280973
The primary objective of the study is to test the feasibility of a nurse-led telerehabilitation
Editor: Doris YP Leung, Hong Kong Polytechnic
intervention in improving self-efficacy among stroke survivors. The findings of the trial are
University, HONG KONG
intended for use in a future larger study.
Received: January 11, 2023
Accepted: May 10, 2023
Methods
Published: June 2, 2023
Participants would be recruited at the University of Ghana Hospital and randomized into an
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review intervention group and a control group. Participants aged� 18 years, diagnosed of stroke at
process; therefore, we enable the publication of most 12months prior the recruitment and requiring moderate level of assistance would be
all of the content of peer review and author considered for eligibility. Participants in the intervention group will receive individualized and
responses alongside final, published articles. The
comprehensive nurse-led rehabilitation therapies in physical, emotional, cognitive and nurs-
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0280973 ing education domains for 6 months, in addition to treatment as usual (TAU). The control
© group will only receive treatment as usual. Follow-up evaluations will occur immediately, 30Copyright: 2023 Osei et al. This is an open
access article distributed under the terms of the days and 90 days after the intervention.
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original Discussion
author and source are credited.
Providing stroke rehabilitation services in low-resource settings presents a significant chal-
Data Availability Statement: No datasets were
lenge due to limited infrastructure and a lack of trained healthcare professionals. The current
generated or analysed during the current study. All
relevant data from this study will be made available study has the potential of contributing to the growing body of evidence on the impact of tele-
upon study completion. rehabilitation services in mitigating these challenges in low-resource settings.
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PLOS ONE Nurse-led telerehabilitation intervention to improve stroke efficacy
Funding: This study was made possible by a grant Trial registration
from the World Innovation Summit for Health
(WISH) a member of the Qatar Foundation. PACTR202210685104862, Pan African Clinical Trial Registry.
Funding was received by SKJO. Website: https://
2022.wish.org.qa/ The funding body did not
contribute the study design.
Introduction
Competing interests: The authors have declared
that no competing interests exist. In low- and middle-income settings, stroke remains one of the major causes of disability and
mortality [1–3]. Patients who suffer a stroke may experience variable degrees of impairment
Abbreviations: IRB, Institutional Review Board;
and, in more serious situations, death. The aftermath of a stroke depends on several factors,
LMICs, Low and Middle Income Setting; PC,
Personal Computer; TAU, Treatment; WHO, World including patient characteristics, emergency health-seeking behaviour, the nature of the stroke,
Health Organization. and post-stroke sequelae [4–6]. It is crucial for stroke survivors with impairments to undergo
rehabilitation as part of the recovery process [7].
According to Knect et al. [8], rehabilitation after stroke plays a critical role in improving
functional, and cognitive outcomes. Other studies have shown that providing emotional and
psychological support for the patient and their caregivers during the rehabilitation process can
greatly contribute to overall success [9, 10].
Traditionally, stroke rehabilitation begins after the patient has been physiologically stabi-
lized and is still on hospital admission [11]. This initial rehabilitation phase is primarily
focused on improving physical functioning and facilitating the patient’s transition back to
their home. This is followed by continuous rehabilitation, which typically takes place between
8 weeks and 6 months after the onset of the stroke. During continuous rehabilitation, patients
make practical adjustments in their homes and try to navigate their natural environment with
minimal assistance [12].
Despite the enormous impact of rehabilitation on recovery and life adjustment post-stroke,
the delivery of equitable and affordable access to rehabilitation remains a challenge globally
[13]. This challenge is more prominent in low and middle income countries (LMICs) due to
limited rehabilitation infrastructure and inadequate number of trained health workers [14]. In
Ghana, access to rehabilitation especially during the continued phase and post-hospital dis-
charge is met with major challenges, including the high cost of available services, limited dedi-
cated stroke rehabilitation services and units, socio-cultural barriers, long waiting times, poor
education on rehabilitation and poor communication with healthcare providers [14, 15]. As a
result, persons recovering from stroke may have several unmet rehabilitative needs which
remains unresolved, and adversely impact the recovery process [14].
