INTRODUCTION:

Stroke is a leading cause of disability worldwide, impacting 15 million people each year. Of these, 5 million die from the condition, and another 5 million are left with long-term disabilities¹. The effects of stroke are especially severe in low- and middle-income nations like India, where limited access to rehabilitation services and poor adherence to post-stroke care hinder optimal recovery². Although effective stroke rehabilitation can significantly improve functional independence and quality of life, maintaining adherence to these programs is a significant challenge³.

Adherence to rehabilitation therapy refers to how well a patient's participation in rehabilitation exercises matches the prescribed treatment plan⁴. Poor adherence is associated with slower functional recovery, higher disability rates, and reduced quality of life for stroke survivors⁵. Studies show that up to 50% of stroke patients do not complete their prescribed rehabilitation programs, leading to increased dependency and a greater risk of secondary complications⁶. Despite the clear benefits of rehabilitation, non-adherence is an under-explored issue in stroke care, particularly in the Indian healthcare context⁷.

Nurses are crucial in promoting rehabilitation adherence by tracking patient progress, providing education, and offering motivational support⁸. Interventions in rehabilitation nursing, such as goal-setting strategies, structured adherence monitoring, and psychological reinforcement, have been shown to enhance adherence rates and functional outcomes⁹. However, the specific impact of nursing-led adherence programs on stroke recovery is not well-documented in India, highlighting the need for further research⁹.

The main goal of this study is to investigate the relationship between adherence to rehabilitation nursing interventions and functional outcomes in stroke survivors. Specifically, it aims to evaluate the effect of adherence on mobility improvements¹⁰ (Functional Mobility Scale, Timed Up and Go Test), independence in activities of daily living (Barthel Index), and psychological well-being (PHQ-9 Depression Scale). Additionally, the study explores factors influencing adherence, such as patient motivation, family support, and access to rehabilitation resources¹¹.

The hypothesis is that greater adherence to rehabilitation nursing programs will lead to improved functional mobility, increased independence in activities of daily living, and lower levels of post-stroke depression¹². This study aims to inform clinical strategies for enhancing rehabilitation compliance and optimizing stroke recovery outcomes by identifying key factors that influence adherence.

The results of this research will contribute to evidence-based nursing practices in stroke rehabilitation, with implications for policy-making and the development of structured adherence-monitoring programs in India¹³.

METHODS:

This study was conducted at Index Medical College, Hospital and Research Center, a tertiary healthcare facility with a dedicated stroke rehabilitation unit. Utilizing a prospective cohort design, the research aimed to evaluate how adherence to rehabilitation nursing interventions affects the functional outcomes of stroke survivors. A group of 200 stroke patients was enrolled and observed over 24 weeks, with assessments conducted at Baseline (Week 0), Week 12, and Week 24.

Participants and Recruitment:

Stroke survivors were systematically recruited from the hospital's neurology and rehabilitation units.

The criteria for inclusion were as follows:

· Adults aged 50 years and older who had experienced their first ischemic or hemorrhagic stroke.

· Medically stable and eligible for rehabilitation within two weeks after the stroke.

· Able to participate in rehabilitation programs, either independently or with assistance.

· Consented to take part in a structured study on rehabilitation adherence.

Exclusion criteria included:

· Severe cognitive impairment (MMSE score<18) that could hinder participation in rehabilitation.

· Multiple strokes or other neurological conditions affecting mobility.

· Severe comorbidities (e.g., heart failure, advanced cancer) that could limit rehabilitation.

Study Groups and Intervention Details:

Participants were categorized into two adherence groups based on their participation rates in rehabilitation over the 24weeks:

· High-Adherence Group (n = 100) – Completed 80% or more of the prescribed rehabilitation sessions.

· Low-Adherence Group (n = 100) – Completed less than 80% of the prescribed rehabilitation sessions.

Rehabilitation adherence was tracked using a combination of objective and self-reported methods:

· Digital logs recording attendance at rehabilitation sessions.

· Self-reported rehabilitation diaries kept by patients.

· Nurse-led adherence tracking, including weekly progress reports.

Both groups received standardized rehabilitation nursing interventions, which included:

· Mobility Training: Task-oriented exercises for walking, balance, and coordination.

