Compared to individuals of a similar age without stroke, individuals post-stroke exhibit reduced physical activity and elevated sedentary time (English et al., 2016; Mahendran et al., 2016; Ezeugwu and Manns, 2017), which likely contribute to the development of secondary complications and hospital readmission. A crucial yet often overlooked post-stroke recovery timeframe is the period from hospital discharge to the commencement of outpatient therapies. This window delineates an individual's transition from a structured therapeutic environment managed by a diverse team of healthcare professionals (Langhorne et al., 2020) to an environment characterized by isolation, self-reliance, disorganization, and often a lack of accessibility to fundamental resources (Adeoye et al., 2019). Coincidently, this timeframe also represents a period of enriched neuroplasticity potential, whereby underlying cellular and molecular mechanisms can propel functional recovery efforts (Cassidy and Cramer, 2017). During this sensitive period, physical activity as part of sensorimotor rehabilitation may prove more impactful (Dromerick et al., 2021). Yet, plateaus or decreases in physical activity are frequently observed post-stroke. A longitudinal study examining physical activity change over the first 6 months following stroke using accelerometers reported that, though the time spent in an upright position increased during the first month after stroke relative to initial hospitalization, no further changes in activity (e.g. upright time, number of transfers, etc.) occurred over the next five months (Askim et al., 2013). Others have also found that, despite increases in activity during inpatient rehabilitation, significant declines were observed by 6 months post-stroke following hospital discharge (Tieges et al., 2015). Lastly, during the subacute period (days to weeks post-stroke), individuals typically completed an average of 5,535 steps per day—a value that diminishes to <4,100 steps per day in the chronic phase (>6 months post-stroke) which is substantially less than the 8,338 steps on average taken by adults without stroke (Fini et al., 2017). These collective findings underscore low engagement in physical activity and missed opportunities to instill autonomy and investment in individuals' health following a major medical event.

As factors such as fatigue, mood, cognition, and motivation contribute to sedentary behaviors (Hopman and Verner, 2003; Tieges et al., 2015; Thilarajah et al., 2018), it is not surprising that post-stroke wellness strategies focused solely on exercise do not foster lasting lifestyle change (Prince et al., 2014; Martin et al., 2015). Rather, long-term engagement in physical activity following stroke depends on a combination of psychological and social factors encompassing self-efficacy, physical activity beliefs, and social support (Morris et al., 2012). A multi-faceted wellness approach is therefore warranted.

We devised an eight-week program (Stroke Management TRaining and Inpatient Rehabilitation Discharge Education, STRIDE) that focused exclusively on individuals preparing to discharge from an inpatient rehabilitation facility (IRF) to home following stroke. The STRIDE program featured three main components entailing [1] activity monitoring using commercially available activity monitors, [2] social support through partnerships with fellow stroke survivors and STRIDE personnel, and [3] weekly education. Forging connections with fellow stroke survivors provides opportunities to exchange personal testimony and support (Damush et al., 2007), while mitigating feelings of depression and/or isolation. The benefits gained from these enhanced personal connections may compel individuals to re-examine preconceived notions of their disability (Graham et al., 2008). Given the advent of inexpensive wearable technology spurring reductions in sedentary behaviors (Fini et al., 2015), combining this technology with social support may yield a synergistic effect in promoting accountability, motivation, and engagement in one's health and recovery post-stroke. The purpose of this pilot study was to determine the feasibility of STRIDE. We defined feasibility as successful initiation of each STRIDE-related component (i.e., activity monitoring, weekly education and quizzes, and social support/communication) and our ability to recruit and enroll our target population from the IRF setting. Successful evaluation of STRIDE component initiation was based on the creation, organization, and delivery of content to participants. Examples of component initiation include the construction of weekly educational models in both online and written formats, in-person activity monitor device training at the IRF, and the establishment of virtual links to access weekly quizzes. Relatedly, our primary goal was to determine participation engagement with STRIDE as demonstrated by their adherence with activity monitoring and documentation, correspondence with a fellow STRIDE participant and STRIDE coordinator, and completion of weekly education and quizzes. A secondary and more exploratory goal of this work was to assess the potential individual-level impact of STRIDE by measuring personal factors such as physical activity, self-efficacy, and quality of life at the beginning and end of STRIDE and also by conducting semi-structured interviews upon STRIDE completion.

