The Stroke Management Training and Inpatient Rehabilitation Discharge Education (STRIDE) Mindfulness/Meditation and Neuroplasticity Participant Materials

Background

After having the opportunity to have a clinical in Acute Inpatient Rehabilitation (AIR) at UNC, I completely fell in love working with patients with neurological conditions including patients with strokes. I loved it so much that I changed my trajectory of my PT career and I hope to continue working with this population in this setting in the future. I heard about Dr. Cassidy’s Stroke Management Training and Inpatient Rehabilitation Discharge Education (STRIDE) study during my AIR clinical experience and admired the purpose making me excited to see if I could be a part of the study. I reached out and was thrilled to be able to join the research team and be directly involved throughout the entire fall semester. I spent time deep in the research of this study: I recruited patients, I spoke with patients weekly as they were in the study, I helped synthesize interviews, etc. I loved being a part of the research team and seeing how much time, work and effort it takes to create a program like the STRIDE study. It was through my weekly conversations with participants that I realized there was still room to grow this research study for future use. My participants were craving more knowledge about other areas related to stroke. With my capstone, I hope to enhance the STRIDE program and provide additional resources for patients with strokes at UNC AIR who decide to participate in the STRIDE study, but also provide information that could potentially be used in other locations or programs in the future.

 

Statement of Need

The STRIDE program is intended to help bridge the gap between being in acute inpatient rehabilitation (with all the support and guidance) to the transition home (where patients are left to figure things out and hopefully get back to their lives with their “new normal”). In the STRIDE study, patients are given a Fitbit to track movement, education modules with corresponding self-assessment quizzes, and communication between a research coordinator and a buddy (fellow stroke patient) to call once a week. The goal of daily activity monitoring, social support, and education is to help participants stay engaged in their health and wellness after discharge from the hospital after a stroke. The current modules within the program cover the necessities of stroke. Specifically, they include powerpoints and written documents explaining stroke knowledge, secondary conditions, psychosocial aspects, caregiver roles, safety, nutrition, aerobic exercise, and community resources and support. However, after working directly with patients throughout the study, participants were craving more information about stroke and gaining independence at home. Thus, Dr. Cassidy loved this idea and wanted to have more modules in a “library” of other resources for the patients if they would like to learn more about other areas related to stroke within their free time and have access to this information in the same way their required modules were made. Two areas that patients specifically mentioned they were curious about or did not understand was in relation to mindfulness/meditation and neuroplasticity. Thus, I created powerpoint modules, outlines, handouts, and voiceovers and a self-assessment tool to enhance the mission of the research study and answer the needs and wants of the participants.

 

Purpose

The purpose of this capstone is to review the current literature regarding mindfulness/meditation and neuroplasticity and translate that knowledge into applicable, meaningful, and digestible materials to help STRIDE participants become independent and knowledgeable of their condition to live longer and fuller lives.

 

Products

In the STRIDE study, the participants are given weekly modules on a specific topic provided both in a written outline and/or through a video link. My additional module topics (mindfulness/meditation and neuroplasticity) follow the same format including a powerpoint of the material, a written outline from the material in the powerpoint, and a voiceover recording of the powerpoint. Additionally, I created handouts of the biggest points if individuals did not want to look at an entire powerpoint/outline for both topics as well.  

Mindfulness and Meditation Products

FinalCopyMindfulnessandMeditationModule

FinalCopyMindfulnessandMeditationHandout

FinalMindfulnessandMeditationOutline

https://youtu.be/UJ3g0hOcrg4

Neuroplasticity Products 

FinalCopyNeuroplasticityModule

FinalCopyNeuroplasticityHandout

FinalNeuroplasticityOutline

https://youtu.be/uHL5TIbsOoU

 

Evaluation Component

Throughout my capstone project, I consistently shared my progress with my primary advisor about ideas, formatting, information, health literacy, and product drafts. I also sent my products to my committee members when I finalized rough drafts and final copies to adjust based on their feedback and clinical input as they work directly with this population. Lastly, I utilized Dr. Cassidy’s research group to keep updated on the progress and provide drafts for their feedback.

In the STRIDE study, the participants are provided a short self-assessment through a few quiz questions to determine if they picked up and understood the takeaways from the educational modules. To see if the participants understood the material, I created a self-evaluation tool that is the same format as what is currently used in the STRIDE study with 3 multiple choice or true/false questions to verify understanding. I also enhanced the self-evaluation tools from what is currently used to add short-answer and scales to evaluate the understanding, helpfulness, and impact the material had on the participants.

Evaluation Form and Quiz Questions

FinalCopyPatientEducationMaterialEvaluations

 

Self-Assessment

At the early stages of this capstone, I wanted to create educational materials about in-depth nutrition needs after a stroke, mindfulness and meditation, neuroplasticity, and presentation for PTs who work with the neuro population. I received the feedback that the nutrition module could become out of our scope of PT practice and the presentation may not be as helpful when the STRIDE study is solely for stroke survivors when they discharge from acute inpatient rehabilitation. Thus, I changed my plan to focus on mindfulness/meditation and neuroplasticity patient materials as the core focus for my project to address the population of this research study and stay within the PT scope of practice. Initially for my mindfulness/meditation material I was considering a YouTube channel of practice videos for participants to have access to, but soon found out through research and many hours of listening to apps, that these resources are out there, and I could provide guidelines of those instead. Thus, I added specific resources (apps) and links (YouTube) that I personally thought fit the patient population by certified individuals rather than attempt to create something I was not qualified to do.