· ADL Independence Training: Assistance with dressing, bathing, feeding, and toileting.

· Psychosocial Support: Motivational reinforcement, patient education, and emotional counseling.

Outcome Measures:

The study evaluated functional mobility, independence in activities of daily living (ADL), and psychological well-being using validated clinical scales. Data collection was conducted at Baseline (Week 0), Week 12, and Week 24 by rehabilitation nurses who were blinded to the study conditions.

Functional Mobility Measures:

· Functional Mobility Scale (FMS): This tool evaluates the capacity to walk independently over distances of 5meters, 50 meters, and 500meters. Higher scores indicate better mobility.

· Timed Up and Go (TUG) Test: This assessment measures the time taken to rise from a chair, walk 3 meters, turn around, and sit back down. Quicker times suggest improved mobility and a lower risk of falls.

ADL Independence Measure:

Barthel Index (BI): This index assesses self-care tasks such as feeding, dressing, grooming, bathing, and mobility. Higher scores indicate greater independence in ADLs.

Psychological Well-Being Measure:

Patient Health Questionnaire-9 (PHQ-9): This questionnaire evaluates depressive symptoms in stroke survivors. Lower scores indicate better psychological well-being.

Statistical Analysis:

Data were analyzed using SPSS (version 26.0). Descriptive statistics summarized baseline characteristics and adherence rates.

The following statistical tests were performed:

· Independent t-tests – These compared functional mobility, activities of daily living (ADL) independence, and depression scores between high-adherence and low-adherence groups.

· Repeated measures ANOVA – This test evaluated changes in functional outcomes at Baseline, Week 12, and Week 24 within each group.

· Multivariate regression analysis – This analysis identified predictors of functional recovery, adjusting for age, stroke type, and adherence level. A p-value of <0.05 was considered statistically significant for all analyses.

RESULTS:

Baseline Characteristics:

A total of 200 stroke survivors were enrolled in the study and were classified into two groups based on adherence levels:

● High-Adherence Group (≥80% adherence, n=100)

● Low-Adherence Group (<80% adherence, n=100)

Baseline characteristics were comparable between both groups, ensuring that any observed differences in functional outcomes were attributable to adherence levels rather than pre-existing conditions.

Table 1: Baseline Characteristics of Study Participants

Variable	High-Adherence (n=100)	Low-Adherence (n=100)	p-value
Age (Mean ± SD, years)	63.8 ± 7.6	64.5 ± 8.1	0.527
Gender (Male/Female)	55/45	57/43	0.721
Stroke Type (Ischemic/ Hemorrhagic)	67/33	65/35	0.784
Baseline Functional Mobility (FMS)	1.98 ± 0.42	1.94 ± 0.39	0.589
Baseline TUG Test (Seconds)	21.5 ± 3.1	21.8 ± 3.4	0.611
Baseline Barthel Index (BI)	43.2 ± 8.0	42.8 ± 8.3	0.743
Baseline PHQ-9 Depression Score	14.1 ± 3.4	14.3 ± 3.2	0.812

Impact of Adherence on Functional Mobility:

Participants who adhered to ≥80% of their prescribed rehabilitation programs showed significantly greater improvements in mobility compared to those with lower adherence levels.

Table 2: Functional Mobility Outcomes by Adherence Level

Time Point	FMS Score (Mean±SD)	TUG Test (Seconds, Mean±SD)
Baseline (Week 0)	1.98±0.42 (High-Adherence) vs. 1.94± 0.39 (Low-Adherence)	21.5±3.1 (High-Adherence) vs. 21.8± 3.4 (Low-Adherence)
Week 12	3.45±0.50 (High-Adherence) vs. 2.75± 0.52 (Low-Adherence) (p < 0.001)	15.8±2.5 (High-Adherence) vs. 18.9±2.9 (Low-Adherence) (p = 0.002)
Week 24	4.38±0.45 (High-Adherence) vs. 3.10± 0.51 (Low-Adherence) (p<0.001)	11.9±2.1 (High-Adherence) vs. 16.5±2.8 (Low-Adherence) (p < 0.001)

Figure 1: Functional Mobility Scale (FMS) vs. Adherence Levels

(Graph showing a significantly steeper improvement in FMS scores among high-adherence participants.)