Of the 99 individuals screened, 20 individuals enrolled in STRIDE (Figure 1). Enrollment obstacles included language barriers, lack of interest and/or time, medical reasons beyond immediate stroke, global or receptive aphasia, and concerns of adherence based on participant admission and/or assessed by the STRIDE coordinator and/or physician (JMB). Of the 20 participants enrolled (Table 1), 10 engaged in STRIDE for the full 8 weeks, 4 engaged in STRIDE for at least 1 week, and 6 were unable to begin STRIDE upon IRF discharge. On average, participants began STRIDE approximately 10 ± 5 days (range: 4–23 days) following IRF discharge. Reasons for program attrition or inability to begin STRIDE upon hospital discharge included unanticipated death, time constraints, and other unforeseen obstacles experienced after enrollment.

This work demonstrates the development and preliminary deployment of an eight-week stroke management program (STRIDE) across individuals recently discharged to home following their IRF stay. The components of STRIDE, encompassing weekly education, communication with peers and the STRIDE coordinator, and activity monitoring, collectively bridged inpatient and outpatient stroke care. The successful execution of most STRIDE-related components in many from our target cohort from the IRF setting support the feasibility of this program. However, as discussed below, several opportunities were also identified for consideration toward future work. Preliminary examination of changes in self-reported measures and semi-structured interviews also signify the potential of individual-level impact.

Considerable challenges arise during the transition from IRF to home, including the continuity of rehabilitation care, feelings of isolation, and confronting and accepting one's disability status (Buntin, 2007; Cott et al., 2007; Duncan et al., 2020). A qualitative study examining the process of community reintegration one-year after stroke reported that one of the most profound challenges for individuals was their adjustment of expectations related to physical participation (Wood et al., 2010). Aligning with a person-centered rehabilitation model (Jesus et al., 2022) that champions autonomy, collaboration, and self-determination, several self-management programs in post-stroke care have emerged (Nott et al., 2021; Caetano et al., 2023). Pivotal elements of these programs typically encompass education, communication, self-monitoring, goal setting, and problem solving (Littlewood et al., 2013; Clark et al., 2020). The STRIDE program incorporated several of these elements in a novel manner.

Weekly education and quizzes enabled participants to gradually build knowledge over time as compared to the presentation of copious amounts of information in a compressed timeframe (i.e., typically during the hospital discharge process). The reinforcement of knowledge in weekly STRIDE educational modules also aligns with effective post-stroke education practices (Cameron, 2013). Participant feedback further highlighted the relevance of educational topics and content provided in STRIDE, with some participants initiating conversations with their physician and/or gaining a greater understanding of how their stroke experience impacts the lives of their family members. In a few cases, participants requested additional educational topics and suggested a different ordering of weekly modules. Based on this feedback, future STRIDE iterations may promote additional autonomy by providing participants with a “menu” of educational modules for them to choose in any order depending on their individual needs.

Another successful component of STRIDE was daily activity monitoring; although, future iterations of STRIDE should adopt more effective strategies for verifying activity documentation in addition to prepaid return envelopes and self-reports to the STRIDE coordinator (Table 2). Verification of activity documentation for future work may therefore entail participants texting photos of their daily or weekly journal entries to the STRIDE coordinator. Apart from this cohort, the general public has quickly adopted the use of fitness tracking technology (e.g., devices and smartphone apps) to monitor physical activity with approximately one in five Americans utilizing a fitness tracking device (Vogels, 2020). As physical inactivity plays a role in various disease processes and economic burden (Ding et al., 2016), the goal of this technology is to facilitate behavioral change (Patel et al., 2015). Work has shown a positive effect on physical activity as measured by an increase in 1,850 steps per day when comparing interventions featuring a fitness tracking technology in comparison to control interventions (Laranjo et al., 2021). Physical activity promotion with fitness tracking technology also extends to clinical populations including stroke (Lynch et al., 2018; Caetano et al., 2023). However, the purpose of the activity monitors in STRIDE extended beyond the promotion of physical activity, as we sought to empower participants through [1] learning new technology, [2] monitoring relevant metrics, and [3] recording these metrics in an activity journal/log. For several participants, the monitors enhanced self-awareness, which sometimes resulted in behavioral modification and goal setting (Table 3). Because our outcome measure in STRIDE focused on adherence rather than a particular activity metric, we were able to broaden our enrollment criteria, thereby, ensuring the accessibility of STRIDE across a wide range of physical ability levels, technology proficiencies, and socioeconomic realities. It is important to acknowledge the increasing utilization of commercially available activity monitors to assess post-stroke mobility (Peters et al., 2021) and the ongoing work needed in this field to determine the accuracy of these devices in stroke (Holubová et al., 2022). A trade-off in our work, which encouraged Fitbit wear on the paretic upper extremity for purposes of donning/doffing ease, was likely data accuracy. Recent work has shown that the accuracy of these devices in stroke varies according to body placement which, in turn, varies according to the level of assistive device use during ambulation (Holubová et al., 2022). Future iterations of STRIDE that may utilize tracker metrics as primary or secondary outcome measures, may therefore revisit tracker placement in order to achieve both donning/doffing ease and data accuracy.