These challenges exist partly due to the nature of conventional stroke rehabilitation during
the continuous phase. Patients who are undergoing post-discharge rehabilitation mostly have
to present themselves at the health facility, receive planned therapy and travel back to their
homes [15]. This approach however is wrought with issues such as long travel distances and
financial burden which often deter the stoke survivors from returning to use available services
inf any. During the COVID-19 pandemic, such travels were virtually impossible in some set-
tings creating a greater need to consider other innovative measures of continuing rehabilitative
support even at a distance [16].
Telerehabilitation is becoming a highly considered approach to delivering stroke rehabilita-
tion services. The approach has yielded positive outcomes, including improved stroke self-effi-
cacy, motor functioning, and emotional well-being [17–19]. Telerehabilitation–an emerging
means of delivering rehabilitation services remotely using information technology- is pro-
jected to be a tremendous solution to the current challenges associated with rehabilitation
accessibility. Additionally, a few studies focusing stroke telerehabilitation in Ghana has found
the approach to be feasible, acceptable among patients and clinicians and appropriate for
addressing challenges such as barriers to physiotherapy [20, 21].
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PLOS ONE Nurse-led telerehabilitation intervention to improve stroke efficacy
With a limited number of stroke specialists in the country, stroke nurses and community
nurses in Ghana have to take a prominent role in supporting stroke rehabilitation [22]. As
indicated earlier, the disabling effects of stroke put patients in a critical situation for
increased rehabilitation support. Nurses are uniquely placed to support these patients after
discharge. According to Kirvevold [12] nurses’ roles in post-discharge stroke rehabilitation
includes but are not limited to coordinating treatment and care, providing assistance to sur-
vivors and family, providing informational support, consolation, monitoring condition
progress, and supporting the resumption of roles and activities. These are all major roles that
are crucial for improving patient outcomes and meeting the rehabilitation needs of stroke
survivors and caregivers [23]. However, similar to conventional stroke rehabilitation, nurses’
involvement in stroke telerehabilitation is limited, particularly in LMICs [24]. Inadequate
specialized nurses, limited policies supporting their role in stroke rehabilitation, and a lack
of recognition by other healthcare professionals and caregivers contribute to limitations of
nurses’ involvement and practice in stroke rehabilitation [25]. Regardless, post-discharge
stroke rehabilitation aligns with the mandate of nursing to promote recovery which places
nurses at the core of the process. Despite this assertion, the critical role of nurses in post-dis-
charge stroke rehabilitation especially in LMICs has not been well articulated in existing
literature.
It is against this background that an innovative programme of care was developed. The
pilot phase of the study seeks to understand the feasibility of a nurse-led telerehabilitation
underpinned by the need to support stroke survivors in ADLs performance
accomplishments.
Conceptual framework
The development of the intervention is guided by the self-efficacy model, which posits that an
individual’s belief in their ability to perform to achieve certain goals–in this case, activities of
daily living–plays a significant role in their motivation and behavioral change [26]. The model
suggests that such belief is influenced by a number of sources including mastery experiences,
vicarious experiences, social persuasion, and emotional state [27]. In the context of stroke
rehabilitations, improving self-efficacy could help stroke survivors better engage in rehabilita-
tion activities and ultimately improve their functional outcomes [28].
The nurse-led telerehabilitation intervention in this study is designed to improve the self-
efficacy of stroke survivors by targeting the factors that influence self-efficacy belief. The inter-
vention aims to provide stroke survivors with opportunities for mastery experiences, as well as
vicarious experiences through modelling and guidance through achieving daily activities goals.
Nursing support would also provide feedback and emotional support to further boost the
stroke survivors’ self-efficacy.
The study objective is to assess the feasibility of a nurse-led holistic telerehabilitation
among Ghanaian stroke survivors. The primary objectives of the trial are as follows:
1. Assess the recruitment and retention rates of participants.
2. Assess the user satisfaction of the nurse-led telerehabilitation intervention.
3. Examine the factors influencing user satisfaction of the nurse-led telerehabilitation
intervention
4. A secondary objective of the trial is to measure whether a nurse-led telerehabilitation would
improve self-efficacy of stroke survivors.