Figure 2: Timed Up and Go (TUG) Test vs. Adherence Levels

(Graph illustrating faster TUG test times in high-adherence participants.)

Impact of Adherence on ADL Independence

Adherence to rehabilitation programs significantly improved ADL independence, as indicated by Barthel Index (BI) scores.

Table 3: ADL Independence (Barthel Index) by Adherence Level

Time Point	High-Adherence (Mean±SD)	Low-Adherence (Mean ± SD)	p-value
Baseline (Week 0)	43.2 ±8.0	42.8±8.3	0.743
Week 12	64.5±9.1	55.2±8.8	p < 0.001
Week 24	84.1±10.2	67.5±9.4	p < 0.001

Figure 3: Barthel Index Scores vs. Adherence Levels

(Graph showing greater gains in ADL independence in high-adherence participants.)

Impact of Adherence on Psychological Well-Being (PHQ-9 Scores):

Participants in the high-adherence group experienced significantly greater reductions in depression symptoms compared to the low-adherence group.

Table 4: Depression Score (PHQ-9) by Adherence Level

Time Point	High-Adherence (Mean±SD)	Low-Adherence (Mean±SD)	p-value
Baseline (Week 0)	14.1±3.4	14.3±3.2	0.812
Week 12	8.9±2.6	10.7±2.8	p < 0.001
Week 24	4.8±1.9	9.2±2.7	p < 0.001

Figure 4: PHQ-9 Scores vs. Adherence Levels

(Graph showing a larger reduction in depression symptoms among high-adherence participants.)

Multivariate Regression Analysis: Predictors of Functional Recovery:

A multivariate regression model was used to assess the impact of adherence on stroke recovery.

Table 5: Regression Analysis of Functional Recovery Predictors

Variable	Beta Coefficient (β)	p-value
Rehabilitation Adherence (%)	+4.5	p < 0.001
Baseline Mobility (FMS Score)	+2.0	p = 0.004
Age (≥65 vs. <65 years)	-1.6	p = 0.015

DISCUSSION:

Interpretation of Key Findings:

This research offers compelling evidence that greater compliance with rehabilitation nursing interventions markedly enhances functional mobility, independence in activities of daily living (ADL), and psychological well-being among stroke survivors. Those participants who followed at least 80% of their prescribed rehabilitation regimens showed more significant improvements in Functional Mobility Scale (FMS) scores, quicker Timed Up and Go (TUG) test results, higher Barthel Index (BI) scores, and reduced PHQ-9 depression scores compared to participants with lower adherence levels. Adherence emerged as the most significant predictor of stroke recovery, with a β coefficient of +4.5 (p<0.001) in multivariate regression analysis, highlighting that higher adherence rates were linked to notably better functional outcomes. These results indicate that focusing on monitoring and enhancing rehabilitation adherence should be a central element of stroke recovery programs, as failing to adhere results in slower recovery, increased disability, and poorer psychological health.

Comparison with Existing Literature:

The findings of this research are consistent with earlier studies that highlight the critical role of adherence in stroke rehabilitation. Numerous studies have shown that patients who regularly engage in rehabilitation programs achieve notably better functional recovery and experience less disability. For instance, Langhorne et al. (2018) discovered that stroke survivors who strictly followed rehabilitation protocols were 2.5 times more likely to regain independent mobility compared to those who did not adhere¹⁰. Similarly, Kwakkel et al. (2015) found that greater adherence to rehabilitation was associated with a 35% improvement in ADL independence six months after a stroke¹¹. The current study corroborates these findings, indicating that participants with high adherence had Barthel Index scores that were 24% higher than those with low adherence at 24 weeks (p<0.001).

Moreover, adherence significantly impacted psychological well-being. Hackett and Pickles (2014) noted that poor adherence to rehabilitation was linked to a higher incidence of post-stroke depression¹². This study confirmed this connection, showing that participants with high adherence had PHQ-9 depression scores that were 48% lower than those in the low-adherence group (p < 0.001). These results underscore the necessity for structured psychological support to enhance both adherence and mental health outcomes in stroke survivors.

