What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review

Life after stroke; Realist review; Programme theory; Supportive pathways ALL Metrics - Views Downloads How to cite this article Lennon O, O'Neill M, Walsh K and Horgan F. What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.12688/hrbopenres.14034.3) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Study Protocol Revised What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved] Olive Lennon https://orcid.org/0000-0001-7005-3616 1, Mary O'Neill2, Killian Walsh3, Frances Horgan https://orcid.org/0000-0002-8773-9953 2Olive Lennon https://orcid.org/0000-0001-7005-3616 1, Mary O'Neill2, Killian Walsh3, Frances Horgan https://orcid.org/0000-0002-8773-9953 2 PUBLISHED 14 Jul 2025 Author details Author details 1 University College Dublin, School of Public Health Physiotherapy, and Sports Science, Dublin, Leinster, Ireland 2 School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 3 Royal College of Surgeons in Ireland, Mercer Library, Dublin, Leinster, Ireland 2 School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 3 Royal College of Surgeons in Ireland, Mercer Library, Dublin, Leinster, Ireland Olive Lennon Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Mary O'Neill Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Killian Walsh Roles: Data Curation, Methodology, Writing – Review & Editing Roles: Data Curation, Methodology, Writing – Review & Editing Frances Horgan Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS Ever-growing numbers of individuals are surviving stroke and living with the consequences. Life after stroke is a key pillar in addressing the burden of stroke for the remaining lifespan for those with stroke. No consensus on how to best promote agency and fulfilment in life after stroke or the resources required to achieve this currently exists. In this realist review protocol we outline the methods we will use to gain an understanding of supporting Life after Stroke through the development of programme theories. These will consist of context–mechanism–outcome configurations (CMOCs) and will acknowledge the resources required. The review will follow the RAMESES five-stage structured methodology to (1) define the scope of the review, and the development of initial programme theories for supporting life after stroke, (2) develop a comprehensive search strategy to identify relevant research, (3) review primary studies and extract data, (4) synthesise evidence (5) refine programme theories iteratively throughout the process using an Expert Panel and reference group, to including stroke researchers, health care professionals working in stroke care, people with lived experience of stroke and carers, and stroke support agencies. This realist review will examine the mechanisms and contexts for a supported life after stroke care pathway. The CMOCs developed will help explain how generative causation within the life after stroke pathway works. The findings will help inform policy and practice and inform future realist evaluations of Life after Stroke support pathways. Life after stroke; Realist review; Programme theory; Supportive pathways Corresponding Author(s) Frances Horgan ([email protected]) Grant information: Health Research Board Ireland [APA-2022-019]. This work was also supported by the Irish Heart Foundation and the HSE National Stroke Clinical Programme. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Lennon O et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Lennon O, O'Neill M, Walsh K and Horgan F. What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.12688/hrbopenres.14034.3) First published: 23 Jan 2025, 8:10 (https://doi.org/10.12688/hrbopenres.14034.1) Latest published: 14 Jul 2025, 8:10 (https://doi.org/10.12688/hrbopenres.14034.3) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. We are very grateful to the reviewers for their invaluable feedback. We made minor changes to the protocol between versions 1 and 2, in line with reviewer comments (see responses to reviewers (1, 2 and 3) for consideration of each of the specific changes). We revised the original title and aim of the study to more clearly inform the reader about the scope and purpose of the manuscript. We provided more clarity about the members of the stakeholder and expert panel, our expert panel includes people with lived experience of stroke and carers and we made this detail clearer in the abstract and expert panel table. Carers are key stakeholders in life after stroke. We added details to ensure that the context for the work was clearer for the reader, and the context for this work would focus on life after stroke. We added more detail to the data analysis section and expanded on our approach to coding and thematic analysis to ensure greater transparency and the interpretation of our future work when we are reporting the full study. We made changes to Table 3, this involved providing a more narrative explanation in the text that connects to the contents of Table 3. In addition we incorporated references in Table 3 to support the relevance of each theme listed in the Table. There were a small number of typographical errors and complex sentences which we corrected and addressed. We are very grateful to the reviewers for their invaluable feedback. We made minor changes to the protocol between versions 1 and 2, in line with reviewer comments (see responses to reviewers (1, 2 and 3) for consideration of each of the specific changes). We revised the original title and aim of the study to more clearly inform the reader about the scope and purpose of the manuscript. We provided more clarity about the members of the stakeholder and expert panel, our expert panel includes people with lived experience of stroke and carers and we made this detail clearer in the abstract and expert panel table. Carers are key stakeholders in life after stroke. We added details to ensure that the context for the work was clearer for the reader, and the context for this work would focus on life after stroke. We added more detail to the data analysis section and expanded on our approach to coding and thematic analysis to ensure greater transparency and the interpretation of our future work when we are reporting the full study. We made changes to Table 3, this involved providing a more narrative explanation in the text that connects to the contents of Table 3. In addition we incorporated references in Table 3 to support the relevance of each theme listed in the Table. There were a small number of typographical errors and complex sentences which we corrected and addressed. See the authors' detailed response to the review by Nicola Hancock Stroke is a leading cause of death and disability, affecting survivors physically, emotionally, cognitively and socially, and impacting their wider family and social networks1–5. In 2022, in Ireland, 5961 adults were admitted to acute hospitals following stroke, a year-on-year increase since 20196. Sixty-six per cent of individuals discharged home, had documented mild to moderate stroke-related disability. By 2035 there will be a 34% increase in stroke events in the EU, and by 2047, the projected rise in prevalent cases in the community is 27%7,8. There is no consensus on what is meant by best care following discharge from specialist stroke services1. The Burden of Stroke in Europe Report describes life after stroke under four categories: health and activity issues, adjustment and wellbeing and information and support7,8. Multiple unmet needs after stroke have been described in the literature including body function and structure, activities, participation, environmental and personal domains8–10. Published Irish data on unmet needs identified mobility problems, emotional issues, fatigue, concentration difficulties, negative financial changes and low return-to-work rates after stroke11. A qualitative synthesis described the disruption to life experienced by people and their families and the need to adapt and rebuild a post-stroke life and identity12. Documented post-stroke experiences included autonomy, uncertainty, engagement, hope and social relations as key challenges for participation in life after stroke8,9,13. The Stroke Action Plan for Europe (SAPE) (2018–2030) recognises Life after Stroke as one of seven key pillars to address the burden of stroke and long-term consequences1. The SAPE general principles for Life after Stroke and the World Stroke Organisation include a call for the recognition by society, of the worth and value of people with stroke-related disabilities14–17. Our rapid realist review seeks to identify the mechanisms that promote agency and fulfilment in life after stroke and the resources required to achieve this. We will explore the contexts in which interventions have been successful, and will include the views and opinion of stakeholders in building programme level theories. This realist review will ask “what works for whom, why does it work and in what circumstances?”18. Realist synthesis is a theory driven approach and realist philosophy is based on ontological assumptions of a “real world”19. A