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PLOS ONE Nurse-led telerehabilitation intervention to improve stroke efficacy
Methods and analysis
Study design
The trial is a parallel-group (intervention and control groups) randomized controlled study
with 1:1 allocation to assess feasibility of a nurse-led telerehabilitation intervention adminis-
tered remotely at the homes of Ghanaian stroke survivors. Post intervention process evalua-
tion will employ a mixed method approach to exploring feasibility elements of the
intervention.
Study setting
Study participants would be recruited from the University of Ghana Hospital in Accra, Ghana.
The facility has a dedicated stroke outpatient clinic for clients and a physiotherapy unit. We
have already engaged with the chief nurse officer, lead physiotherapist, and head of the stroke
clinic of the hospital, who are key to the success of the participant recruitment process.
Eligibility criteria
Study participants will be considered for inclusion if they meet the following criteria:(1) is 18
years or above (2) diagnosed of a stroke with an onset of 1 week to 12 months prior the inter-
vention (3) has FIM score of 55–100 (Level 3 moderate assistance) (4) total NIHSS score of
5–15 (moderate stroke). However, study participants would be excluded subject to these crite-
ria: (1) has no access to a smartphone and standard internet connectivity (1.0 mgbs) (2) is
unavailable for follow-up interviews (3) has a cognitive impairment (as documented in the
patient’s medical records) that makes it difficult to comprehend the information provided and
limits capacity to provide consent.
Recruitment and screening
Participants would be recruited from the medical department and the stroke clinic of the Uni-
versity of Ghana Hospital. Patients at the study setting would be approached onsite by recruit-
ment nurses who are independent from the study investigators and provided comprehensive
background information about the study, including its risks and benefits during first encoun-
ter as part of inviting them to consider participating. If they opt to participate, eligibility clini-
cal screening based on aforementioned criteria will be completed by the recruiting nurse.
In this regard, the nurse will complete the FIM and NIHSS scores to ascertain eligibility.
Informed consent would be obtained by researchers at this point (S1 Fig). This informed con-
sent has been approved by the Noguchi Institutional Review Board 032/21-22.
Randomization, allocation and blinding
After eligible participants have provided informed consent and undergone baseline screening,
they would be randomly assigned to the intervention group (Nurse-led rehabilitation support
+ Treatment as usual) and control group (only treatment as usual).
Randomization would be conducted by an independent researcher who is not involved in
the study. She will use a combination of block and stratified randomization to assign 40 partic-
ipants to either the intervention group or the control group. Prior to the assignment, partici-
pants would be stratified based on the type of stroke (hemorrhagic vs ischemic). Within each
stratum, participants will be assigned using block randomization with block size of four. Addi-
tionally, the independent researcher would generate random sequence for the block order
with an online random sequence generator (sealedenvelope.com). The sequence numbers
would be written and placed in opaque envelopes by the independent researcher. Immediately
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PLOS ONE Nurse-led telerehabilitation intervention to improve stroke efficacy
a participant signs the consent form, the principal investigator (SKJO) would inform to
sequentially open the envelope in the corresponding block and assign participant to the group
indicated in the envelope.
Participants will not be blinded to the assigned group. Also, It will not be possible to blind
the interventionists (stroke nurses and other health professionals) providing the intervention
in this study. Essentially both parties (participants and interventionists would be unmasked.
However, the assessors of study outcomes would be blinded to the allocation of participants.
Also, assessors gathering baseline data on self-efficacy and any other data after group alloca-
tion would be blinded to the allocation status of participants.
Intervention
Eligible participants would randomly be assigned to either the treatment or control group. Par-
ticipants in control group would receive treatment as usual (TAU) which comprise of two
weekly in-person physiotherapy sessions and two sessions with a medical doctor at the Univer-
sity of Ghana Hospital Participants in the control group would receive upper and lower limb
physical rehabilitation and undergo medical review (medication review and symptom man-
agement) with medical doctors.
