Elucidating the Concept of Task Challenge in Stroke Rehabilitation

Abstract

Stroke is a life-altering experience that can profoundly impact a person’s identity, function, participation, and wellbeing. These impacts extend beyond the individual, with significant consequences for whānau and society. Reducing the impact of stroke is therefore a critical priority and rehabilitation plays a central role in this endeavour. Stroke rehabilitation involves a biopsychosocial and person-centred process that can promote recovery and support people to (re-)engage in meaningful life roles. This process is commonly described as being underpinned by core principles, including timing, person-centred care, and challenge. Although many of these underpinning principles have been extensively researched and endorsed in clinical guidelines, several remain poorly understood, inconsistently implemented, and variably effective in clinical practice. As the impact of stroke continues to grow, gaps between research and practice are likely to widen, further limiting the capacity of rehabilitation to respond to the needs of people with stroke. This highlights a pressing need to advance stroke rehabilitation and the principles that inform it.

One potential avenue for advancing stroke rehabilitation lies in optimising the principle of ‘challenge’. Prior literature has variably referred to challenge as “how hard a task is” or the “amount of physical or mental effort put forth by a person”. Emerging research suggests that, when carefully tailored to the person, challenge may produce better rehabilitation experiences and outcomes. Yet, despite its therapeutic potential, challenge remains poorly understood, and in turn, risks being suboptimally applied in both research and practice. To enhance its use, a comprehensive understanding of the concept is required. Therefore, this doctoral thesis aimed to advance understanding of the concept of challenge in stroke rehabilitation. Adopting a pragmatist philosophical position, this thesis comprised three interrelated qualitative studies exploring challenge from the perspectives of people with stroke, whānau, and rehabilitation therapists.

Study A, a concept analysis study, captured how challenge is conceptualised in the stroke rehabilitation literature from the perspectives of people with stroke and physiotherapy, occupational therapy, and speech-language therapy disciplines. A principle-based framework was used to ask philosophical questions of the literature and build a theoretical understanding of challenge. This analysis delineated key conceptual components, characterising challenge as a multifaceted, multidimensional, and dynamic concept in stroke rehabilitation. This informed a proposed definition of challenge as an interaction between the task, the person’s ability, and their subjective experience, which when optimised to the individual, may foster learning, recovery, and engagement in rehabilitation and everyday life.

Study B, a video-reflexive ethnography study, explored how people with stroke, physiotherapists, occupational therapists, and speech-language therapists understand and experience challenge in stroke rehabilitation practice. Findings revealed four interrelated themes: (i) Challenge is an interpretive lens, (ii) The terms and conditions of engaging with rehabilitation challenge, (iii) Making challenge make sense, and (iv) Meeting or leaving each other in the challenge. These themes demonstrated that challenge in stroke rehabilitation practice is shaped by nuanced personal and relational dynamics. People with stroke and therapists often viewed challenge through their unique experiential and professional lenses, respectively. Explicit and implicit practices could facilitate shared understanding and the co-construction of meaningful experiences of challenge, grounded in trust, emotional safety, and mutual attunement. However, when genuine collaboration was lacking, this risked misaligned understandings, a strained therapeutic relationship, and could diminish the perceived value of stroke rehabilitation.

Study C, a focused video analysis study, examined how challenge is operationalised in stroke rehabilitation practice. Three intersecting practices were identified: (i) Structuring the temporal phases of challenge, (ii) Establishing the macro-architecture of challenge, and (iii) Modulating challenge through micro-calibrations. These practices described when, what, and how challenge-related work was enacted across a rehabilitation session, and encompassed an interplay of explicit and implicit technical and relational practices. While both people with stroke and therapists actively contributed to these practices, the extent and nature of their influence and collaboration varied according to the task, personal and relational dynamics, and the rehabilitation context.

Taken together, this thesis elucidates the key conceptual components of challenge, foregrounds the central role of the therapeutic relationship in shaping its experience, and articulates how it is dynamically implemented in practice. The integration of these theoretical, experiential, and practical findings advance understandings of challenge beyond ambiguous descriptions and toward a robust conceptual foundation capable of strengthening both research and practice. In doing so, this thesis offers clear direction for optimising the use of challenge in ways that may enhance experiences of and outcomes from stroke rehabilitation.