Disability and Rehabilitation

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/idre20

Development of the “Kalmer” relaxation

intervention: co-design with stroke survivors with
aphasia

Rebecca El-Helou, Brooke Ryan & Ian Kneebone

To cite this article: Rebecca El-Helou, Brooke Ryan & Ian Kneebone (2022): Development of
the “Kalmer” relaxation intervention: co-design with stroke survivors with aphasia, Disability and
Rehabilitation, DOI: 10.1080/09638288.2022.2069294

To link to this article: https://doi.org/10.1080/09638288.2022.2069294

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DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2022.2069294

ORIGINAL ARTICLE

Development of the “Kalmer” relaxation intervention: co-design with stroke

survivors with aphasia
Rebecca El-Heloua,b , Brooke Ryana,b and Ian Kneebonea,b
a
Graduate School of Health, University of Technology Sydney, Sydney, Australia; bCentre of Research Excellence in Aphasia Recovery and
Rehabilitation, La Trobe University, Melbourne, Australia

ABSTRACT ARTICLE HISTORY

Purpose: Anxiety is common after stroke and more prevalent in survivors with aphasia. Relaxation is an Received 4 June 2021
effective first-line therapy. The current study aimed to obtain the perspectives of stroke survivors with Revised 11 April 2022
aphasia to inform the development of an accessible, technology-based, relaxation intervention. Accepted 17 April 2022
Materials and methods: Qualitative co-design methods were used with twelve people with aphasia after
KEYWORDS
stroke. The “Kalmer” Relaxation treatment package materials were iteratively based on participants’ expe­ Relaxation; stroke; aphasia;
riences and preferences; barriers and facilitators to treatment compliance were explored. Participants co-design; qualitative
were also asked to consider how the intervention might be evaluated in a research trial.
Results: A thematic analysis highlighted the importance and need for the development of an appropriate
and inclusive relaxation product, to be implemented by health professionals early post-stroke. Several
behavioural strategies to improve treatment adherence were recommended. Participants had varying per­
spectives on clinically meaningful treatment outcomes.
Conclusions: Overall, a co-designed accessible relaxation product was viewed as a necessary component
of usual stroke care. Acceptability and feasibility and preliminary efficacy of the “Kalmer” intervention
should be trialled in future studies.

� IMPLICATIONS FOR REHABILITATION

� Co-designing psychological interventions for people with aphasia after stroke is needed to meet the
needs of this at-risk population.
� Technology-based relaxation interventions to manage anxiety after stroke are viewed positively by
people with aphasia and deemed acceptable and feasible.
� Clinical trials of these co-designed relaxation interventions are required before recommending inte­
gration into routine practice.

Introduction
Worldwide stroke effects over 13 million people annually [1].
Stroke survivors can experience physical and cognitive disabilities
that vary in their nature and severity [2–5]. One major conse­
quence of stroke can be the development of mood disturbances
[5–7]. Anxiety is common after stroke, with a point prevalence of
25% [6,7] and it is associated with poor outcomes, such as
reduced quality of life, social relationships, and worse rehabilita­
tion outcomes [6,7]. Approximately, 30–34% of stroke survivors
will also be diagnosed with a significant language-based commu­
nication disability called aphasia [8]. People with aphasia com­
monly experience impairments in reading, writing, speaking, and
listening, with the nature and severity of these deficits varying
across individuals [9]. Given the importance of communication in
one’s social, occupational, and daily functioning, it is unsurprising
that people with aphasia are at a higher risk of developing
depression and anxiety and experience worse rehabilitation out­
comes than survivors without stroke-related impair­
ments [8,10–13].
In Australia, the setting for this study, data from the Stroke
Foundation Rehabilitation Audits indicates that stroke survivors
are not receiving adequate psychological care to address their
problematic mood impairments [14]. Specifically, 31% of stroke
services do not have access to psychologists for appropriate
advice and treatment planning [14]. This number is likely to be
higher for stroke survivors with aphasia who are often seen as
not appropriate for psychological therapy [15]. Audit data from
the United Kingdom [16] and New Zealand also report limited
access to psychology services across rehabilitation wards [17,18].
Systematic reviews have concluded that there is a dearth of
evidence as to effective and appropriate psychological treatments
for anxiety in stroke survivors [19–22]. Further, individuals with
communication deficits, such as aphasia are typically excluded
from treatment development and evaluation studies [15,21].
Research has also highlighted that multi-disciplinary stroke clini­
cians have poor self-efficacy when providing psychological inter­
ventions, such as counselling for people with aphasia [23–26].
Hence, research is needed to understand the best way this