Participants in the intervention group would receive comprehensive nursing neurorehabil-
itation support in addition to existing service at the hospital (treatment as usual). The compo-
nents of the intervention are guided by relevant literature, established guidelines [29–31] and
have been reviewed by a panel of experts including two neuroscience nurses, two community
health nurses, three neurologists, one stroke specialist, one physiotherapist and a stroke survi-
vor. Patients would undergo assessment and receive various therapies in appropriate domains
for 6months. A follow-up evaluation would be performed at the end, 30- and 90-days after the
intervention (S2 Fig). The intervention would involve the following components;
Initial and ongoing patient assessment. Participants would undergo various assess-
ments on motor function, cognitive capacity, anxiety and depressive levels and nutritional
status utilizing evidenced-based assessment tools. The initial assessment would span in the
first week of the intervention. Based on the problems and needs identified during the assess-
ment, participants would receive a bundle of interventions in the domains of cognitive reha-
bilitation, physical rehabilitation, emotional support, and stroke education. These
interventions would be provided twice a week in 1hr-to-1hr 30mins per session via video
calls on WhatsApp or phone calls. These calls would be scheduled weekly with the partici-
pants after needs and availability assessment to improve response. Participants with close-by
caregivers would be asked to provide the contacts of their caregivers as back-up. A partici-
pant in the intervention may have 192 sessions maximum or 48 sessions minimum in the
span of the intervention.
Cognitive rehabilitation domain. This domain is mainly focuses on supporting partici-
pants to establish a daily routine, improving memory and attention and mitigating spatial
neglect [32]. We would guide participants in clearly structuring their daily activities based on
their preferences and setting priorities [9]. Participants also be guided in visual scanning activi-
ties, attention training exercises and utilizing memory aids [33].
Physical rehabilitation domain. The aim of physical rehabilitation will be the recovery of
the patient’s motor functioning impacted by stroke [8]. Participants would undergo stroke-
specific impairment assessment using the Fugl-Meyer Assessment (FMA) [34]. Based on iden-
tified needs the participant would undergo graded physical therapy including passive and
activities range of motion exercises, constraint-induced exercises, and stress ball usage with
the support of their caregivers. Caregivers would be provided education on how to support
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PLOS ONE Nurse-led telerehabilitation intervention to improve stroke efficacy
participants through the therapy, and handle equipment such as stress ball. Additionally, par-
ticipants and their caregivers would be educated on proper use of assistive devices for gait and
mobility training.
Emotional support. This domain is geared towards assessing and supporting the emo-
tional status of participants and their caregivers. We would provide counselling sessions to
help identify the extent of loss which greatly influences the emotional status and recovery of
participants [35]. Additionally, study participants would be guided in recognizing their own
emotions and identifying personalized but effective coping strategies [9].
Stroke education. Education lasting from 30 to 60mins based on participant’s and care-
giver’s learning needs would be provided for participants and their relatives per session. The
target of the information provided would focus on improving the participant’s understand-
ing of the disease condition, modifiable risk factors of recurrence, pain management, pre-
venting pressure ulcers, oral and catheter care, continence management, the importance of
following professional dietary recommendations, and healthy nutrition in the recovery pro-
cess [36].
See (Table 1) for details regarding the intervention presented based on the TiDieR
checklist.
Outcomes and outcome measures
Primary outcomes. Based on the CONSORT checklist [37] the pilot study is primarily
aimed at assessing the preliminary feasibility and acceptability of the intervention in the Gha-
naian context.
Feasibility. Feasibility would be measured by retention rate, rate of adverse events and
recording the details of resources used in implementing the intervention. Additionally, dura-
tion of sessions and cost of internet for the research team and study participants would be
captured.
Participant satisfaction. This will include the use of a 12-item Patient Satisfaction with Tele-
health questionnaire to assess the level of satisfaction of participants on delivery of the inter-
vention, time spent, quality of audio-visual channels involved and overall perceived benefits
[38].
