Suzanne J. Ackerley

Background: Walk ‘n Watch (WnW) is a structured, progressive walking exercise intervention developed for Canadian inpatient stroke rehabilitation. Although its mechanisms align with UK guidance for intensive walking therapy, stroke rehabilitation in the UK is delivered predominantly in the community. This change in service context has implications for safety, feasibility, and fidelity, necessitating structured pre-implementation intervention adaptation to support delivery. Methods: A prospective adaptation process used ADAPT guidance. A multidisciplinary coalition and learning collaborative (UK clinicians, clinical- academics, people with lived experience, and Canadian WnW developers) participated in stakeholder co-production activities. Informed by ADAPT steps 1-2, co-production focused on rationale, core components, contextual mapping and planning adaptations. Discussions were analysed through rapid deductive mapping using Consolidated Framework for Implementation Research (CFIR) domains. Candidate fidelity-consistent adaptations were refined by the learning collaborative. Conceptual outputs of the process were synthesised. Results: Three intervention core components were confirmed: 1) prioritised, high-volume, weight-bearing walking-related activities at moderate effort; 2) structured progression of steps based on performance on a walking test (e.g. Six-Minute Walk Test); 3) objective monitoring of steps and cardiovascular intensity. Several contextual determinants across CFIR domains were likely to influence UK community implementation. Fidelity-consistent modifications to the adaptable periphery were specified across four areas: 1) therapy & practice, 2) environment & safety, 3) monitoring & feedback, and 4) workflow & documentation. Adaptations included hybrid supervision, planned out-of-session practice, and monitoring using validated proxies. A WnW Adaptation Model was produced. Conclusions: This paper provides a transparent pre-implementation adaptation of WnW for delivery within UK community stroke rehabilitation. Anchoring adaptations to intervention mechanisms and principles through co-production and implementation science frameworks, this work establishes a foundation for piloting and hybrid effectiveness–implementation evaluation. The WnW Adaptation Model offers support for future implementation efforts. Discussion positions adaptation as a pragmatic means for applying optimisation principles. PLAIN LANGUAGE TITLE: Adapting the Walk ‘n Watch walking exercise programme for home-based stroke rehabilitation in the UK: A structured step-by-step process PLAIN LANGUAGE SUMMARY: Background: Walk ‘n Watch (WnW) is a structured exercise programme that helps people improve their walking. It was originally developed for people recovering from stroke in hospital in Canada. While the approach fits well with United Kingdom (UK) recommendations for intensive therapy, stroke rehabilitation in the UK often takes place at home. Because of this difference, WnW needs careful adaptation for safe and effective delivery. Methods: Published ADAPT guidance was used to adapt WnW. UK therapists, researchers, people with stroke, and Canadian WnW developers undertook adaptation activities. Together, they identified which parts of WnW were essential, explored differences between the Canadian and UK settings, and planned changes. Discussions were reviewed using an established framework to develop adaptations that kept the most important parts of WnW intact (fidelity-consistent adaptations). The adaptation process was summarised. Results: Three essential intervention parts were confirmed: 1) prioritised, high-volume, weight-bearing walking-related activities at moderate effort; 2) structured progression of steps based on performance on a walking test; 3) objective monitoring of steps and cardiovascular intensity. Several factors were likely to influence delivery in the UK community. Changes focused on four areas: 1) therapy & practice, 2) environment & safety, 3) monitoring & feedback, and 4) workflow & documentation. They included using both in-person and online sessions, planning safe between session practice, and using non-digital monitoring. A WnW Adaptation Model was produced. Conclusions: This paper clearly describes the steps taken to adapt WnW for delivery in UK community stroke rehabilitation. By working closely with stroke experts and using established research frameworks, the adapted programme keeps the most important parts of WnW while allowing it to fit into real-life. The WnW Adaptation Model offers support for further testing and may assist others looking to adapt WnW. Discussion offers perspective on how adaptation aligns with optimising interventions.

