Exploration of stress management interventions to address psychological stress in stroke survivors: A protocol for a scoping review

Introduction: Several studies have shown that stroke survivors report experiencing high and unremitting levels of stress, which can negatively affect brain repair processes and psychological outcomes and thereby compromise recovery. However, it is presently unclear which interventions have been trialled to manage stress in stroke survivors and whether they translate to clinically relevant outcomes. The aim of this scoping review will be to examine stress management interventions in stroke survivors in order to map the types of interventions trialled, commonly reported stress outcome measures and whether a reduction in stress contributes to reductions in relevant clinical outcomes. Methods and analysis: The methodological framework described in Arksey and O’Malley will be applied to this review. A draft search strategy was developed in collaboration with an experienced senior health research librarian. A systematic search of Medline, Embase, CINAHL, Cochrane library, PsycInfo and Clinicaltrials.gov as well as hand searching of reference lists and reviews will identify relevant studies for inclusion. To be eligible for inclusion, studies must report on the outcomes of an intervention targeting stress management and resilience in stroke survivors. Study selection and critical appraisal of selected studies will be carried out independently by two authors, with discrepancies resolved by consensus. Data will be charted using a standard extraction form. Results will be tabulated and narratively summarised to highlight findings relevant to our research questions and to inform recommendations for future research. Ethics and dissemination: This study does not require ethics approval. This scoping review will provide a synthesis of evidence for stress management interventions in stroke survivors. It will identify and clarify the gaps in stress research specific to stroke pathologies and highlight promising interventions for future research. Findings will be relevant to researchers and healthcare workers and will be disseminated via publications in peer-reviewed journals and presented at conferences

Direct comparison of virtual reality and 2D delivery on sense of presence, emotional and physiological outcome measures

Introduction: Virtual-reality (VR) technology has, over the last decade, quickly expanded from gaming into other sectors including training, education, and wellness. One of the most popular justifications for the use of VR over 2D is increased immersion and engagement. However, very little fundamental research has been produced evaluating the comparative impact of immersive VR on the user’s cognitive, physiological, and emotional state.Methods: A within-subject cross-over study design was used to directly compare VR and 2D screen delivery of different subject matter content. Both physiological and self-report data were collected for scenes containing calming nature environments, aggressive social confrontations, and neutral content.Results: Compared to 2D, the VR delivery resulted in a higher sense of presence, higher ratings of engagement, fun, and privacy. Confrontational scenes were rated as more tense whilst calming scenes were rated as more relaxing when presented in VR compared to 2D. Physiological data indicated that the scenes promoted overall states of arousal and relaxation in accordance with the scene subject matter (both VR and 2D). However, heart rate (HR) and galvanic skin response (GSR) were consistently higher throughout the VR delivery condition compared to 2D, including responses during scenes of neutral and calming subject matter.Discussion: This discrepancy between emotional and physiological responses for calming and neutral content in VR suggest an elevated arousal response driven by VR immersion that is independent of the emotional and physiological responses to the subject matter itself. These findings have important implications for those looking to develop and utilize VR technology as a training and educational tool as they provide insights into the impact of immersion on the user

Opposing associations of stress and resilience with functional outcomes in stroke survivors in the chronic phase of stroke: A cross-sectional study

Stroke survivors report significant levels of psychological distress post stroke. To date, most studies conducted have focused on the relationship between psychological stress and functional outcomes in the acute phase of stroke. However, no studies had considered the role of stress over the chronic phase, where stress may continue to exert negative effects on cognitive and psychological processes. Further, the role of potentially modulatory variables, such as psychological resilience, on stroke outcomes has been understudied. The purpose of this study was to consider the relationships between stress and resilience with functional outcomes in long-term survivors of stroke. People (N = 70) who had experienced a stroke between 5 months and 28 years ago were included in the cross-sectional study, along with age-matched controls (N = 70). We measured stress using both the Perceived Stress Scale and biological markers, and resilience using both the Brief Resilience Scale and the Connor-Davidson Resilience Scale. Stroke outcomes were assessed using the Stroke Impact Scale. We found that, compared with age-matched controls, stroke survivors reported greater levels of perceived stress, and lower levels of resilience. In stroke survivors, both perceived stress and resilience were independently associated with stroke outcomes in linear regression models. In particular, these relationships were observed for cognitive outcomes including mood, memory, and communication. The association between stress and stroke outcome did not differ across time post stroke. Given that resilience is a modifiable psychological construct, future research may consider whether strategies directed at enhancing resilience may improve recovery from stroke