Clinical and Practical Implications:

Strengthening Rehabilitation Nursing Roles:

The results of this research underscore the crucial role that rehabilitation nurses play in promoting compliance with stroke recovery programs. However, in many hospital environments, the systematic inclusion of adherence monitoring in nursing care is lacking, which limits patient participation. Given that adherence to rehabilitation was identified as the most critical predictor of functional recovery (β = +4.5, p<0.001), it is essential to fully integrate nursing-led adherence strategies into rehabilitation protocols.

Recommendation: Rehabilitation nurses should undergo formal training in techniques to reinforce adherence. Hospitals should implement systems for monitoring adherence, including digital tracking and follow-up processes. Nurses should provide structured motivational counseling sessions to boost patient dedication to rehabilitation.

Implementing Adherence Monitoring Systems:

One of the key outcomes of this research was that following rehabilitation protocols was identified as the most crucial factor for functional recovery. However, many stroke survivors face obstacles in maintaining regular rehabilitation practices due to issues like lack of motivation, transportation challenges, and inadequate caregiver support.

Recommendation: It is advised that hospitals adopt digital systems to track adherence, such as mobile health apps, SMS reminders, and tele-rehabilitation sessions. Moreover, nurses should perform weekly follow-ups with stroke survivors to assess adherence levels. Additionally, offering incentives based on adherence, like free physiotherapy sessions for patients who consistently adhere, should be considered.

Addressing Psychological Barriers to Adherence:

The research revealed a significant link between greater adherence and reduced PHQ-9 depression scores, indicating that poor mental health could be a major obstacle to sticking with rehabilitation. Individuals experiencing depressive symptoms might lack the motivation to engage in therapy, resulting in poorer functional outcomes.

Recommendation: Incorporate regular depression screenings into stroke rehabilitation programs. Train nurses to identify psychological barriers to adherence and offer counseling. Establish support groups and peer mentoring to boost patient motivation.

Study Limitations:

While this research provides compelling evidence linking rehabilitation adherence to stroke recovery, it is essential to acknowledge several limitations:

1. Conducted at a Single Hospital: The study was conducted in a single medical facility, which limits its applicability to other healthcare settings. Future research should incorporate multi-center trials to enhance generalizability.

2. Limited Follow-Up Period: Participants were monitored for 24 weeks. Although significant improvements were observed, the long-term effects of rehabilitation adherence remain uncertain. Future studies should consider longitudinal research with follow-ups extending 12–24 months.

3. Reliance on Self-Reported Adherence: Some adherence data were obtained from patient-maintained rehabilitation diaries, which may introduce recall bias. Future investigations should utilize wearable activity trackers or objective attendance records for more accurate adherence assessment.

FUTURE RESEARCH DIRECTIONS:

Long-Term Impact of Rehabilitation Adherence:

This study evaluated stroke recovery over a six-month period; however, the long-term effects of adherence remain undetermined. Future research should investigate functional outcomes at one-year and two-year follow-ups to ascertain the sustainability of improvements driven by adherence.

Effectiveness of Tele-Rehabilitation Adherence Models:

Digital health interventions, including tele-rehabilitation programs and mobile adherence tracking, have the potential to enhance adherence rates among stroke patients. It is imperative that future research endeavors assess the efficacy of these technologies in maintaining sustained engagement in rehabilitation activities.

Gender-Specific Differences in Rehabilitation Adherence:

This study did not investigate gender-specific variations in adherence patterns. It is recommended that future research examine whether men and women exhibit differential responses to adherence-based interventions and, if necessary, develop gender-specific rehabilitation strategies.

CONCLUSION:

This study presents compelling evidence that adherence to rehabilitation nursing interventions substantially improves functional mobility, independence in activities of daily living (ADL), and psychological well-being among stroke survivors. The findings indicate that structured adherence-monitoring programs should be incorporated into stroke rehabilitation protocols to enhance patient outcomes. Given that adherence emerged as the most significant predictor of recovery, it is recommended that hospitals implement nursing-led adherence programs and utilize digital adherence tracking to bolster patient engagement. Future research should investigate the long-term effects, telerehabilitation models, and gender-specific adherence strategies to refine stroke recovery protocols further.

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Received on 27.09.2025 Revised on 15.11.2025

Accepted on 31.12.2025 Published on 02.05.2026

Available online from May 05, 2026

Int. J. of Advances in Nursing Management. 2026;14(2):81-86.

DOI: 10.52711/2454-2652.2026.00017

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