realist lens conceptualises services and interventions that support Life after Stroke as a dynamic process19,20. Context-mechanism-outcome configurations (CMOCs) explain generative causation, what mechanisms are activated and how these interactions lead to different outcomes21,22. Our review will be conducted and reported according to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES)22. The PRISMA-P checklist will be used23. Figure 1 outlines the five stages of the realist review in accordance with Pawson’s work24. The aim of this realist review is to describe the mediators which enable a personally meaningful life after stroke. By determining the contexts, mechanisms and resources, the results will help guide clinicians, healthcare providers and peers to support people after stroke to regain a sense of identity, purpose, fulfilment and life satisfaction. The specific research questions being asked include: What mediators or mechanisms enable interventions designed to support a personally meaningful life after stroke to result in the anticipated outcomes for people in their life after stroke? What contextual factors and resources help facilitate achievement of a personally meaningful life after stroke following supportive interventions for people in their life after stroke? An expert panel was convened and included clinicians, researchers, a recognised international expert, healthcare professionals working in stroke care, advocacy and stroke support workers from NGOs. The expert panel also included people with lived experience of stroke and carers. Table 1 provides a breakdown of the members of the expert group. This group will have an important role, placing a spotlight on key literature, providing lived experience as someone who works in stroke care or has personal experience of stroke to aid the interpretation of data and complex concepts, in assessing the available evidence and in enhancing the credibility of the programme-level theories developed and their relevance clinically. Potential explanations for how supports to achieve a personally meaningful Life after Stroke might work are first required. Describing candidate programme theories (CPTs) for a realist review is an important step, and will provide a scaffold on which the causal mechanisms can generate outcomes in specific contexts25. This step will begin with scoping the existing literature and describing early hypotheses about an intervention’s mechanism of action and expert-level insights26,27. A preliminary search of CINAHL and PubMed by title, abstract, keywords and subject headings was conducted in conjunction with a liaison librarian using search strings derived from the PICOC headings detailed in Table 2. This guided the first group of CPTs developed. Consultation between the researchers provided a first level refinement of these CPTs, often collapsing CPTs or separating them out where differing constructs were determined. These were then presented to the expert panel and further refined, taking account of their perspectives and experiences in relation to contexts, mechanisms and outcomes of supports for Life after Stroke. Here the panel were tasked with confirming, refuting or refining the CPTs23. The broad search terms derived from the CPTs are summarised in Table 3 and will be developed further with a liaison librarian, aligned to the RAMESES guidance22,23,28. | Candidate programme theory | Theme | Early COMCs | Author and Reference | |---|---|---|---| | 1 | Supported self- management after stroke | Having agency and access to supportive resources, when and as required, from healthcare professionals and or family and or peers to manage life after stroke creates a space and a support system in which stroke survivors can feel comfortable to flourish and work towards their hopes and priorities to achieve a personally meaningful life after stroke. | Agency and access to supportive resources (Chouliara et al. 2023)30 Manage life after stroke (Ghazzawi et al. 2016)31 Meaningful life (Sexton et al. 2024)32 | | 2 | Goals and priorities and identifying needs after stroke | When transitioning from active rehabilitation, the conversation should move from shared rehabilitation goals to a more skilled conversation, in collaboration with services and therapists. This conversation establishes their readiness for life after stroke. It should articulate what is a priority for the person with stroke and their family, what is important to them and what they need to re-establish a sense of identity. This will help promote adjustment to the new normal and allow active citizenship that may include engaging in work, vocational or other endeavours. | Transitions (O’Callaghan et al. 202433; Chen et al. 202134) Collaboration with services and therapists (Heredia-Callejón et al. 202335) Promote adjustment (Ghazzawi et al. 201631) | | 3 | Peer support | For those who wish to engage with formal peer support resources and training; or adequately resourced informal peer support or incidental peer support, these can all play an important role in adjustment to life after stroke. This is achieved by providing a safe space to talk, promoting self-compassion and perspectives of gratitude, decreasing isolation and increasing a sense of connectedness and fulfilment in the community. | Peer support (Sadler et al. 201736) Decrease isolation and increasing a sense of connectedness and fulfilment in the community (Yang et al. 202237) | | 4 | Communication | Ongoing communication that includes active listening and a skilled communication partner (or specific supports such as speech and language therapy), allows the person with stroke and their wider support network (or nominated supporter) to air their feelings and express complex emotions or trauma. They can communicate their hopes for their future life and seek the help they require and to re-engage in more activities that are meaningful for them after their stroke. | Ongoing communication (Harrison et al. 201738) Specific supports for those with language difficulty after stroke e.g. speech and language therapist facilitated (Chiaramonte & Vecchio 202139; Manning et al. 201940) To re-engage in activities after their stroke that are meaningful for them (Wray et al. 201941) | | 5 | Psychological supports | Psychological supports, including; professional support, to talk therapy, to active listening; can provide ‘headspace’ that helps people with stroke to work through complex emotions and internal thoughts. This can help them to develop a compassionate view of themselves, helps them to restore their locus of control and ability to seek help, leading to improved perceptions of well-being and self-esteem in their life after stroke. | Psychological supports, self-esteem (Fletcher et al. 202442) Self-esteem (Hall et al. 202243) Peer and social support (Harrison et al. 201738) | | 6 | Living well after stroke | In individuals who have an understanding of risk factors for stroke (including medication adherence, physical activity, participation, healthy dietary habits, smoking cessation, safe substance use, alcohol and other emotional self-regulation and mood), self-evaluation of risk and self-directed choices should be supported by positive messaging and nudges for those who wish to change unhealthy lifestyle behaviours. Adequately resourced services, with supports for behaviour change that are underpinned by behaviour change theory and techniques including monitoring and feedback, can positively impact cardiovascular health and wellness. | Risk factors for stroke (Gladstone and Poppe 202044) Self-evaluation of risk and self-directed choices (Lennon et al. 201845) Supports for behavioural change (Gangwani et al. 202246) | Our initial review of the literature allowed us to develop initial candidate programme theories which we have presented in Table 3. They include supported self-management after stroke setting goals and priorities and identifying needs after stroke, peer support, communication within the health system and communication supports for people with aphasia after stroke, psychological supports for adjustment to a new post stroke identity and supporting a healthy lifestyle after stroke supporting the person with stroke to have a personally meaningful life after stroke to address risk factors after stroke and adopting a healthy lifestyle. These are initial, testable explanations of potential components and will allow us to gain an understanding of supporting Life after Stroke through the development of programme theories. We will evaluate context–mechanism–outcome configurations (CMOCs) further to guide the evaluation into what works, for whom, under what circumstances, and how. These theories are not fixed and will be refined as the evaluation progresses through a review of the literature and further discussions with the expert panel. While the literature discusses self-management, setting goals and priorities, peer support, communication and psychological supports and supporting a healthy lifestyle after stroke it rarely does so in the context of post-discharge care, long term supports and a life after stroke context. Multiple