Factors influencing user satisfaction: Qualitative data of participant experiences and in-
depth factors that influence their rate level of satisfaction would be captured in order to pro-
vide in-depth explanation of satisfaction levels. This would be guided by an interview probe
designed for purpose.
Secondary outcome. Self-efficacy. The secondary and clinical outcome in focus would be
Stroke Self-efficacy. The goal is assessed potential effectiveness of the intervention in improv-
ing self-efficacy among patients. This would be measured the Stroke Self Efficacy Question-
naire (SSEQ). The SSEQ is a 13-item scalar questionnaire that measures the stroke survivor’s
ability and confidence in performing tasks under self-care, mobility and effective coping. The
scale is also vital for assessing the functional performance of the study participants after the
intervention [39, 40]. This tool is most appropriate because it has been proven to have good
face validity with a Cronbach Alpha of 0.90 suggesting good internal consistency and higher
criterion validity when compared with other self-efficacy scales [41].
Proposed sample size
We aim at recruiting 20 participants per group (total = 40 participants). The size however is
guided by Julious’ rule of thumb for 12 participants per group in pilot trial [42]. The potential
attrition rate estimated is 20% per group. During the follow-up phase, qualitative data on
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PLOS ONE Nurse-led telerehabilitation intervention to improve stroke efficacy
Table 1. Details of intervention.
Component of What (procedures) Who How (mode of Where (location When (schedule), Tailoring
the intervention delivery) of intervention) How much, dose,
intensity
Initial Patient’s baseline Stroke nurses, and • Individual • Patient’s Only once as this All participants would undergo
comprehensive assessment on: physiotherapist and one-on-one home serves as the this initial assessment for
assessment • Motor functioning neuropsychologist as • Calls via cell • Rehab center baseline identification problem.
• Cognitive capacity consultants. phones assessment.
• Levels of anxiety & • video calls
depression
Ongoing Identifying patient’s Stroke nurses • Individual Patient’s home Bi-Weekly • Individualized
assessment • needs one-on-one Every other week
• priority areas • Calls via cell Monthly
• progress and possible phones As needed
deterioration • video calls
• motor functioning
• cognitive capacity
• levels of anxiety and
depression
Cognitive • Guiding patients to Stroke nurses • Individual Patient’s homes • Every other Based on cognitive needs
rehabilitation establish a structured one-on-one week participants may be guided in
domain routine. • calls via cell • A total of 12 using different strategies to:
• Attention training phones. sessions • improve memory and attention.
exercises. • video calls throughout the • mitigate spatial neglect
• learning the proper project
use of memory aids
Physical • Passive and/or active Stroke nurses, • Individual Patient’s homes Twice a week. A Physical domains sessions are
rehabilitation range of motion physiotherapist one-on-one maximum of 48 tailored to the functional needs of
domain exercises • Calls via cell sessions participants. Based on physical
• constraint induced phones throughout the needs, intervention may be guided
therapy and stress-ball project. in using different strategies to:• video call
usage. • Aid those who can walk and
stand with aids.
• Education on proper
usage of assistive • Those who cannot walk but
devices would also be stand with some gait issues.
provided • And those who cannot stand at
all
Emotional • Understanding the Stroke nurses • Individual Patient’s homes • Biweekly Participants would have to the
support domain extent of loss one-on-one • A maximum of opportunity to identify individual
• Recognizing emotions • calls via cell 12 sessions coping strategies.
and mood changes phones throughout the
• Identifying • Video calls project
personalized coping
strategies
Stroke education • modifiable risk factors Stroke nurses • Individual Patient’s homes Every three weeks Certain education topics would be
domain • pain management one-on-one during the provided on one-on-one and based
• Calls via cell intervention on patient needs whereas topics on• pressure ulcer
phones period. modifiable risk factors andprevention
nutrition may be provided in
• nutrition and • Video calls group sessions
continence. • Group
sessions
https://doi.org/10.1371/journal.pone.0280973.t001
participant experiences through one-on-one interviews would be captured from 15 conve-
niently sampled participants from the intervention group. According to Hennick and Kaisser
[43] a 15 sample is appropriate for reaching data saturation. An interview guide designed for
purpose who be used to gather needed data.