Communication was another critical self-management element implemented in STRIDE, occurring through buddy partnerships and STRIDE coordinator correspondence. Participants adhered to the bimonthly communication schedule with the STRIDE coordinator. In fact, the majority of participants increased their communication frequency with the coordinator to a weekly basis, which underscores the valuable role of the STRIDE coordinator in this program. Self-management programs often feature a “transition coach” that “functions as a facilitator of interdisciplinary collaboration encouraging self-management, modeling empowerment, providing information, and facilitating interdisciplinary collaboration across transitions” (Cott et al., 2007). Our STRIDE coordinator fulfilled several of these functions by establishing partnerships with participants during their IRF stay, initiating communication with participants immediately upon discharge to home, addressing participants' questions based on needs of that individual, and also serving as an active listener for participants. Communication between participants, however, did not flourish. Peer support is a vital component of stroke self-management programs as it cultivates the sharing of testimony and learning amongst individuals (Clark et al., 2020). Our intention was to assemble buddy partnerships between participants with similar IRF discharge timeframes, but this proved challenging due in part to recruiting and enrolling participants sharing similar discharge timeframes. We surmise that a lack of structure or framework embedded in the partnerships was ultimately the reason why this component of STRIDE was not successful. A future approach may entail a second STRIDE coordinator responsible for facilitating partnerships by providing appropriate conversational topics and questions for the participants relevant to the stage of post-stroke recovery while also ensuring that both partners contribute to the conversation. This strategy aligns with group self-management programs that typically rely on a leader or a professional familiar in stroke rehabilitation and recovery (Fryer et al., 2016). Lastly, it is critical to acknowledge that there is no guarantee of successful partnerships formed solely on the basis of stroke as a shared experience. Past qualitative work found that individuals participating in post-stroke peer support groups valued peer interactions to a greater extent when there were contextual similarities amongst peers beyond the common experience of stroke (Morris and Morris, 2012). Future strategies to enhance partnerships may therefore focus more on participants' life experiences and circumstances than on the timeframe of IRF discharge.

This work was not formally powered to identify changes in self-reported outcome measures following STRIDE participation. However, a tendency toward balance self-efficacy gains is encouraging. Nott et al. (2021) reported that self-efficacy mediated the impact of a 12-week self-management program on occupational performance and satisfaction in participants post-stroke. Others have shown balance self-efficacy as a predictor of post-stroke community reintegration satisfaction (Pang et al., 2007), which, collectively, underscores the role of self-efficacy in stroke (Gangwani et al., 2022). We also observed that many participants appeared to increase their self-reported physical activity, and future work may examine relationships between activity monitoring adherence, specific activity variables, and self-report scores (i.e., PASE). Given that STRIDE was only an eight-week program occurring early post-stroke and that community reintegration extends well-beyond this timeframe (Wood et al., 2010), we did not expect substantial changes in self-reported quality of life. As stroke self-management programs have the potential to improve quality of life (Fryer et al., 2016), extending the length of STRIDE to provide support during the first 12–24 months post-stroke may be a beneficial next step. A formal randomized controlled clinical trial is ultimately necessary to determine if changes in self-efficacy, physical activity, and quality of life are due to STRIDE.

To conduct the next iteration of STRIDE using a more formal, controlled study design, it is necessary to acknowledge and critically reflect on the 50% completion rate across enrolled participants. This completion rate represents participant-specific issues arising after STRIDE enrollment and IRF discharge that were beyond the control of STRIDE personnel. Future work will therefore require revision of our enrollment criteria and/or implementation strategy by considering factors related to a potential participant's functional capacity, socioeconomic factors, comorbidities, and discharge environment that may contribute to STRIDE engagement for the full eight-week duration.

This preliminary work overall demonstrated the development and successful deployment of an eight-week post-stroke program consisting of weekly education, activity monitoring, and communication during a critical and overlooked timeframe of stroke recovery. Overall findings from this work support the utilization of post-discharge education and coordination, which should remain a key component of future programs.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by University of North Carolina at Chapel Hill Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

JC: Conceptualization, Formal analysis, Funding acquisition, Investigation, Resources, Supervision, Writing—original draft. RF: Data curation, Project administration, Writing—review & editing. RV: Data curation, Resources, Writing—review & editing. AG: Data curation, Resources, Writing—review & editing. MM: Data curation, Writing—review & editing. AT: Data curation, Writing—review & editing. BM: Writing—review & editing. ML: Conceptualization, Writing—review & editing. JB: Conceptualization, Funding acquisition, Writing—review & editing.