sources including electronic databases, organisational websites and grey literature will be searched and we will cross reference citations in identified articles and suggested sources from the expert panel. The following databases CINAHL, EBSCOhost, MEDLINE, PubMed, EMBASE, Web of Science, Scopus, ScienceDirect Journals, and Google Scholar will be searched to identify the studies relevant to the review questions. The searches will include combinations of the keywords based on the population-intervention-comparison-outcome-context (PICOC) tool. This will help to describe the inclusion and exclusion criteria. An indicative search strategy for Ovid Medline is included (Table 4). Papers will be included based on their relevance to the research question and IPTs19. We will assess the relevance and rigor of included works as we test the IPTs29. Data extraction will be a three-step process, initial title and abstract screening using the inclusion and exclusion criteria (Table 2); followed by full-text review and appraisal. All authors will screen documents for initial relevance. Any conflicts will be discussed by all authors. A bespoke data extraction form will be used to extract and review information for programme theory refinement to include context, mechanisms, outcomes and resources relating to the research questions. Following data extraction, the selected papers will be imported into the qualitative software NVivo [91] version 14 (Mac), to facilitate coding and thematic data analysis to identify CMOCs. We will use the Braun and Clarke (29) thematic analysis framework to analyse the findings from each selected paper; (1) familiarity with the information, (2) generate codes, search for themes, (3) review the themes, (4) define and (5) name the themes and (6) produce the findings. Results and discussion sections will be coded in order to identify context, mechanism, outcome configurations in the findings. The expert panel will help to improve the final theoretical framework and we will revisit any stage of the process to ensure that we have enough data and reach a state of ‘theory’. The first draft IPTs will be presented to the expert panel for feedback to ensure appropriate interpretation of results. The expert panel will ensure that the refined IPTs are robust, contextually appropriate and reflect the complexities associated with the implementation of the intervention and relevant outcomes25. Realist inquiry facilitates an understanding of the extent to which an intervention works, for whom, in what context, why and how. This methodology has previously proven useful in research relating to stroke care in the context of early supported discharge47, neuropsychology rehabilitation42 and in evaluating outpatient rehabilitation and community support services post stroke48. This protocol adds to the growing number of publications in stroke care. It provides details for a realist review that will enable a better understanding of the specific contexts in which certain mechanisms are activated to enable long-term support to achieve a personally meaningful life after stroke. The review will address both the visible and often hidden forces that generate the outcomes of interest48,49. Life after stroke has only been regarded as a separate entity in recent years. Few of the current adult UK stroke guidelines specifically address longer term stroke management50, reflecting the paucity of evidence in this area and the limited programme theory available to support the required complex interventions. The realist review proposed in this protocol, rather than judging the effectiveness of an intervention, is concerned with answering how supports provided for Life after Stroke work, who they work for and in what circumstances. Realist programme theories that can coherently explain how supports are expected to work in Life after Stroke will provide researchers, policy makers and service funders/providers with new insights and robustly generated programme theories that can be developed, implemented or evaluated in existing stroke care pathways. Key to the knowledge gain associated with this methodologic approach is the inclusion of reference panels comprising healthcare professionals and experience-based experts in the development of the research questions, the search strategy and in the refinement of the review’s findings to both an Irish and a personal context. Ethical approval and consent were not required. Open Science Framework: CLASP project - Life after stroke and supportive stroke pathways: Protocol for a rapid realist review. https://doi.org/10.17605/OSF.IO/UJC5X51. The project contains the following underlying data: Extended File 1: PRISMA-P – complete checklist of items in reporting scoping reviews Extended File 2: Search Terms – complete list of search terms used in all databases Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). The authors are grateful to our Public and Patient Involvement (PPI) partners who worked with us on the grant application, this research methodology and who participated as Expert Panel members in developing candidate programme theories to inform this review. Faculty Opinions recommendedReferences - 1. Norrving B, Barrick J, Davalos A, et al.: Action Plan for Stroke in Europe 2018–2030. Eur Stroke J. 2018; 3(4): 309–336. PubMed Abstract | Publisher Full Text | Free Full Text - 2. Irish National Audit of Stroke national report 2020. National Office of Clinical Audit, Dublin, Ireland, [Accessed 1st September April 2024]. Reference Source - 3. GBD 2017 US Neurological Disorders Collaborators, Feigin VL, Vos T, et al.: Burden of neurological disorders across the US from 1990–2017: a Global Burden of Disease study. JAMA Neurol. 2021; 78(2): 165–176. PubMed Abstract | Publisher Full Text | Free Full Text - 4. 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Fletcher K, Wydera S, Thorpe N, et al.: A rapid realist review of clinical Neuropsychology Rehabilitation programmes to improve psychological wellbeing and Quality of Life for people with Acquired Brain Injuries. Neuropsychol Rehabil. 2024; 34(8): 1035–1070. PubMed Abstract | Publisher Full Text | Free Full Text - 43. Hall J, Kroll T, van Wijck F, et al.: Co-creating digital stories with UK-based stroke survivors with the aim of synthesizing collective lessons from individual experiences of interacting with Healthcare Professionals. Front Rehabil Sci. 2022; 3: 877442. PubMed Abstract | Publisher Full Text | Free Full Text - 44. Gladstone D, Poppe A: Canadian stroke best practices on behalf of the Canadian stroke best practice recommendations secondary prevention of stroke writing group and in collaboration with the Canadian stroke consortium. Reference Source - 45. Lennon O, Blake C, Booth J, et al.: Interventions for behaviour change and self-management in stroke secondary prevention: protocol for an overview of reviews. Syst Rev. 2018; 7(1): 231. PubMed Abstract | Publisher Full Text | Free Full Text - 46. Gangwani R, Cain A, Collins A, et al.: Leveraging factors of self-efficacy and motivation to optimize stroke recovery. Front Neurol. 2022; 13: 823202. PubMed Abstract | Publisher Full Text | Free Full Text - 47. Fisher RJ, Chouliara N, Byrne A, et al.: Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study. Health Serv Deliv Res. 2021; 9(22). PubMed Abstract | Publisher Full Text - 48. Ataman R, Ahmed S, Berta W, et al.: Sustainability of an outcome measure in outpatient stroke rehabilitation: a Realist Evaluation. J Eval Clin Pract. 2024; 30(4): 559–574. PubMed Abstract | Publisher Full Text - 49. Jagosh J: Realist synthesis for public health: building an ontologically deep understanding of how programs work, for whom, and in which contexts. Ann Rev Public Health. 2019; 40(1): 361–372. PubMed Abstract | Publisher Full Text - 50. National Clinical Guideline for stroke for the UK and Ireland. London: Intercollegiate Stroke Working Party, 2023; [accessed 02/09/2024]. Reference Source - 51. Lennon O, O’Neill M, Walsh K, et al.: Life after stroke and supportive stroke pathways: protocol for a rapid realist review. [Dataset]. Open Science Framework. 