Similar cognitive deficits in mice and humans in the chronic phase post-stroke identified using the touchscreen-based paired-associate learning task

For many chronic stroke survivors, persisting cognitive dysfunction leads to significantly reduced quality of life. Translation of promising therapeutic strategies aimed at improving cognitive function is hampered by existing, disparate cognitive assessments in animals and humans. In this study, we assessed post-stroke cognitive function using a comparable touchscreen-based paired-associate learning task in a cross-sectional population of chronic stroke survivors (≥ 5 months post-stroke, n = 70), age-matched controls (n = 70), and in mice generated from a C57BL/6 mouse photothrombotic stroke model (at six months post-stroke). Cognitive performance of stroke survivors was analysed using linear regression adjusting for age, gender, diabetes, systolic blood pressure and waist circumference. Stroke survivors made significantly fewer correct choices across all tasks compared with controls. Similar cognitive impairment was observed in the mice post-stroke with fewer correct choices compared to shams. These results highlight the feasibility and potential value of analogous modelling of clinically meaningful cognitive impairments in chronic stroke survivors and in mice in chronic phase after stroke. Implementation of validated, parallel cross-species test platforms for cognitive assessment offer the potential of delivering a more useful framework for evaluating therapies aimed at improving long-term cognitive function post-stroke

Development of a modular stress management platform (Performance Edge VR) and a pilot efficacy trial of a bio-feedback enhanced training module for controlled breathing.

This paper describes the conceptual design of a virtual reality-based stress management training tool and evaluation of the initial prototype in a pilot efficacy study. Performance Edge virtual-reality (VR) was co-developed with the Australian Defence Force (ADF) to address the need for practical stress management training for ADF personnel. The VR application is biofeedback-enabled and contains key stress management techniques derived from acceptance and commitment and cognitive behavioural therapy in a modular framework. End-user-provided feedback on usability, design, and user experience was positive, and particularly complimentary of the respiratory biofeedback functionality. Training of controlled breathing delivered across 3 sessions increased participants' self-reported use of breath control in everyday life and progressively improved controlled breathing skills (objectively assessed as a reduction in breathing rate and variability). Thus the data show that a biofeedback-enabled controlled breathing protocol delivered through Performance Edge VR can produce both behaviour change and objective improvement in breathing metrics. These results confirm the validity of Performance Edge VR platform, and its Controlled Breathing module, as a novel approach to tailoring VR-based applications to train stress management skills in a workplace setting

Exploring the relationship between fatigue and circulating levels of the pro-inflammatory biomarkers interleukin-6 and C-reactive protein in the chronic stage of stroke recovery: a cross-sectional study

Background The precise mechanisms underlying the aetiology of post-stroke fatigue remain poorly understood. Inflammation has been associated with clinically significant fatigue across a number of neurological disorders; however, at present there is a lack of evidence regarding the association of fatigue and inflammation in the chronic phase of stroke recovery. Aims The aim of this study was to examine fatigue in a cohort of stroke survivors in the chronic phase of stroke, compared with matched controls, and to explore associations between the pro-inflammatory cytokine interleukin-6, high-sensitivity C-reactive Protein and fatigue. Methods We performed an exploratory cross-sectional study of 70 people in the chronic phase of stroke recovery, and 70 age matched controls. Fatigue was assessed using the Fatigue Assessment Scale. Interleukin-6 was measured in serum using a commercially available enzyme immunoassay kit. Both outcome measures were assessed contemporaneously. Results Clinically significant fatigue, defined as a score ≥24 on the Fatigue Assessment Scale, was reported by 60% of stroke survivors, and 15.7% of controls. The odds of experiencing clinically significant fatigue was 8.04 times higher among stroke survivors compared to control participants (odds ratio 8.045; 95% CI: 3.608, 17.939; P ​< ​0.001). The fatigue score was significantly correlated with the level of both interleukin-6 and high-sensitivity c-reactive protein, however once entered into a linear regression model with cardiovascular covariables, this relationship was no longer statistically significant. Conclusions This study shows that fatigue may be associated with systemic inflammation in the chronic phase of stroke. The pathological mechanisms underlying post-stroke fatigue and its clinical implications require further study