CONTACT Rebecca El-Helou rebecca.el-helou@student.uts.edu.au Discipline of Clinical Psychology, Graduate School of Health, University of Technology
Sydney, Broadway, NSW, Australia
Supplemental data for this article can be accessed online at https://doi.org/10.1080/09638288.2022.2069294
� 2022 Informa UK Limited, trading as Taylor & Francis Group
2 R. EL-HELOU ET AL.
population can be provided with psychological treatment that
considers their communication needs.
In the general population, relaxation has been shown to be an
efficacious psychological treatment that can both reduce anxiety
and depressive symptoms [27,28]. The research suggests that
relaxation also benefits older persons as well as individuals suffer­
ing from chronic physical health issues [27], patient characteristics
common in stroke survivors. Relaxation classes are also viewed
positively and deemed worth recommending to peers by those
with stroke [29,30]. Further, mainstream talk-based therapies gen­
erally aren’t communicatively accessible for stroke survivors with
aphasia [15,31,32] thus a specifically designed tailored relaxation
intervention may prove to be a suitable treatment
option [15,31,33].
Technology-based relaxation interventions that can be utilised
at home may be particularly useful for stroke survivors because of
their location and/or physical disability [30,33–35]. Such treat­
ments may also be of benefit to stroke survivors during their hos­
pitalisation given psychology services are often limited in most
stroke wards [14]. Supporting the potential for benefit, research
has shown that stroke survivors experience high levels of satisfac­
tion and treatment compliance with technology-based interven­
tions and in particular people with aphasia can access and use
such technologies [35,36]. One study piloting an at-home technol­
ogy-based relaxation intervention for stroke survivors not only
identified reduced anxiety symptoms but demonstrated a greater
reduction in symptoms compared to no treatment controls [37].
Notably, the benefits from this intervention were still present
12 months later [38]. Furthermore, there is evidence to suggest
that this type of relaxation intervention might be beneficial for
those with mild aphasia [39]. However, the effect of such inter­
ventions on stroke survivors with more severe communication
deficits remains unknown.
Most recently, a study in the United Kingdom trialled a brief
mindfulness DVD intervention for stroke patients including those
with mild to moderate aphasia [33]. The study found that the
mindfulness relaxation techniques used in the program were per­
ceived as acceptable, feasible, and helpful for managing anxiety
[33]. However, it is important to note that this study focused on
both stroke survivors with and without aphasia, and those with
aphasia only made up 38% of the study sample [33]. Furthermore,
the severity of the participants’ aphasia was not identified using
formal measures [33]. The study also acknowledged that not all
stroke survivors will have access to DVD players and proposed
that future studies seek to develop other technology-based inter­
ventions, such as online videos which are more accessible to peo­
ple with stroke [33,40]. The current study seeks to extend this
promising preliminary research by obtaining the input of stroke
survivors with aphasia to inform the development of an access­
ible, technology-based, relaxation intervention that is suitable for
survivors with severe stroke-related communication impair­
ments [33].
A significant problem that researchers face when developing
and evaluating health interventions is poor user engagement,
treatment compliance, and higher attrition rates than expected
[41,42]. Concerningly, 35% of Speech and Language Pathologists
have reported that people with aphasia are declining professional
services to manage their mood concerns [24]. To overcome this
issue, particularly in this group, interventions must be aligned
with patients’ needs and preferences [41–44]. Thus, the Medical
Research Council framework for developing complex interventions
advises that knowledge exchange should be addressed by
ensuring end-users, in this case, people with aphasia and stroke,
are consulted in the process of developing interventions [45].
Co-design is also known as the participatory design is one
method of engaging stakeholders in the process of intervention
development [46,47]. This method is a process whereby consum­
ers, researchers, and developers, collaboratively develop and
innovate products and or services to improve end users’ out­
comes and satisfaction [41,44,47]. Specifically, co-design has pro­
ven to successfully promote uptake of health-based interventions
[48–51]. According to reviews, studies using co-design vary widely
in their approaches [46,52]. Whilst there are differences across the
methods of co-design, the majority of studies utilise an iterative
approach whereby stakeholders are continuously consulted
throughout the stages of intervention development through focus
groups, interviews, or surveys [46]. As a first step to developing a
low-cost, and inclusive, relaxation intervention, this study involved
end-users in the development of a relaxation intervention
through qualitative enquiry, primarily using focus groups.
Aims
The overarching aim of this study was to co-design a technology-
based relaxation intervention for stroke survivors with aphasia.
The further aims of this study were to qualitatively investigate the
acceptability and feasibility of the intervention for people
with aphasia.
Methods
Research design
This Qualitative study utilised a general qualitative inquiry
approach meaning the study was not constrained to a particular
methodology to allow for greater flexibility in data collection pro­
cedures. Thematic Analysis can be used as a stand-alone method
as outlined in the literature [53,54].
Context
This paper will report on the impact of COVID-19 on this work in
accordance with the CONSERVE CONSORT guidelines (see
Supplementary File 2) [55]. Recruitment for this study commenced
in September 2020 and data collection ended in April 2021.
During this time there were COVID-19 restrictions on travel and
in-person data collection with groups could have potentially been
unsafe. Thus, the authors of this paper decided to move all
recruitment and data collection methods online as a mitigating
strategy in June 2020 and ethical approval was sought.
Ethical considerations
This project along with the COVID-19 modifications was approved
by the relevant Human Research Ethics Committees of the
University of Technology Sydney (HREC REF NO. ETH20-5387).
Before their participation, informed consent was obtained from
each participant using ZoomTM [56] by a psychologist trained in
Supportive Communication Strategies for people with aphasia
[57]. Participants were provided tailored information sheets that
were formatted to principles that aimed to enhance communica­
tive accessibility for people with aphasia (e.g., white space, bold­
ing, large font, and pictures). During the consent process, the
registered psychologist shared the information sheet on their
computer screen and verbally read and paraphrased (where
required) the information sheets to the participations. Participants
were given multiple opportunities to ask the research team ques­
tions before consenting. Verification techniques (asking yes/no