2024. http://www.doi.org/10.17605/OSF.IO/UJC5X Version 3 VERSION 3 PUBLISHED 14 Jul 2025 Revised - Reviewer Response 09 Aug 2025Rita Chiaramonte, University of Catania, Catania, Italy09 Aug 2025Reviewer ResponseThe study aims to describe a realist review protocol focused on understanding how to support life after stroke. The topic is highly relevant, given the increasing number of stroke survivors ... Continue reading The study aims to describe a realist review protocol focused on understanding how to support life after stroke. The topic is highly relevant, given the increasing number of stroke survivors and the ongoing need to address their long-term quality of life and well-being. The use of a realist methodology is appropriate for capturing the complexity of post-stroke recovery and support systems. However, several points would benefit from further clarification and development to strengthen the protocol and ensure its methodological effectiveness. TITLE: The title is appropriate, but the study design is not clearly indicated. ABSTRACT:- please define better the aim of the study. - Define better it is a pilot study - However it is not clear what keys will be investigate, please specify in methods - The authors mentions a lack of consensus on promoting agency and fulfilment post-stroke, but it would be helpful to further define what is meant by agency and fulfilment in this context. Are these grounded in specific theoretical or clinical frameworks (e.g., self-management, person-centered care, psychological recovery models)? - Please specify what timeframe is considered "life after stroke"—e.g., subacute phase, long-term survivorship, or both. Your aim may vary significantly depending on whether the focus is on the early months post-discharge or chronic living with stroke sequelae. - While the five stages of the RAMESES method are appropriately listed, it would be helpful to provide explicit inclusion and exclusion criteria for the types of studies that will be reviewed. For example: - Are only qualitative studies included? Policy documents, or intervention studies also be considered? - Are studies involving specific subpopulations (e.g., aphasia, dysarthria, rehabilitation…)? - The authors mention that a comprehensive search strategy will be developed, but some preliminary details would improve transparency. For instance: - Will there be any date or language restrictions? - How will the quality or relevance of included sources be assessed? - The review protocol would benefit from a more detailed description of how initial programme theories will be constructed. Will this be based solely on literature, or also on prior empirical data? I think only literature, really? - DISCUSSION: CONLCUSION- Could the authors more clearly distinguish how this review will add to or differ from other reviews in stroke rehabilitation or long-term support? This protocol addresses a critical area of stroke care and is based on an appropriate and robust methodological approach. However, as this is a purely descriptive, pilot study, further details are needed in key methodological sections. I encourage the authors to further explore these aspects, which will significantly improve the clarity and rigor of the protocol.TThe study aims to describe a realist review protocol focused on understanding how to support life after stroke. The topic is highly relevant, given the increasing number of stroke survivors and the ongoing need to address their long-term quality of life and well-being.Competing Interests: none Close The use of a realist methodology is appropriate for capturing the complexity of post-stroke recovery and support systems. However, several points would benefit from further clarification and development to strengthen the protocol and ensure its methodological effectiveness. TITLE: The title is appropriate, but the study design is not clearly indicated. ABSTRACT:- please define better the aim of the study. - Define better it is a pilot study - However it is not clear what keys will be investigate, please specify in methods - The authors mentions a lack of consensus on promoting agency and fulfilment post-stroke, but it would be helpful to further define what is meant by agency and fulfilment in this context. Are these grounded in specific theoretical or clinical frameworks (e.g., self-management, person-centered care, psychological recovery models)? - Please specify what timeframe is considered "life after stroke"—e.g., subacute phase, long-term survivorship, or both. Your aim may vary significantly depending on whether the focus is on the early months post-discharge or chronic living with stroke sequelae. - While the five stages of the RAMESES method are appropriately listed, it would be helpful to provide explicit inclusion and exclusion criteria for the types of studies that will be reviewed. For example: - Are only qualitative studies included? Policy documents, or intervention studies also be considered? - Are studies involving specific subpopulations (e.g., aphasia, dysarthria, rehabilitation…)? - The authors mention that a comprehensive search strategy will be developed, but some preliminary details would improve transparency. For instance: - Will there be any date or language restrictions? - How will the quality or relevance of included sources be assessed? - The review protocol would benefit from a more detailed description of how initial programme theories will be constructed. Will this be based solely on literature, or also on prior empirical data? I think only literature, really? - DISCUSSION: CONLCUSION- Could the authors more clearly distinguish how this review will add to or differ from other reviews in stroke rehabilitation or long-term support? This protocol addresses a critical area of stroke care and is based on an appropriate and robust methodological approach. However, as this is a purely descriptive, pilot study, further details are needed in key methodological sections. I encourage the authors to further explore these aspects, which will significantly improve the clarity and rigor of the protocol.T Version 2 VERSION 2 PUBLISHED 25 Mar 2025 Revised

is closed on this version, please comment on the latest version above. - Author Response 03 Oct 2025Frances Horgan, School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland03 Oct 2025Author ResponseDear Professor Chiaramonte, Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. Title: ... Continue reading Dear Professor Chiaramonte, Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. Title: The current title is unclear. Please revise it to more explicitly reflect the aim and methodology of the study. The title should clearly inform the reader about the scope and purpose of the manuscript. Response – we have revised the title of the protocol as follows “What are the mechanisms and contexts for a supported Life After Stroke Pathway: Protocol for a Rapid Realist Review” to reflect the scope and purpose of our review.

The aim of the study is currently unclear in the abstract. This will help readers quickly understand the intent and contribution of the work. Response – we have revised the aim of the review to ensure that readers will be clear on the intent and contribution of our review in the context of a life after stroke care pathway, the revised aim is as follows: This realist review will examine the mechanisms and contexts for a supported life after stroke care pathway. Table 3: Table 3 would benefit from more detailed discussion and contextualization in the main text. This will enhance the reader’s understanding and make the manuscript more engaging. Please provide more narrative explanation in the text that connects to the contents of Table 3. Response – we have added some additional details linking the text and CIPTs to Table 3. Consider incorporating references to support the relevance of each theme listed in the table. For example, for the theme “Communication”, see the following: DOI: 10.23736/S1973-9087.20.06242-5 Reply – Thank you for this suggestion, we have added references to Table 3 to support the relevance of each theme listed in the table. Table 3 represents the developmental framework for your next study. This should be emphasized more clearly, highlighting that while the literature discusses these themes, it rarely does so in the context of post-discharge care—and not as comprehensively as your study aims to do. Reply – Thank you for this feedback, we have highlighted this focus of our work and this detail preceded Table 4. On behalf of the author team, thank you for taking the time to review our protocol. Frances Horgan Dear Professor Trusson, Thank you for your very positive feedback and suggested changes. We have reviewed the protocol to improve its readability, we have addressed the complex sentences as follows: Page 3 - Second sentence under the heading 'the expert panel'. Response – the long sentence relating to the members of the expert panel has been broken up to improve readability. Page 6 -The entries under the heading 'Early COMCs' in Table 3. Response – the long sentences relating to the Early COMCs in Table 3 have been reviewed, revised and broken up to improve readability. Page 8 - Last sentence in the first paragraph of the discussion. Response – the last sentence of paragraph 1 of the Discussion has been reviewed and revised to improve readability. We apologise that we missed some typographical errors, we have proofread the protocol again and we have corrected these typographical errors. Kind regards, Frances Horgan on behalf of the author teamDear Professor Chiaramonte,Competing Interests: No competing interests were disclosed. Close Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. Title: The current title is unclear. Please revise it to more explicitly reflect the aim and methodology of the study. The title should clearly inform the reader about the scope and purpose of the manuscript. Response – we have revised the title of the protocol as follows “What are the mechanisms and contexts for a supported Life After Stroke Pathway: Protocol for a Rapid Realist Review” to reflect the scope and purpose of our review.