Objectives: To determine whether neurorehabilitation can be enhanced through regional implementation of group-based telerehabilitation, we implemented the NeuroRehabilitation OnLine (NROL) innovation regionally and evaluated scale-up from a systems perspective. Design: Observational, exploratory service evaluation using a mixed-methods convergent parallel design. Setting: Stroke and neurological rehabilitation services from four organisations across a regional healthcare system in the UK. Participants: Therapy staff from community-based services and patients with a stroke or neurological condition receiving active community rehabilitation including NROL from April 2022 to March 2024. Intervention: A regional multidisciplinary group-based neurological telerehabilitation innovation (NROL). Outcome measures: Selected Proctor’s implementation outcomes, to establish system-level adoption, acceptability and sustainability of the regional NROL innovation. Results: NROL was adopted by all intended organisations and continues as part of usual care with participation growing. It was acceptable to therapy staff and patients across the region, well-used, valued and supported increased therapy provision. For sustainability, staffing and travel efficiencies were identified through effective collaborative regional systems working. The importance of continued wide stakeholder engagement, robust evaluation and alignment was highlighted. Conclusions: NROL was successfully embedded into real-world practice at a system level and enhanced neurorehabilitation. Looking forward, longer-term sustainment of this innovation will require a compelling business case and value proposition for decision-makers, addressing economic, equality and operational efficiency considerations.

Background: Delivering recommended intensity of neurorehabilitation remains a challenge, with telerehabilitation offering one solution. NeuroRehabilitation OnLine (NROL) is a multidisciplinary, group-based telerehabilitation model embedded within one region in England, showing promise and alignment with healthcare strategic priorities. The importance of scaling successful evidence-informed practices is recognised, however careful adaptation is required to ensure contextual fit and sustainability. Objective: To describe the adaptation of NROL for implementation in a new context. Methods: The four-step ADAPT guidance was applied with previously identified implementation strategies to guide the adaptation of NROL from Region 1 to Region 2. Adaptation activities were co-produced. Contextual factors were detailed using the Consolidated Framework for Implementation Research and the Intervention Sustainability Assessment Tool. The adapted innovation was described using the TIDieR-Rehab checklist. Results: NROL was successfully adapted for Region 2. Step 1 confirmed strategic fit but identified barriers including workforce, infrastructure and resource. Led by an adaptation team and supported by a learning collaborative, Step 2 responded to barriers, retaining core components while tailoring role configuration and materials. Step 3 demonstrated feasibility and acceptability through piloting and phased integration, and improved fit within service pathways. Step 4 focused on sustainment, supported by training, stakeholder engagement, and reporting. Conclusion: This study offers key considerations for scale-up, providing an example of context-sensitive adaptation to a new region, demonstrating how frameworks and co-production can support the adaptation of telerehabilitation models. This example has potential wider use for researchers and implementers tasked with delivering impact, though highlights the effort and resource needed.

Introduction: The six-month review (6MR) for stroke survivors is recommended in clinical guidelines. However, the purpose of the review lacks clarity and has been implemented in variable ways. This study aims to better understand the purpose of the 6MR by comparing and contrasting the perspectives of different interest-holders, and to identify what impact this might have on the functioning of services. Method: This paper reports a qualitative analysis drawn from a multiple case study project. Participants were recruited from three interest-holder groups: Service Providers (staff members), Service Influencers (managers, commissioners and regional leaders), and Service Users (stroke survivors and their carers). Data were collected from semi-structured interviews, clinical observations, and documentary evidence. Interest-holder groups were analysed separately using reflexive thematic analysis. Themes were then compared across interest-holder groups. Results: Thirty-six participants were recruited across three interest-holder groups: Service Providers (n = 8), Service Influencers (n = 6), and Service Users (n = 22). Seven themes were identified: two each for Service Providers and Service Influencers, and three for Service Users. Service providers emphasised a desire to deliver person-centred care but were often constrained by systemic pressures. Service influencers saw the review primarily as a mechanism for population-level data collection and service planning, while also acting as a safety net to capture unmet or evolving needs. Service users typically viewed the review as a routine check-up rather than a pivotal moment in the pathway. For some, it marked the end of formal support while others valued the sense of reassurance and validation it provided. Conclusion: Interest-holders have differing views on the purpose of the 6MR, with tensions emerging between system-level priorities and person-centred care. Greater clarity on the function of the 6MR may help reduce unwarranted variation in its implementation and ensure it delivers meaningful value to all involved.