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PLOS ONE Nurse-led telerehabilitation intervention to improve stroke efficacy
Data collection, entry and management
Data would be gathered from participants before the intervention but after recruitment and
after the intervention. Baseline data would be gathered on two occasions prior to the interven-
tion. Before randomization, data on participant demographic characteristics, patient history,
functional status, psychological functioning and cognitive capacity would be gathered. Baseline
data on patient’s self-efficacy would be collected before the first session of the intervention via
phone survey. The second phase of data collection would take place immediately after the end
intervention capturing quantitative date on user satisfaction, qualitative data on experiences
throughout the intervention only for participants in the intervention group and stroke-self effi-
cacy levels for participants in both group. The third and final phase of data collection would be
executed 4 weeks and 12 weeks after the intervention respectively capturing stroke efficacy lev-
els in both groups. The data collection process would be undertaken by an independent assessor
who are unaware of participant allocation. After completing each phase of data collection, the
quantitative data would be entered into a spreadsheet using Microsoft Excel. The data would be
processed for outliers and missing inputs. Qualitative interviews would be audiotaped, audios
would be saved in a PC folder and later transcribed for analysis. The entered information and
saved audios would be protected by a password only accessible by the research team.
Data analysis
Quantitative data analysis would be conducted using SPSS v26. The socio-demographic charac-
teristics of participants would be summarized in frequencies and percentages. Continuous data
gathered would be scrutinized for normality and necessary transformation would be applied if
needed. Continuous variables would be summarized using means and SD. Mann-Whitney test
or its parametric equivalent (if possible) would be employed to analyses the difference stroke
self-efficacy levels in both groups at same points of follow-up evaluation. A Friedman test or its
parametric equivalent (if possible) would be employed to ascertain changes in stroke self-effi-
cacy level over the time. Results would be classified as significant if p<0.05 (two-tailed). All
qualitative transcripts exported to NVivo version 10 would be analyzed by reading that data
line by line and making noting down insights as meaning units while the reading is ongoing.
The meaning units would be labeled with a code, this would be done repeatedly to capture all
aspects of the content (data). The codes would then be categorized into sub-categories and
broader categories for identification of themes [44]. Both quantitative and qualitative data
would be compared to identify similarities and differences for the purpose of convergence.
Ethics and dissemination
The current study is targeted at determining the feasibility of a nurse-led telerehabilitation
intervention for stroke patients in a low-resource setting. The study will illuminate the level of
feasibility and effectiveness of this approach in settings similar to Ghana. Additionally, the
study is crucial in further development and designing for similar interventions aimed at
increasing accessibility to stroke rehabilitation using digitalisation. The study has ethical clear-
ance from the Noguchi Memorial Institute of Research–IRB. Additionally, the trial has been
registered in a public domain (PACTR202210685104862, Pan African Clinical Trial Registry).
In the case of protocol modifications, both the IRB and trial registry would be informed using
appropriate channels.
The findings of the study would be disseminated through peer-reviewed journals, nursing
online and offline communities and conferences. Various key stakeholders including the
Noguchi Memorial Institute of Research, the Ministry of Health Ghana and the University of
Ghana Hospital (Legon) would be provided feedback and possibly recommendations based on
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PLOS ONE Nurse-led telerehabilitation intervention to improve stroke efficacy
the findings associated with the proposed study. De-identified dataset at individual partici-
pant-level will be disseminated through peer review journals.
Possible risks and mitigation
There are minimal perceived risks to study participants involved in the intervention. However,
all participants would undergo periodic risk assessments to unearth potential risks of adverse
outcomes. The assessment would be carried out in their homes by the research investigators.