questions) were used to determine that the participant had
understood the information provided. During the consent process,
participants were informed that the nature of research around
mental health could potentially cause distress. To manage this
concern, participants were provided the opportunity to debrief
with a psychologist if required. Participants were also informed
that they could stop their participation at any time.
Recruitment
To recruit participants safely during the COVID-19 pandemic,
aphasia community groups were approached via email/phone
contact only. Online advertisements were also placed on the
Stroke Foundation website and other social media platforms, such
as the Australia Aphasia Association, and Aphasia Victoria
Facebook pages. Recruitment occurred from October 2020 to
April 2021. From there participants were recruited after verifying
they had aphasia as a result of stroke using convenience sam­
pling. Participants’ aphasia was verified by the Speech and
Language Pathologist researcher (BR), using her clinical judge­
ment. To determine the severity of participant’s communication
impairments, the Aphasia Severity Rating (ASR) measure was
selected to assign each participant a score ranging from zero to
four with a higher score indicating a greater level of impairment
[58]. Regarding exclusion criteria, only Australian stroke survivors
with aphasia aged over 18 were eligible for the study. Thus, peo­
ple with aphasia from traumatic brain injury were not part of this
study’s sample. There were no other exclusion criteria.
Recruitment ceased after information power was achieved [59].
Materials for the development of the “Kalmer” relaxation
intervention
Before running the focus groups, the research team developed
sample materials for the intervention. Following the co-design
methodology outlined by Saunders in 2000 [60], these sample
materials were used as “generative tools” for co-design.
Generative tools are visual or auditory materials that are created
and grouped together to make “tool kits” [60,61]. These “tool kits”
were used by participants to elicit discussion around ideas and
preferences for relaxation as well as their emotional responses to
the sample materials [60,61]. Participants could use these tools to
engage their senses and express their needs both visually and
verbally [60,61]. To generate sample materials, the research team
hired male and female professional voice recording artists to
record and revise several samples of a Progressive Muscle
Relaxation script, a Three-part Yogic Breathing Script, and an
Imaginal relaxation script. These scripts were based on those
taken from Winkler et al. manual [62] and modified for people
with aphasia with the support of a Speech and Language
Pathologist. To modify these scripts, the language used was sim­
plified and the number of words was reduced, whilst still retain­
ing the core meaning of the sentence. These modifications were
analysed using The Flesch-Kincaid readability analysis function in
Microsoft Word and the Grade Level test ensuring the readability
level of the scripts was at a Grade 7 level or lower [63,64]. These
scripts are free for use and trialled previously in persons with
neurological disorders including stroke [37,38,65–67]. Additionally,
an animator was engaged to develop an instructional animation
to accompany the Progressive Muscle Relaxation recording. The
psychologist researcher [REH] also filmed a live video of herself
demonstrating how to complete Progressive Muscle Relaxation.
The research group also contracted a graphic designer to develop
a logo for the intervention and discussed ideas for the name of
the intervention.
DEVELOPMENT OF “KALMER” RELAXATION INTERVENTION 3
Measures
Observational measures were presented to participants to con­
sider and discuss Minimal Clinically Important Difference (MCID),
i.e., “the smallest improvement on outcome measures that would
make the intervention worthwhile.” Both anxiety and depression
outcome measures were selected for the study. The latter was
selected as it was anticipated it would be used as a secondary
outcome; up to 14% of stroke survivors will have a dual diagnosis
of depression and anxiety [68,69]. The observational measures
chosen were the Behavioural Outcomes of Anxiety (BOA) 10 item
questionnaire [39,70] and The Stroke Aphasic Depression
Questionnaire 10 item questionnaire (SADQ-10) [6] as they
have all been validated in the stroke population and they are suit­
able for people who cannot self-report their symptoms due to
having severe communication deficits. On the BOA, scores can
range from 0 to 30, and scores above 17 indicate likely significant
anxiety. On the SADQ-10, scores range from 0 to 30, and scores
above 6 suggest likely significant depression.
Procedure
Data collection occurred in stages, with the first focus group
(N ¼ 5) consisting of three meetings spread across three different
time points. The second focus group (N ¼ 3) consisted of two sep­
arate meetings across different time points. This approach was of
benefit because it allowed time for the researchers to respond to
feedback iteratively by modifying existing sample materials and
developing new materials as the focus groups occurred.
Following this, four separate individual interviews (N ¼ 4) were
conducted to verify agreement had been generally reached
[53,54]. The first focus group had the opportunity to iteratively
provide feedback over two meetings and materials were refined
during the third meeting. Over two meetings, the second focus
group provided feedback on sample materials and was shown the
refinements made from the previous meeting. Participants from
this second focus group provided additional feedback until they
were pleased with the final revision. The individual interviews
allowed for participants to provide feedback and additional revi­
sions until information power was reached [59].
Data collection occurred from November 2020 up to April
2021. Due to the COVID-19 pandemic, all data collection was
online via ZoomTM [56,71] and was led by an experienced Speech
and Language Pathologist and/or a registered psychologist
trained in supportive communication strategies. Questions and
topic guides (see Appendix 1) were pilot tested with a person
with aphasia before running the groups to ensure they were com­
municatively accessible to people with aphasia. The two focus
groups varied in their duration with one group totalling 4 h across
three different ZoomTM [53] sessions, and the other 3 h over two
ZoomTM [56] sessions. All individual interviews did not exceed 1 h
in duration. All research participants were given the opportunity
to invite family members to the focus group to assist with
communication.
To inform the development of the relaxation intervention,
focus group/interview questions focused on participants’ past
experiences with relaxation and breathing exercises and their atti­
tudes towards relaxation. Sample relaxation materials, also known
as “generative tools” [60] for co-design, were shown to partici­
pants, i.e., audio clips of voice recording artists reading progres­
sive muscle relaxation scripts and imaginal relaxation scripts, and
visual animations to accompany the audio. Participants were
asked to discuss their preferences as a group and provide feed­
back on the suitability and acceptability of the sample materials.
They were also shown materials for the name and logo of the
4 R. EL-HELOU ET AL.