Background: Delivering recommended intensity of neurorehabilitation remains a challenge, with telerehabilitation offering one solution. NeuroRehabilitation OnLine (NROL) is a multidisciplinary, group-based telerehabilitation model embedded within one region in England, showing promise and alignment with healthcare strategic priorities. The importance of scaling successful evidence-informed practices is recognised, however careful adaptation is required to ensure contextual fit and sustainability. This study describes the adaptation of NROL for implementation in a new context. Methods: The four-step ADAPT guidance was applied with previously identified implementation strategies to guide the adaptation of NROL from Region 1 to Region 2. Adaptation activities were co-produced. Contextual factors were detailed using the Consolidated Framework for Implementation Research and Intervention Sustainability Assessment Tool. The adapted innovation was described using the TIDieR-Rehab checklist. Results: NROL was successfully adapted for Region 2. Step 1 confirmed strategic fit but identified barriers including workforce, infrastructure and resource. Led by an adaptation team and supported by a learning collaborative, Step 2 responded to barriers, retaining core components while tailoring role configuration and materials. Step 3 demonstrated feasibility and acceptability through piloting and phased integration, and improved fit within service pathways. Step 4 focused on sustainment, supported by training, stakeholder engagement, and reporting. Discussion: This study offers a transferable approach for scale-up, providing an example of context-sensitive adaptation to a new region, demonstrating how frameworks and co-production can support the adaptation of telerehabilitation models. This example has potential wider use for researchers and implementers tasked with delivering impact, though highlights the effort and resource needed. PLAIN LANGUAGE SUMMARY: Stroke and neurological rehabilitation services often struggle to provide enough therapy due to staffing and system challenges. Digital delivery of rehabilitation offers one solution. NeuroRehabilitation OnLine (NROL) is a programme that offers live, group therapy and peer-support remotely for people recovering neurological conditions. It has been delivered within one region of England, showing promise and alignment with healthcare priorities. The importance of spreading successful, evidenced practices is recognised, but requires careful consideration to ensure they fit well and can be continued in the new location. This study explains how NROL was adapted for use in a second region. The four-step process called the ADAPT guidance was used with previously identified practical strategies to guide changes to NROL for Region 2. Relevant staff from both regions worked together to ensure the programme met local needs. Evidenced tools were used to understand what made the new region different and to describe the adapted programme clearly. NROL was successfully adapted for Region 2. Step 1 confirmed NROL alignment with healthcare priorities but highlighted challenges including limited staffing and resource. Led by a small team, Step 2 responded to challenges. The core parts of NROL were kept the same, like live group therapy and technology support, but changes were made to the staffing structures and materials. Step 3 tested the changes with small pilot groups and used feedback to improve the programme before wider roll-out and refinement. Step 4 focused on maintaining and reporting the adapted programme. This work offers a transferable approach for spreading evidenced health innovations, providing an example of local needs driving relevant change, and demonstrating how tools and teamwork can support the adaptation process of digital health programmes. This example has potential wider use for researchers and clinical staff tasked with delivering change, though highlights the effort and resource needed.

Background Implementation involves complex interventions, hence the updated Medical Research Council (MRC) framework for developing and evaluating complex interventions (2021) is one approach implementation scientists could use to guide their research. However, despite extensive citations, there is limited evidence of how it has been used in its entirety and little integration with relevant implementation conceptual knowledge. To address this, we provide a novel example of using the updated MRC framework, uniquely demonstrating the potential for incorporating implementation science frameworks, strategies and outcomes. This example uses a telerehabilitation intervention, NeuroRehabilitation OnLine (NROL), implemented within an existing healthcare system. Methods Within a clinical-academic partnership we completed the MRC Framework checklist, and context was described using the updated Consolidated Framework for Implementation Research (CFIR). We used a deliberative process to operationalise the MRC phases: adaptation of NROL based on the ADAPT guidance and establishing feasibility of NROL through concurrent implementation and evaluation. Phases are described in two iterations: within a single service, then when scaled-up as a regional innovation. Stakeholders were involved throughout. Implementation strategies were identified using the CFIR-ERIC matching tool. Selected Proctor’s implementation outcomes were evaluated. Results The MRC framework provided a useful structure when applied iteratively to address key uncertainties for the implementation, and considerations for sustainability, of the complex intervention NROL. Context description was crucial for phase-specific considerations across iterations. An additional sustainment phase was added to the framework, reflecting that the value proposition discussions with decision-makers inevitably culminated in decision-points. This guided decision-making for NROL to be scaled-up. Implementation Research Logic Models were co-produced and iterated to depict programme theory and formalise integration of implementation conceptual knowledge. Conclusion We provide a novel example of the application of the updated MRC framework being described in full, and to our knowledge is the first to comprehensively integrate implementation conceptual knowledge. Synergistic in nature, the MRC framework benefitted the conceptualisation of implementation through use of its phases, and implementation science knowledge was useful in enacting the core elements within the MRC framework. In this example, we emphasised sustainability throughout and include a distinct ‘Sustainment’ phase to advance the MRC framework.