The aim of the study is currently unclear in the abstract. This will help readers quickly understand the intent and contribution of the work. Response – we have revised the aim of the review to ensure that readers will be clear on the intent and contribution of our review in the context of a life after stroke care pathway, the revised aim is as follows: This realist review will examine the mechanisms and contexts for a supported life after stroke care pathway. Table 3: Table 3 would benefit from more detailed discussion and contextualization in the main text. This will enhance the reader’s understanding and make the manuscript more engaging. Please provide more narrative explanation in the text that connects to the contents of Table 3. Response – we have added some additional details linking the text and CIPTs to Table 3. Consider incorporating references to support the relevance of each theme listed in the table. For example, for the theme “Communication”, see the following: DOI: 10.23736/S1973-9087.20.06242-5 Reply – Thank you for this suggestion, we have added references to Table 3 to support the relevance of each theme listed in the table. Table 3 represents the developmental framework for your next study. This should be emphasized more clearly, highlighting that while the literature discusses these themes, it rarely does so in the context of post-discharge care—and not as comprehensively as your study aims to do. Reply – Thank you for this feedback, we have highlighted this focus of our work and this detail preceded Table 4. On behalf of the author team, thank you for taking the time to review our protocol. Frances Horgan Dear Professor Trusson, Thank you for your very positive feedback and suggested changes. We have reviewed the protocol to improve its readability, we have addressed the complex sentences as follows: Page 3 - Second sentence under the heading 'the expert panel'. Response – the long sentence relating to the members of the expert panel has been broken up to improve readability. Page 6 -The entries under the heading 'Early COMCs' in Table 3. Response – the long sentences relating to the Early COMCs in Table 3 have been reviewed, revised and broken up to improve readability. Page 8 - Last sentence in the first paragraph of the discussion. Response – the last sentence of paragraph 1 of the Discussion has been reviewed and revised to improve readability. We apologise that we missed some typographical errors, we have proofread the protocol again and we have corrected these typographical errors. Kind regards, Frances Horgan on behalf of the author team - Discussion is closed on this version, please comment on the latest version above. Author details Author details 1 University College Dublin, School of Public Health Physiotherapy, and Sports Science, Dublin, Leinster, Ireland 2 School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 3 Royal College of Surgeons in Ireland, Mercer Library, Dublin, Leinster, Ireland 2 School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 3 Royal College of Surgeons in Ireland, Mercer Library, Dublin, Leinster, Ireland Olive Lennon Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Mary O'Neill Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Killian Walsh Roles: Data Curation, Methodology, Writing – Review & Editing Roles: Data Curation, Methodology, Writing – Review & Editing Frances Horgan Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Health Research Board Ireland [APA-2022-019]. This work was also supported by the Irish Heart Foundation and the HSE National Stroke Clinical Programme. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (3) Copyright © 2025 Lennon O et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. metrics VIEWS $counts.viewCount downloads Citations CITE how to cite this article Lennon O, O'Neill M, Walsh K and Horgan F. What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.12688/hrbopenres.14034.3) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 3 VERSION 3 PUBLISHED 14 Jul 2025 Revised Views 0 How to cite this report: Chiaramonte R. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15617.r48350) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v3#referee-response-48350 https://hrbopenresearch.org/articles/8-10/v3#referee-response-48350 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 27 Aug 2025 Approved VIEWS 0 Thank you for the opportunity to review this protocol for a rapid realist review aimed at conceptualizing support for life after stroke—an under-researched area in the stroke care pathway. I appreciated the efforts of the authors to improve their ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close I appreciated the efforts of the authors to improve their ... Continue reading Thank you for the opportunity to review this protocol for a rapid realist review aimed at conceptualizing support for life after stroke—an under-researched area in the stroke care pathway. I appreciated the efforts of the authors to improve their study according to the suggestions of the reviewers. The protocol closely follows RAMESES methodological guidance and appropriately uses context–mechanism–outcome configurations to develop programme theories aligned with the study’s objectives. I appreciated the efforts of the authors to improve their study according to the suggestions of the reviewers. The protocol closely follows RAMESES methodological guidance and appropriately uses context–mechanism–outcome configurations to develop programme theories aligned with the study’s objectives. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Rehabilitation CITE HOW TO CITE THIS REPORT Chiaramonte R. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15617.r48350) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v3#referee-response-48350 https://hrbopenresearch.org/articles/8-10/v3#referee-response-48350 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Version 2 VERSION 2 PUBLISHED 25 Mar 2025 Revised Views 0 How to cite this report: Trusson D. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15524.r46546) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v2#referee-response-46546 https://hrbopenresearch.org/articles/8-10/v2#referee-response-46546 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 10 Apr 2025 Diane Trusson, University of Nottingham, Nottingham, UK Approved VIEWS 0 Thank you for the opportunity to review this manuscript. It is good to see this very important, yet under-researched, topic within stroke research being addressed. It seems that the manuscript is much stronger as a result of the revisions made ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close Thank you for the opportunity to review this manuscript. It is good to see this very important, yet under-researched, topic within stroke research being addressed. It seems that the manuscript is much stronger as a result of the revisions made in response to the previous reviewer's comments. Consequently I have no further recommendations in terms of the methodology for the proposed realist review. The only comment I have is in terms of readability. There are a number of long, complex sentences which would be clearer if they were broken up. Specifically the following: Page 3 - Second sentence under the heading 'the expert panel'. Page 6 -The entries under the heading 'Early COMCs' in table 3. Page 8 - Last sentence in the first paragraph of the discussion. I would also recommend that the authors proofread the manuscript before it is submitted. Overall I congratulate the authors on this work and look forward to reading the realist review in due course. The only comment I have is in terms of readability. There are a number of long, complex sentences which would be clearer if they were broken up. Specifically the following: Page 3 - Second sentence under the heading 'the expert panel'. Page 6 -The entries under the heading 'Early COMCs' in table 3. Page 8 - Last sentence in the first paragraph of the discussion. I would also recommend that the authors proofread the manuscript before it is submitted. Overall I congratulate the authors on this work and look forward to reading the realist review in due course. - Is the rationale for, and objectives of, the study clearly described? Yes - Is the study design appropriate for the research question? Yes - Are sufficient details of the methods provided to allow replication by others? Yes - Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests: No competing interests were disclosed. CITE HOW TO CITE THIS REPORT Trusson D. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15524.r46546) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v2#referee-response-46546 https://hrbopenresearch.org/articles/8-10/v2#referee-response-46546 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Views 0 How to cite this report: Chiaramonte R. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15524.r46543) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v2#referee-response-46543 https://hrbopenresearch.org/articles/8-10/v2#referee-response-46543 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 07 Apr 2025 Approved with Reservations VIEWS 0 The study aims to identify consensus on best practices for care following discharge from specialist stroke services. Title: The current title is unclear. Please revise it to more explicitly reflect the aim and methodology ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close Title: The current title is unclear. Please revise it to more explicitly reflect the aim and methodology ... Continue reading The study aims to identify consensus on best practices for care following discharge from specialist stroke services. Title: The current title is unclear. Please revise it to more explicitly reflect the aim and methodology of the study. The title should clearly inform the reader about the scope and purpose of the manuscript.

The aim of the study is currently unclear in the abstract. This will help readers quickly understand the intent and contribution of the work. Table 3: Table 3 would benefit from more detailed discussion and contextualization in the main text. This will enhance the reader’s understanding and make the manuscript more engaging. Please provide more narrative explanation in the text that connects to the contents of Table 3. Consider incorporating references to support the relevance of each theme listed in the table. For example, for the theme “Communication”, see the following: DOI: 10.23736/S1973-9087.20.06242-5 Table 3 represents the developmental framework for your next study. This should be emphasized more clearly, highlighting that while the literature discusses these themes, it rarely does so in the context of post-discharge care—and not as comprehensively as your study aims to do. Title: The current title is unclear. Please revise it to more explicitly reflect the aim and methodology of the study. The title should clearly inform the reader about the scope and purpose of the manuscript.