proposed intervention and reached a consensus on the accept­
ability of the final name and logo. After receiving initial feedback
from the first focus group, requested changes were made to the
sample materials, and scripts were re-recorded. Subsequently, the
revised sample materials were presented for further comments by
focus group members and individual interview participants. After
a consensus and information power were reached the research
team used all the constructive feedback and suggestions from
participants to develop the final intervention. This included re-
recording relaxation scripts, adding additional scripts suggested
by members, developing the name and the logo of the interven­
tion, and finding a suitable video hosting platform to share the
videos on for future evaluation studies.
Following the method of Palmer et al. [72], participants were
subsequently shown the anxiety and depression outcome meas­
ures (BOA and SADQ-10) and asked to consider MCID for stroke
patients after using the intervention. Participants were also asked
to comment on what specific anxiety and depressive symptoms
on those measures they believed the intervention should target
for improvement.
All interviews were video-recorded online via ZoomTM [56]
using encrypted software and transcribed verbatim by the psych­
ologist. The researcher, REH, then used the videos to determine
the severity of each participant’s aphasia, using the ASR measure.
The videos were subsequently erased, and the transcripts stored
securely at the University of Technology Sydney.
Data analysis
Qualitative data was collected analysed by the female research
psychologist (REH) using thematic analysis according to the
method of Clarke and Braun [54,73]. The analyst had prior training
and experience in thematic analysis delivered by a secondary
senior author (BR). No prior relationship was established between
REH and participants before the study’s commencement.
Following the focus groups and interviews, all visual recordings
were transcribed onto Microsoft word and read thoroughly by the
research psychologist alongside field notes made during the focus
groups. Following the guidance and recommendations of Braun
and Clarke, no methodological, theoretical, or philosophical frame­
works were employed to analyse the data so as not to comprom­
ise the integrity of the data [53,74]. An inductive approach was
used, meaning initial codes were created from reading the tran­
scripts. These codes were then grouped into broader categories
to make themes and subthemes. See Table 1 for a detailed
explanation of the data analysis process. The primary analyst
(REH) acknowledges that her education and training in psych­
ology may have biased her interpretation of the data. Specifically,
REH was aware of the nature and severity of mood problems after
stroke and had assumptions about the value of accessible inter­
ventions for this clinical group.
Rigour
This paper reported on this qualitative study in adherence to the
Consolidated Criteria for Reporting Qualitative Research (COREQ)
(see Supplementary File 1) [75]. A secondary senior author and
analyst (BR) provided supervision and peer debriefing meetings
throughout all stages of the thematic analysis as recommended in
the literature [76].
Results
Twelve people with aphasia participated in the study (see Table 2
for participant demographic information). Thematic analysis iden­
tified three overarching themes (see Table 3). The first theme,
“The importance and need for appropriate psychological care
after stroke” contained two subthemes, the first subtheme
explored how Mood disturbances are common and can be severe
after stroke, and the second, explored participants’ experiences
navigating the dearth of appropriate psychological treatment
options for people with aphasia. The second overarching theme,
“Perspectives on Relaxation” was comprised of two subthemes.
The first subtheme was centred on participants’ “general positive
views towards using relaxation,” and the second explored
“technology as a suitable medium for relaxation therapy.” The third
overarching theme was participants’ “Perspectives on developing
the intervention” and was comprised of two subthemes the first
being “Different preferences when using relaxation strategies,” fol­
lowed by “acceptability of the “Kalmer” relaxation intervention” and
finally, “improving treatment adherence/compliance.”
Core theme 1: the importance and need for appropriate
psychological care after stroke
Participants all indicated that psychological rehabilitation was just
as important to them as their physical rehabilitation after their
stroke. Participants also noted their personal experiences with
managing their mental health following stroke and the lack of
treatment options available to them.