Magnetic resonance spectroscopy indicated higher excitation-inhibition ratios within motor cortex during subacute recovery than age-similar healthy controls. Measures obtained from adaptive threshold hunting paired-pulse transcranial magnetic stimulation indicated greater tonic inhibition in patients compared with controls. Therapeutic approaches that aim to normalize motor cortex inhibition during the subacute stage of recovery should be explored.

High interindividual variability in the recovery of upper limb (UL) function after stroke means it is difficult to predict an individual's potential for recovery based on clinical assessments alone. The functional integrity of the corticospinal tract is an important prognostic biomarker for recovery of UL function, particularly for those with severe initial UL impairment. This article presents a protocol for evaluating corticospinal tract function within 1 week of stroke. This protocol can be used to select and stratify patients in trials of interventions designed to improve UL motor recovery and outcomes after stroke. The protocol also forms part of the PREP2 algorithm, which predicts UL function for individual patients 3 months poststroke. The algorithm sequentially combines a UL strength assessment, age, transcranial magnetic stimulation, and stroke severity, within a few days of the stroke. The benefits of using PREP2 in clinical practice are described elsewhere. This article focuses on the use of a UL strength assessment and transcranial magnetic stimulation to evaluate corticospinal tract function.

Background. The PREP2 algorithm combines clinical and neurophysiological measures to predict upper-limb (UL) motor outcomes 3 months poststroke, using 4 prediction categories based on Action Research Arm Test (ARAT) scores. The algorithm was accurate at 3 months for 75% of participants in a previous validation study. Objective. This study aimed to evaluate whether PREP2 predictions made at baseline are correct 2 years poststroke. We also assessed whether patients’ UL performance remained stable, improved, or worsened between 3 months and 2 years after stroke. Methods. This is a follow-up study of 192 participants recruited and assessed in the original PREP2 validation study. Participants who completed assessments 3 months poststroke (n = 157) were invited to complete follow-up assessments at 2 years poststroke for the present study. UL outcomes were assessed with the ARAT, upper extremity Fugl-Meyer Scale, and Motor Activity Log. Results. A total of 86 participants completed 2-year follow-up assessments in this study. PREP2 predictions made at baseline were correct for 69/86 (80%) participants 2 years poststroke, and PREP2 UL outcome category was stable between 3 months and 2 years poststroke for 71/86 (83%). There was no difference in age, stroke severity, or comorbidities among patients whose category remained stable, improved, or deteriorated. Conclusions. PREP2 algorithm predictions made within days of stroke are correct at both 3 months and 2 years poststroke for most patients. Further investigation may be useful to identify which patients are likely to improve, remain stable, or deteriorate between 3 months and 2 years.

Background. Stroke is a leading cause of adult disability owing largely to motor impairment and loss of function. After stroke, there may be abnormalities in γ-aminobutyric acid (GABA)-mediated inhibitory function within primary motor cortex (M1), which may have implications for residual motor impairment and the potential for functional improvements at the chronic stage. Objective. To quantify GABA neurotransmission and concentration within ipsilesional and contralesional M1 and determine if they relate to upper limb impairment and function at the chronic stage of stroke. Methods. Twelve chronic stroke patients and 16 age-similar controls were recruited for the study. Upper limb impairment and function were assessed with the Fugl-Meyer Upper Extremity Scale and Action Research Arm Test. Threshold tracking paired-pulse transcranial magnetic stimulation protocols were used to examine short- and long-interval intracortical inhibition and late cortical disinhibition. Magnetic resonance spectroscopy was used to evaluate GABA concentration. Results. Short-interval intracortical inhibition was similar between patients and controls (P = .10). Long-interval intracortical inhibition was greater in ipsilesional M1 compared with controls (P < .001). Patients who did not exhibit late cortical disinhibition in ipsilesional M1 were those with greater upper limb impairment and worse function (P = .002 and P = .017). GABA concentration was lower within ipsilesional (P = .009) and contralesional (P = .021) M1 compared with controls, resulting in an elevated excitation-inhibition ratio for patients. Conclusion. These findings indicate that ipsilesional and contralesional M1 GABAergic inhibition are altered in this small cohort of chronic stroke patients. Further study is warranted to determine how M1 inhibitory networks might be targeted to improve motor function.