The aim of the study is currently unclear in the abstract. This will help readers quickly understand the intent and contribution of the work. Table 3: Table 3 would benefit from more detailed discussion and contextualization in the main text. This will enhance the reader’s understanding and make the manuscript more engaging. Please provide more narrative explanation in the text that connects to the contents of Table 3. Consider incorporating references to support the relevance of each theme listed in the table. For example, for the theme “Communication”, see the following: DOI: 10.23736/S1973-9087.20.06242-5 Table 3 represents the developmental framework for your next study. This should be emphasized more clearly, highlighting that while the literature discusses these themes, it rarely does so in the context of post-discharge care—and not as comprehensively as your study aims to do. - Is the rationale for, and objectives of, the study clearly described? Partly - Is the study design appropriate for the research question? Yes - Are sufficient details of the methods provided to allow replication by others? Yes - Are the datasets clearly presented in a useable and accessible format? Yes

1. Chiaramonte R, Vecchio M: Dysarthria and stroke. The effectiveness of speech rehabilitation. A systematic review and meta-analysis of the studies.Eur J Phys Rehabil Med. 2021; 57 (1): 24-43 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed. Reviewer Expertise: Rehabilitation CITE HOW TO CITE THIS REPORT Chiaramonte R. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15524.r46543) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v2#referee-response-46543 https://hrbopenresearch.org/articles/8-10/v2#referee-response-46543 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Views 0 How to cite this report: Hancock N. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15524.r46508) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v2#referee-response-46508 https://hrbopenresearch.org/articles/8-10/v2#referee-response-46508 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 27 Mar 2025 Nicola Hancock, University of East Anglia, Norwich, UK Approved VIEWS 0 No ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close No new comments Competing Interests: No competing interests were disclosed. Reviewer Expertise: Stroke rehabilitation, technology for rehabilitation, stroke service innovation CITE HOW TO CITE THIS REPORT Hancock N. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15524.r46508) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v2#referee-response-46508 https://hrbopenresearch.org/articles/8-10/v2#referee-response-46508 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Version 1 VERSION 1 PUBLISHED 23 Jan 2025 Views 0 How to cite this report: Hancock N. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15406.r45178) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v1#referee-response-45178 https://hrbopenresearch.org/articles/8-10/v1#referee-response-45178 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 17 Mar 2025 Nicola Hancock, University of East Anglia, Norwich, UK Approved VIEWS 0 Thank you for the opportunity to review this protocol for a rapid realist review that aims to conceptualise support for Life After Stroke- this is an under-researched part of the stroke pathway and, according to my interpretation of the protocol, ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close Thank you for the opportunity to review this protocol for a rapid realist review that aims to conceptualise support for Life After Stroke- this is an under-researched part of the stroke pathway and, according to my interpretation of the protocol, the review will make a valuable contribution to understanding what works for whom and in what context, after discharge from statutory stroke services. It is pleasing to see that the protocol closely adheres to RAMESES methodological guidance and seeks to develop programme theories using context-mechanism-outcome configurations, which are appropriate to the intended aims of the study. As such, i have only minor suggestions for improvement, which i hope are useful to the authorship team: - It is important that people with lived experience are included in the summary of expert panel members in the abstract. i appreciate that their involvement is clearer later on in the manuscript (table 1), but a commitment to the full range of stakeholders should be explicit at the outset. -The review question, in the second paragraph of page 3, is general and does not include any reference to the population or context of life after stroke. Perhaps the addition of 'for people in their life after stroke' or similar would help here? - A minor point, but suggest figure 1 legend simply says 'According to Pawson (ref) rather than "Pawson's work' -the commitment to stakeholder engagement is laudable in the protocol, but i see no reference to carers. Carers are key stakeholders in life after stroke but seem to be absent from the expert panel- perhaps they will be included/represented by the SSOs but this could be clearer. -the search strategies are very comprehensive -a brief expansion of detail of the approach to coding and thematic analysis in the data analysis would enhance transparency and the interpretation of future work reporting the full study. It is pleasing to see that the protocol closely adheres to RAMESES methodological guidance and seeks to develop programme theories using context-mechanism-outcome configurations, which are appropriate to the intended aims of the study. As such, i have only minor suggestions for improvement, which i hope are useful to the authorship team: - It is important that people with lived experience are included in the summary of expert panel members in the abstract. i appreciate that their involvement is clearer later on in the manuscript (table 1), but a commitment to the full range of stakeholders should be explicit at the outset. -The review question, in the second paragraph of page 3, is general and does not include any reference to the population or context of life after stroke. Perhaps the addition of 'for people in their life after stroke' or similar would help here? - A minor point, but suggest figure 1 legend simply says 'According to Pawson (ref) rather than "Pawson's work' -the commitment to stakeholder engagement is laudable in the protocol, but i see no reference to carers. Carers are key stakeholders in life after stroke but seem to be absent from the expert panel- perhaps they will be included/represented by the SSOs but this could be clearer. -the search strategies are very comprehensive -a brief expansion of detail of the approach to coding and thematic analysis in the data analysis would enhance transparency and the interpretation of future work reporting the full study. - Is the rationale for, and objectives of, the study clearly described? Yes - Is the study design appropriate for the research question? Yes - Are sufficient details of the methods provided to allow replication by others? Partly - Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Stroke rehabilitation, technology for rehabilitation, stroke service innovation CITE HOW TO CITE THIS REPORT Hancock N. Reviewer Report For: What are the Mechanisms and Contexts for a Supported Life After Stroke Pathway: Protocol for a Rapid Realist Review [version 3; peer review: 3 approved]. HRB Open Res 2025, 8:10 (https://doi.org/10.21956/hrbopenres.15406.r45178) The direct URL for this report is: https://hrbopenresearch.org/articles/8-10/v1#referee-response-45178 https://hrbopenresearch.org/articles/8-10/v1#referee-response-45178 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 25 Mar 2025Frances Horgan, School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland25 Mar 2025Author ResponseDear Professor Hancock, Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. - ... Continue reading Dear Professor Hancock, Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. - It is important that people with lived experience are included in the summary of expert panel members in the abstract. I appreciate that their involvement is clearer later on in the manuscript (table 1), but a commitment to the full range of stakeholders should be explicit at the outset. Response - Our expert panel includes people with lived experience of stroke and carers. We have amended the abstract. -The review question, in the second paragraph of page 3, is general and does not include any reference to the population or context of life after stroke. Perhaps the addition of 'for people in their life after stroke' or similar would help here? Response - thank you we are happy to make this change to ensure that the context is clearer. We have added the suggested additional text so that the review questions are clear. - A minor point, but suggest figure 1 legend simply says 'According to Pawson (ref) rather than "Pawson's work' Response - we have changed the Figure 1 legend to According to Pawson (2002) -the commitment to stakeholder engagement is laudable in the protocol, but I see no reference to carers. Carers are key stakeholders in life after stroke but seem to be absent from the expert panel- perhaps they will be included/represented by the SSOs but this could be clearer. Response - Our expert panel includes carers. We have added this detail in The expert panel section and in Table 1. -a brief expansion of detail of the approach to coding and thematic analysis in the data analysis would enhance transparency and the interpretation of future work reporting the full study. Response – We will use the Braun and Clarke (29) thematic analysis framework to analyse the findings from each selected paper; (1) familiarity with the information, (2) generate codes, search for themes, (3) review the themes, (4) define and (5) names the themes and (6) produce the findings. Results and discussion sections will be coded in order to identify context, mechanism, outcome configurations in the findings. We have added this detail in the Data analysis section. Frances Horgan