Additionally, participants and their caregivers would be provided emergency dial lines and the
contacts of the researchers in case of an adversity. In case of an adverse event such as falls or
emotional collapse, the researcher (and stroke nurse/ other rehabilitation health worker) work-
ing with the patient at moment would immediately assess the situation, notify emergency sup-
port if participant is in immediate danger (e.g. ambulance service, national suicide hotlines
and participant’s emergency contact) for immediate assistance and continue to engage with
the participant and/or their caregivers until help arrives. If the participant is not in immediate
danger, they would be referred to the University of Ghana Hospital for further assistance. All
adverse events related to the intervention would be well-documented, reported to clinicians in
charge and reviewed. Additionally, the research team has liaised with community health
nurses to provide assessment and further recommendation for patients in their homes.
Discussion
Accessibility to stroke rehabilitation in low-resource settings remains a prevalent challenge
due to limited infrastructure and inadequately trained healthcare professionals [13, 14]. In
Ghana, the challenges are exacerbated especially after hospital discharge by barriers including
limited communication from health workers, socio-cultural barriers, inadequate rehabilitation
education, high cost of available services and long waiting times [15].
There is evidence that nurses–the largest health professional group in Ghana, are uniquely
placed to support rehabilitation services and increase accessibility [12].
The current study is deemed to reveal the effects of a nurse-led telerehabilitation interven-
tion on improving the self-efficacy of stroke survivors in a low-resource setting. The interven-
tion is holistic and draws underpinning insights from relevant literature, a multidisciplinary
team and patients.
Although the approach is therapy-based, the primary goal is to offer individualized and
family-centred rehabilitation support coordinated by nurses. Langhorne, Bernhardt & Kwak-
kel [45] asserts that multidisciplinary involvement, individualizing rehabilitation intervention
and increasing intensity is crucial to the improvement of patient outcomes.
The study would also shed light on the feasibility of this emerging approach in delivering
stroke rehabilitation services in a low-resource setting like Ghana. Additionally, the study
would contribute to the existing literature on the potential impact of telehealth on healthcare
delivery services in Ghana and other LMICs.
Limitations
The study is being conducted on a feasibility scale and involves a small size which may not be
sufficient to detect significant differences between study groups albeit the findings can offer
useful insight into telerehabilitation services for stroke survivors. There is a also notable differ-
ence in the dose and type of the intervention for the control and interventional group which
could impact the validity of outcomes. Additionally, the short-term follow-up periods of the
study limit the ability to explore long-term effects of the intervention.
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PLOS ONE Nurse-led telerehabilitation intervention to improve stroke efficacy
Conclusion
The implementation of a nurse-led telerehabilitation intervention for stroke survivors offers a
potential contribution to mitigating the major challenges that threaten the accessibility of
stroke rehabilitation services after acute management and post-hospital discharge.
Supporting information
S1 Fig. Enrolment, interventions and assessment schedule.
(DOCX)
S2 Fig. Workflow chart.
(DOC)
S1 File. SPIRIT checklist.
(DOCX)
S2 File. CONSORT checklist.
(DOCX)
Acknowledgments
The authors would like to acknowledge the immense support offered by Miriam Iddrisu, Joyce
Pwavra and Samuel Adjorlolo (PhD) all of the University of Ghana School of Nursing and
Midwifery. We are also grateful to Dr Ram Hariharan, Dr Siva Nair, Nurse Hellen Oteng and
Jonathan Bayuo (PhD) for their brilliant comments on this manuscript.
Author Contributions
Conceptualization: Stephanopoulos Kofi Junior Osei, Emmanuella Adomako – Bempah,
Adelaide Appiah Yeboah, Lawrence Akuamoah Owiredu, Lillian Akorfa Ohene.
Funding acquisition: Stephanopoulos Kofi Junior Osei, Emmanuella Adomako – Bempah,
Adelaide Appiah Yeboah, Lawrence Akuamoah Owiredu.
Investigation: Stephanopoulos Kofi Junior Osei.
Methodology: Stephanopoulos Kofi Junior Osei, Adelaide Appiah Yeboah, Lawrence Akua-
moah Owiredu.
Project administration: Stephanopoulos Kofi Junior Osei.
Supervision: Lillian Akorfa Ohene.
Writing – original draft: Stephanopoulos Kofi Junior Osei.
Writing – review & editing: Stephanopoulos Kofi Junior Osei, Lillian Akorfa Ohene.
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