Throughout being a part of the research process directly last semester and creating products for the research study through my capstone, I have learned immensely about how to provide materials that are meaningful to patients. I learned how deliberate and intentional each word and each picture need to be to fit such a widespread population of stroke patients with unique circumstances, impairments, and life situations. I learned the importance of providing different ways to learn to patients depending on their needs. Therefore, I included powerpoints, handouts, outlines, and video recordings to provide options depending on patient’s learning styles. Throughout this process, I enjoyed learning about mindfulness and meditation related to stroke as well as the importance of educating patients about neuroplasticity principles to help promote motivation and knowledge, so they want to participate in rehabilitation. I was proud of myself for examining and reviewing the research and evidence behind mindfulness and meditation and neuroplasticity related to stroke and condensing the material to digestible information for patients. I am glad that I have been able to contribute education material for the stroke population that will help enhance the STRIDE program for future participants and hopefully promote greater understanding of how to adjust once home after a stroke to create greater independence.  

 

Acknowledgements

To Jessica Cassidy, PT, DPT, PhD, thank you for including me in your research study to gain key insight into this project and sharing your time to mentor me. Your attentiveness and continual feedback throughout this process was instrumental in helping me create new products to further your research study to provide key information to future STRIDE participants.

To Sean MacBain, PT, thank you for continuing your mentorship past our clinical together to help make my patient materials for STRIDE participants the most clinically meaningful and knowledgeable they could be. Your knowledge and guidance for mindfulness and meditation was extremely meaningful and impactful in helping create those products. Your willingness to help me develop this project and feedback throughout was much appreciated.

To Evwell “E” Batten, OTA, thank you for taking the time to help me in formulating my information to best suit the needs of individuals after a stroke. Your knowledge and guidance from working with these patients every day made your feedback even more important to me and I appreciated your insight throughout this process.

To Ryan Fitzgerald, BS, BA, thank you for incorporating me into the STRIDE research process and guiding and mentoring me throughout the recruitment and duration of the STRIDE study with participants. Your input in that process helped to formulate my ideas for how to enhance the STRIDE study and to create this capstone.  

To Dr. Cassidy’s Research Team, thank you for allowing me to present throughout the creation of my products and providing honest and thoughtful constructive criticism to make it the best products it could be for individuals with strokes in the STRIDE study.  

To Mikalia Guard, SPT, thank you for being the model for key images in products to enhance understanding of the material for participants. Your contribution helped make the information more accessible and was greatly appreciated.

 

References

Mindfulness and Meditation References

1. Rusch HL, Rosario M, Levison LM, et al. The effect of mindfulness meditation on sleep quality: a systematic review and meta-analysis of randomized controlled trials. Ann N Y Acad Sci. 2019;1445(1):5-16. doi:10.1111/nyas.13996
2. Harrison M, Ryan T, Gardiner C, Jones A. Psychological and emotional needs, assessment, and support post-stroke: a multi-perspective qualitative study. Top Stroke Rehabil. 2017;24(2):119-125. doi:10.1080/10749357.2016.1196908
3. Ulrichsen KM, Kaufmann T, Dørum ES, et al. Clinical Utility of Mindfulness Training in the Treatment of Fatigue After Stroke, Traumatic Brain Injury and Multiple Sclerosis: A Systematic Literature Review and Meta-analysis. Front Psychol. 2016;7:912. Published 2016 Jun 23. doi:10.3389/fpsyg.2016.00912
4. Wang X, Smith C, Ashley L, Hyland ME. Tailoring Self-Help Mindfulness and Relaxation Techniques for Stroke Survivors: Examining Preferences, Feasibility and Acceptability. Front Psychol. 2019;10:391. Published 2019 Feb 26. doi:10.3389/fpsyg.2019.00391
5. Jani BD, Simpson R, Lawrence M, Simpson S, Mercer SW. Acceptability of mindfulness from the perspective of stroke survivors and caregivers: a qualitative study. Pilot Feasibility Stud. 2018;4:57. Published 2018 Feb 26. doi:10.1186/s40814-018-0244-1
6. Lawrence M, Booth J, Mercer S, Crawford E. A systematic review of the benefits of mindfulness-based interventions following transient ischemic attack and stroke. Int J Stroke. 2013;8(6):465-474. doi:10.1111/ijs.12135
7. Hilton L, Hempel S, Ewing BA, et al. Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Ann Behav Med. 2017;51(2):199-213. doi:10.1007/s12160-016-9844-2
8. Types of Meditation. headspace. https://www.headspace.com/meditation/techniques. Accessed October 7, 2021.
9. Goldin PR, Gross JJ. Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Emotion. 2010;10(1):83-91. doi:10.1037/a0018441
10. Simkin DR, Black NB. Meditation and mindfulness in clinical practice. Child Adolesc Psychiatr Clin N Am. 2014;23(3):487-534. doi:10.1016/j.chc.2014.03.002