on behalf of the author teamDear Professor Hancock,Competing Interests: The authors have no competing interests Close Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. - It is important that people with lived experience are included in the summary of expert panel members in the abstract. I appreciate that their involvement is clearer later on in the manuscript (table 1), but a commitment to the full range of stakeholders should be explicit at the outset. Response - Our expert panel includes people with lived experience of stroke and carers. We have amended the abstract. -The review question, in the second paragraph of page 3, is general and does not include any reference to the population or context of life after stroke. Perhaps the addition of 'for people in their life after stroke' or similar would help here? Response - thank you we are happy to make this change to ensure that the context is clearer. We have added the suggested additional text so that the review questions are clear. - A minor point, but suggest figure 1 legend simply says 'According to Pawson (ref) rather than "Pawson's work' Response - we have changed the Figure 1 legend to According to Pawson (2002) -the commitment to stakeholder engagement is laudable in the protocol, but I see no reference to carers. Carers are key stakeholders in life after stroke but seem to be absent from the expert panel- perhaps they will be included/represented by the SSOs but this could be clearer. Response - Our expert panel includes carers. We have added this detail in The expert panel section and in Table 1. -a brief expansion of detail of the approach to coding and thematic analysis in the data analysis would enhance transparency and the interpretation of future work reporting the full study. Response – We will use the Braun and Clarke (29) thematic analysis framework to analyse the findings from each selected paper; (1) familiarity with the information, (2) generate codes, search for themes, (3) review the themes, (4) define and (5) names the themes and (6) produce the findings. Results and discussion sections will be coded in order to identify context, mechanism, outcome configurations in the findings. We have added this detail in the Data analysis section. Frances Horgan on behalf of the author team COMMENTS ON THIS REPORT - Author Response 25 Mar 2025Frances Horgan, School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland25 Mar 2025Author ResponseDear Professor Hancock, Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. - ... Continue reading Dear Professor Hancock, Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. - It is important that people with lived experience are included in the summary of expert panel members in the abstract. I appreciate that their involvement is clearer later on in the manuscript (table 1), but a commitment to the full range of stakeholders should be explicit at the outset. Response - Our expert panel includes people with lived experience of stroke and carers. We have amended the abstract. -The review question, in the second paragraph of page 3, is general and does not include any reference to the population or context of life after stroke. Perhaps the addition of 'for people in their life after stroke' or similar would help here? Response - thank you we are happy to make this change to ensure that the context is clearer. We have added the suggested additional text so that the review questions are clear. - A minor point, but suggest figure 1 legend simply says 'According to Pawson (ref) rather than "Pawson's work' Response - we have changed the Figure 1 legend to According to Pawson (2002) -the commitment to stakeholder engagement is laudable in the protocol, but I see no reference to carers. Carers are key stakeholders in life after stroke but seem to be absent from the expert panel- perhaps they will be included/represented by the SSOs but this could be clearer. Response - Our expert panel includes carers. We have added this detail in The expert panel section and in Table 1. -a brief expansion of detail of the approach to coding and thematic analysis in the data analysis would enhance transparency and the interpretation of future work reporting the full study. Response – We will use the Braun and Clarke (29) thematic analysis framework to analyse the findings from each selected paper; (1) familiarity with the information, (2) generate codes, search for themes, (3) review the themes, (4) define and (5) names the themes and (6) produce the findings. Results and discussion sections will be coded in order to identify context, mechanism, outcome configurations in the findings. We have added this detail in the Data analysis section. Frances Horgan on behalf of the author teamDear Professor Hancock,Competing Interests: The authors have no competing interests Close Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. - It is important that people with lived experience are included in the summary of expert panel members in the abstract. I appreciate that their involvement is clearer later on in the manuscript (table 1), but a commitment to the full range of stakeholders should be explicit at the outset. Response - Our expert panel includes people with lived experience of stroke and carers. We have amended the abstract. -The review question, in the second paragraph of page 3, is general and does not include any reference to the population or context of life after stroke. Perhaps the addition of 'for people in their life after stroke' or similar would help here? Response - thank you we are happy to make this change to ensure that the context is clearer. We have added the suggested additional text so that the review questions are clear. - A minor point, but suggest figure 1 legend simply says 'According to Pawson (ref) rather than "Pawson's work' Response - we have changed the Figure 1 legend to According to Pawson (2002) -the commitment to stakeholder engagement is laudable in the protocol, but I see no reference to carers. Carers are key stakeholders in life after stroke but seem to be absent from the expert panel- perhaps they will be included/represented by the SSOs but this could be clearer. Response - Our expert panel includes carers. We have added this detail in The expert panel section and in Table 1. -a brief expansion of detail of the approach to coding and thematic analysis in the data analysis would enhance transparency and the interpretation of future work reporting the full study. Response – We will use the Braun and Clarke (29) thematic analysis framework to analyse the findings from each selected paper; (1) familiarity with the information, (2) generate codes, search for themes, (3) review the themes, (4) define and (5) names the themes and (6) produce the findings. Results and discussion sections will be coded in order to identify context, mechanism, outcome configurations in the findings. We have added this detail in the Data analysis section. Frances Horgan on behalf of the author team Version 3 VERSION 3 PUBLISHED 14 Jul 2025 Revised - Reviewer Response 09 Aug 2025Rita Chiaramonte, University of Catania, Catania, Italy09 Aug 2025Reviewer ResponseThe study aims to describe a realist review protocol focused on understanding how to support life after stroke. The topic is highly relevant, given the increasing number of stroke survivors ... Continue reading The study aims to describe a realist review protocol focused on understanding how to support life after stroke. The topic is highly relevant, given the increasing number of stroke survivors and the ongoing need to address their long-term quality of life and well-being. The use of a realist methodology is appropriate for capturing the complexity of post-stroke recovery and support systems. However, several points would benefit from further clarification and development to strengthen the protocol and ensure its methodological effectiveness. TITLE: The title is appropriate, but the study design is not clearly indicated. ABSTRACT:- please define better the aim of the study. - Define better it is a pilot study - However it is not clear what keys will be investigate, please specify in methods - The authors mentions a lack of consensus on promoting agency and fulfilment post-stroke, but it would be helpful to further define what is meant by agency and fulfilment in this context. Are these grounded in specific theoretical or clinical frameworks (e.g., self-management, person-centered care, psychological recovery models)? - Please specify what timeframe is considered "life after stroke"—e.g., subacute phase, long-term survivorship, or both. Your aim may vary significantly depending on whether the focus is on the early months post-discharge or chronic living with stroke sequelae. - While the five stages of the RAMESES method are appropriately listed, it would be helpful to provide explicit inclusion and exclusion criteria for the types of studies that will be reviewed. For example: - Are only qualitative studies included? Policy documents, or intervention studies also be considered? - Are studies involving specific subpopulations (e.g., aphasia, dysarthria, rehabilitation…)? - The authors mention that a comprehensive search strategy will be developed, but some preliminary details would improve transparency. For instance: - Will there be any date or language restrictions? - How will the quality or relevance of included sources be assessed? - The review protocol would benefit from a more detailed description of how initial programme theories will be constructed. Will this be based solely on literature, or also on prior empirical data? I think only literature, really? - DISCUSSION: CONLCUSION- Could the authors more clearly distinguish how this review will add to or differ from other reviews in stroke rehabilitation or long-term support? This protocol addresses a critical area of stroke care and is based on an appropriate and robust methodological approach. However, as this is a purely descriptive, pilot study, further details are needed in key methodological sections. I encourage the authors to further explore