Walking for wellbeing after stroke: Building a treatment theory to improve real-world walking
This thesis explored ways to enable people with stroke to walk more in the real-world. The starting point for this work was the lack of sustained change in real-world walking following clinic-based interventions after stroke. This lack of translation of gains from physical training into real-world settings is known as a lack of carryover. As recommended by the Medical Research Council guidelines, this thesis employed both quantitative and qualitative methods to iteratively develop an understanding of the likely change process behind sustained change in real-world walking after stroke. Informed by a realist research philosophy, I developed a treatment theory to propose specific intervention components; contextual factors; mechanisms of action; and desired outcomes to address this clinical problem. First, this thesis aimed to determine the effectiveness of current interventions and whether benefits were sustained. Second, it aimed to clarify what real-world walking meant to people with stroke and how they thought it could be better. Third, it sought to build a treatment theory and operationalise this theory into an intervention. Finally, it evaluated the intervention to clarify the processes needed to produce carryover. The systematic review in Phase 1 showed sustained change in real-world walking was possible but certain key components appeared important: collaborative goal planning and context specific training. The qualitative enquiry in Phase 2 found walking in the real-world was a demanding but inherently motivating activity that required significant concentration. Data analysis in Phase 3 indicated active ingredients behind the process of carryover included planning, automaticity, mastery, and normalisation mechanisms. Based on the principles of self-determination theory, the intervention appeared to produce a virtuous cycle of confidence building for some participants that produced gains in physical and social integration through mechanisms of motivational transfer. A key contribution of this thesis is the elucidation of learning-related mechanisms behind sustained change. Three mid-range theories were identified: Control Theory, Self-Determination Theory and Normalisation Process Theory. Collectively these theories helped to explain study findings in Phase 3 and how each of the intervention components worked. In conclusion, this thesis provides support for the importance of self-regulated learning in promoting sustained change in real-world walking. This arguably should prompt a rethinking of current physiotherapy interventions for walking after stroke. Interventions that use collaborative planning, context specific training and caring connections appear to contain the active ingredients needed to build confidence and create carryover, to help people with stroke walk more, and keep on walking.