Neuroplasticity References

1. Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008;51(1):S225-S239. doi:10.1044/1092-4388(2008/018)
2. Cassidy JM, Cramer SC. Spontaneous and Therapeutic-Induced Mechanisms of Functional Recovery After Stroke. Transl Stroke Res. 2017;8(1):33-46. doi:10.1007/s12975-016-0467-5
3. Takahashi CD, Der-Yeghiaian L, Le V, Motiwala RR, Cramer SC. Robot-based hand motor therapy after stroke. Brain. 2008;131(Pt 2):425-437. doi:10.1093/brain/awm311
4. About Stroke . American Stroke Association. https://www.stroke.org/en/about-stroke. Accessed February 18, 2022.
5. Desowska A, Turner DL. Dynamics of brain connectivity after stroke. Rev Neurosci. 2019;30(6):605-623. doi:10.1515/revneuro-2018-0082
6. Kaas JH, Nelson RJ, Sur M, Dykes RW, Merzenich MM. The somatotopic organization of the ventroposterior thalamus of the squirrel monkey, Saimiri sciureus. J Comp Neurol. 1984;226(1):111-140. doi:10.1002/cne.902260109
7. Cramer SC, Sur M, Dobkin BH, et al. Harnessing neuroplasticity for clinical applications. Brain. 2011;134(Pt 6):1591-1609. doi:10.1093/brain/awr039
8. Toner J, Moran A. In praise of conscious awareness: a new framework for the investigation of “continuous improvement” in expert athletes. Front Psychol. 2014;5:769. Published 2014 Jul 16. doi:10.3389/fpsyg.2014.00769
9. Krakauer JW. Motor learning: its relevance to stroke recovery and neurorehabilitation. Curr Opin Neurol. 2006;19(1):84-90. doi:10.1097/01.wco.0000200544.29915.cc
10. Mang CS, Campbell KL, Ross CJ, Boyd LA. Promoting neuroplasticity for motor rehabilitation after stroke: considering the effects of aerobic exercise and genetic variation on brain-derived neurotrophic factor. Phys Ther. 2013;93(12):1707-1716. doi:10.2522/ptj.20130053
11. Austin MW, Ploughman M, Glynn L, Corbett D. Aerobic exercise effects on neuroprotection and brain repair following stroke: a systematic review and perspective. Neurosci Res. 2014;87:8-15. doi:10.1016/j.neures.2014.06.007
12. Szelenberger R, Kostka J, Saluk-Bijak J, Miller E. Pharmacological Interventions and Rehabilitation Approach for Enhancing Brain Self-repair and Stroke Recovery. Curr Neuropharmacol. 2020;18(1):51-64. doi:10.2174/1570159X17666190726104139
13. Jadavji NM, Emmerson JT, MacFarlane AJ, Willmore WG, Smith PD. B-vitamin and choline supplementation increases neuroplasticity and recovery after stroke. Neurobiol Dis. 2017;103:89-100. doi:10.1016/j.nbd.2017.04.001
14. Santoro S, Lo Buono V, Corallo F, et al. Motor imagery in stroke patients: a descriptive review on a multidimensional ability. Int J Neurosci. 2019;129(8):821-832. doi:10.1080/00207454.2019.1567509
15. Kaas JH, Merzenich MM, Killackey HP. The reorganization of somatosensory cortex following peripheral nerve damage in adult and developing mammals. Annu Rev Neurosci. 1983;6:325-356. doi:10.1146/annurev.ne.06.030183.001545
16. Kwakkel G, Veerbeek JM, van Wegen EE, Wolf SL. Constraint-induced movement therapy after stroke. Lancet Neurol. 2015;14(2):224-234. doi:10.1016/S1474-4422(14)70160-7
17. Moawad H, Metrus N. How a Stroke Causes Brain Damage . Verywellhealth. https://www.verywellhealth.com/how-does-a-stroke-cause-brain-damage-3146287. Published January 16, 2020. Accessed March 11, 2022.
18. Mark VW, Taub E, Morris DM. Neuroplasticity and constraint-induced movement therapy. Eura Medicophys. 2006;42(3):269-284.
19. Mang CS, Campbell KL, Ross CJ, Boyd LA. Promoting neuroplasticity for motor rehabilitation after stroke: considering the effects of aerobic exercise and genetic variation on brain-derived neurotrophic factor. Phys Ther. 2013;93(12):1707-1716. doi:10.2522/ptj.20130053
20. Hortobágyi T, Granacher U, Fernandez-Del-Olmo M, et al. Functional relevance of resistance training-induced neuroplasticity in health and disease. Neurosci Biobehav Rev. 2021;122:79-91. doi:10.1016/j.neubiorev.2020.12.019
21. Kramer SF, Hung SH, Brodtmann A. The Impact of Physical Activity Before and After Stroke on Stroke Risk and Recovery: a Narrative Review. Curr Neurol Neurosci Rep. 2019;19(6):28. Published 2019 Apr 22. doi:10.1007/s11910-019-0949-4