these aspects, which will significantly improve the clarity and rigor of the protocol.TThe study aims to describe a realist review protocol focused on understanding how to support life after stroke. The topic is highly relevant, given the increasing number of stroke survivors and the ongoing need to address their long-term quality of life and well-being.Competing Interests: none Close The use of a realist methodology is appropriate for capturing the complexity of post-stroke recovery and support systems. However, several points would benefit from further clarification and development to strengthen the protocol and ensure its methodological effectiveness. TITLE: The title is appropriate, but the study design is not clearly indicated. ABSTRACT:- please define better the aim of the study. - Define better it is a pilot study - However it is not clear what keys will be investigate, please specify in methods - The authors mentions a lack of consensus on promoting agency and fulfilment post-stroke, but it would be helpful to further define what is meant by agency and fulfilment in this context. Are these grounded in specific theoretical or clinical frameworks (e.g., self-management, person-centered care, psychological recovery models)? - Please specify what timeframe is considered "life after stroke"—e.g., subacute phase, long-term survivorship, or both. Your aim may vary significantly depending on whether the focus is on the early months post-discharge or chronic living with stroke sequelae. - While the five stages of the RAMESES method are appropriately listed, it would be helpful to provide explicit inclusion and exclusion criteria for the types of studies that will be reviewed. For example: - Are only qualitative studies included? Policy documents, or intervention studies also be considered? - Are studies involving specific subpopulations (e.g., aphasia, dysarthria, rehabilitation…)? - The authors mention that a comprehensive search strategy will be developed, but some preliminary details would improve transparency. For instance: - Will there be any date or language restrictions? - How will the quality or relevance of included sources be assessed? - The review protocol would benefit from a more detailed description of how initial programme theories will be constructed. Will this be based solely on literature, or also on prior empirical data? I think only literature, really? - DISCUSSION: CONLCUSION- Could the authors more clearly distinguish how this review will add to or differ from other reviews in stroke rehabilitation or long-term support? This protocol addresses a critical area of stroke care and is based on an appropriate and robust methodological approach. However, as this is a purely descriptive, pilot study, further details are needed in key methodological sections. I encourage the authors to further explore these aspects, which will significantly improve the clarity and rigor of the protocol.T Version 2 VERSION 2 PUBLISHED 25 Mar 2025 Revised

is closed on this version, please comment on the latest version above. - Author Response 03 Oct 2025Frances Horgan, School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland03 Oct 2025Author ResponseDear Professor Chiaramonte, Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. Title: ... Continue reading Dear Professor Chiaramonte, Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. Title: The current title is unclear. Please revise it to more explicitly reflect the aim and methodology of the study. The title should clearly inform the reader about the scope and purpose of the manuscript. Response – we have revised the title of the protocol as follows “What are the mechanisms and contexts for a supported Life After Stroke Pathway: Protocol for a Rapid Realist Review” to reflect the scope and purpose of our review.

The aim of the study is currently unclear in the abstract. This will help readers quickly understand the intent and contribution of the work. Response – we have revised the aim of the review to ensure that readers will be clear on the intent and contribution of our review in the context of a life after stroke care pathway, the revised aim is as follows: This realist review will examine the mechanisms and contexts for a supported life after stroke care pathway. Table 3: Table 3 would benefit from more detailed discussion and contextualization in the main text. This will enhance the reader’s understanding and make the manuscript more engaging. Please provide more narrative explanation in the text that connects to the contents of Table 3. Response – we have added some additional details linking the text and CIPTs to Table 3. Consider incorporating references to support the relevance of each theme listed in the table. For example, for the theme “Communication”, see the following: DOI: 10.23736/S1973-9087.20.06242-5 Reply – Thank you for this suggestion, we have added references to Table 3 to support the relevance of each theme listed in the table. Table 3 represents the developmental framework for your next study. This should be emphasized more clearly, highlighting that while the literature discusses these themes, it rarely does so in the context of post-discharge care—and not as comprehensively as your study aims to do. Reply – Thank you for this feedback, we have highlighted this focus of our work and this detail preceded Table 4. On behalf of the author team, thank you for taking the time to review our protocol. Frances Horgan Dear Professor Trusson, Thank you for your very positive feedback and suggested changes. We have reviewed the protocol to improve its readability, we have addressed the complex sentences as follows: Page 3 - Second sentence under the heading 'the expert panel'. Response – the long sentence relating to the members of the expert panel has been broken up to improve readability. Page 6 -The entries under the heading 'Early COMCs' in Table 3. Response – the long sentences relating to the Early COMCs in Table 3 have been reviewed, revised and broken up to improve readability. Page 8 - Last sentence in the first paragraph of the discussion. Response – the last sentence of paragraph 1 of the Discussion has been reviewed and revised to improve readability. We apologise that we missed some typographical errors, we have proofread the protocol again and we have corrected these typographical errors. Kind regards, Frances Horgan on behalf of the author teamDear Professor Chiaramonte,Competing Interests: No competing interests were disclosed. Close Thank you for your very positive feedback and suggested changes to our protocol. We have addressed and made all of these changes as follows. Title: The current title is unclear. Please revise it to more explicitly reflect the aim and methodology of the study. The title should clearly inform the reader about the scope and purpose of the manuscript. Response – we have revised the title of the protocol as follows “What are the mechanisms and contexts for a supported Life After Stroke Pathway: Protocol for a Rapid Realist Review” to reflect the scope and purpose of our review.

The aim of the study is currently unclear in the abstract. This will help readers quickly understand the intent and contribution of the work. Response – we have revised the aim of the review to ensure that readers will be clear on the intent and contribution of our review in the context of a life after stroke care pathway, the revised aim is as follows: This realist review will examine the mechanisms and contexts for a supported life after stroke care pathway. Table 3: Table 3 would benefit from more detailed discussion and contextualization in the main text. This will enhance the reader’s understanding and make the manuscript more engaging. Please provide more narrative explanation in the text that connects to the contents of Table 3. Response – we have added some additional details linking the text and CIPTs to Table 3. Consider incorporating references to support the relevance of each theme listed in the table. For example, for the theme “Communication”, see the following: DOI: 10.23736/S1973-9087.20.06242-5 Reply – Thank you for this suggestion, we have added references to Table 3 to support the relevance of each theme listed in the table. Table 3 represents the developmental framework for your next study. This should be emphasized more clearly, highlighting that while the literature discusses these themes, it rarely does so in the context of post-discharge care—and not as comprehensively as your study aims to do. Reply – Thank you for this feedback, we have highlighted this focus of our work and this detail preceded Table 4. On behalf of the author team, thank you for taking the time to review our protocol. Frances Horgan Dear Professor Trusson, Thank you for your very positive feedback and suggested changes. We have reviewed the protocol to improve its readability, we have addressed the complex sentences as follows: Page 3 - Second sentence under the heading 'the expert panel'. Response – the long sentence relating to the members of the expert panel has been broken up to improve readability. Page 6 -The entries under the heading 'Early COMCs' in Table 3. Response – the long sentences relating to the Early COMCs in Table 3 have been reviewed, revised and broken up to improve readability. Page 8 - Last sentence in the first paragraph of the discussion. Response – the last sentence of paragraph 1 of the Discussion has been reviewed and revised to improve readability. We apologise that we missed some typographical errors, we have proofread the protocol again and we have corrected these typographical errors. Kind regards, Frances Horgan on behalf of the author team - Discussion is closed on this version, please comment on the latest version above. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | ||| |---|---|---|---| | 1 | 2 | 3 | | | Version 3 (revision) 14 Jul 25 | read | || | Version 2 (revision) 25 Mar 25 | read | read | read | | Version 1 23 Jan 25 | read | Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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