Evaluation of a Virtual Reality Platform to Train Stress Management Skills for a Defense Workforce: Multisite, Mixed Methods Feasibility Study

BackgroundPsychological stress-related injuries within first-responder organizations have created a need for the implementation of effective stress management training. Most stress management training solutions have limitations associated with scaled adoption within the workforce. For instance, those that are effective in civilian populations often do not align with the human performance culture embedded within first-responder organizations. Programs involving expert-led instructions that are high in quality are often expensive. ObjectiveThis study sought to evaluate a tailored stress management training platform within the existing training schedule of the Australian Defense Force (ADF). The platform, known as Performance Edge (PE), is a novel virtual reality (VR) and biofeedback-enabled stress management skills training platform. Focusing on practical training of well-established skills and strategies, the platform was designed to take advantage of VR technology to generate an immersive and private training environment. This study aimed to assess the feasibility of delivering the VR platform within the existing group-based training context and intended training population. In this setting, the study further aimed to collect data on critical predictors of user acceptance and technology adoption in education, including perceived usability, usefulness, and engagement, while also assessing training impacts. MethodsThis study used a mixed methods, multisite approach to collect observational, self-reported, and biometric data from both training staff and trainers within a real-world “on-base” training context in the ADF. Validated scales include the Presence Questionnaire and User Engagement Scale for perceived usefulness, usability, and engagement, as well as the State Mindfulness Scale and Relaxation Inventory, to gain insights into immediate training impacts for specific training modules. Additional surveys were specifically developed to assess implementation feedback, intention to use skills, and perceived training impact and value. ResultsPE training was delivered to 189 ADF trainees over 372 training sessions. The platform was easy to use at an individual level and was feasible to deliver in a classroom setting. Trainee feedback consistently showed high levels of engagement and a sense of presence with the training content and environment. PE is overall perceived as an effective and useful training tool. Self-report and objective indices confirmed knowledge improvement, increased skill confidence, and increased competency after training. Specific training elements resulted in increased state mindfulness, increased physical relaxation, and reduced breathing rate. The ability to practice cognitive strategies in a diverse, private, and immersive training environment while in a group setting was highlighted as particularly valuable. ConclusionsThis study found the VR-based platform (PE) to be a feasible stress management training solution for group-based training delivery in a defense population. Furthermore, the intended end users, both trainers and trainees, perceive the platform to be usable, useful, engaging, and effective for training, suggesting end-user acceptance and potential for technology adoption

Impaired microglia process dynamics post-stroke are specific to sites of secondary neurodegeneration

Stroke induces tissue death both at the site of infarction and at secondary sites connected to the primary infarction. This latter process has been referred to as secondary neurodegeneration (SND). Using predominantly fixed tissue analyses, microglia have been implicated in regulating the initial response at both damage sites post-stroke. In this study, we used acute slice based multiphoton imaging, to investigate microglia dynamic process movement in mice 14 days after a photothrombotic stroke. We evaluated the baseline motility and process responses to locally induced laser damage in both the peri-infarct (PI) territory and the ipsilateral thalamus, a major site of post-stroke SND. Our findings show that microglia process extension toward laser damage within the thalamus is lost, yet remains robustly intact within the PI territory. However, microglia at both sites displayed an activated morphology and elevated levels of commonly used activation markers (CD68, CD11b), indicating that the standardly used fixed tissue metrics of microglial activity are not necessarily predictive of microglia function. Analysis of the purinergic P2Y12 receptor, a key regulator of microglia process extension, revealed an increased somal localization on nonresponsive microglia in the thalamus. To our knowledge, this is the first study to identify a non-responsive microglia phenotype specific to areas of SND post-stroke, which cannot be identified by the classical assessment of microglia activation but rather the localization of P2Y12 to the soma