Table 1. Steps involved in the thematic analysis (adapted from steps outlined in Braun and Clarke 2006).
Steps
Familiarisation with data.
Generating initial codes
Searching for themes
Reviewing the data
Defining and naming themes
Producing the report
Description
Transcripts along with field notes were read in their entirety numerous times. Initial impressions of the data were then formed,
and more notes were made alongside the transcript. Patterns in the data were identified.
Initial codes were then generated through grouping quotations that were related to one another or that held a similar message.
The groups were named according to the message they represented and labelled as “codes.”
Broader themes were then generated from these initial codes. Through the supervision of senior secondary researcher/analyst, a
hierarchy was formed of themes and subthemes. During this phase, some themes became subthemes, more broader themes
were generated, and certain codes were discarded if they were no longer considered relevant.
These core themes and subthemes were reviewed again and refined further under supervision. The Secondary Author (BR)
provided feedback on the analysis before write up during research meetings. During this process core themes were re-named,
and more subthemes were created. If there was overlap between any subthemes, they were collapsed into one subtheme.
Overall, three core themes and seven subthemes were identified and named by both the initial coder (REH) and Secondary
Author (BR). These themes were then checked against the original transcripts to ensure they were consistent with the
raw data.
During write up, themes and subthemes were described succinctly and illustrative quotations from participants were selected. No
miscellaneous or minor themes were identified.
 DEVELOPMENT OF “KALMER” RELAXATION INTERVENTION 5

Subtheme 1: mood disturbances are common and can be severe
after stroke
Many focus group participants reported feeling overwhelmed
after their stroke and described a “rollercoaster of emotions.”
Specifically, participants reported feeling anxious about their
future, depressed about their current situation and frustrated
about not being able to communicate or express how they were
feeling to others. One participant described going through the
various stages of grief over her “old life” before finally reach­
ing acceptance.
“You feel sad, then angry and then different, every month it’s a different
emotion. There are different stages of grieving. At the end you must
accept that you will be disabled permanently.”
(Person 2, Focus group 1, Aphasia Severity Rating: 2, Above mean years
since stroke)
“Suicide. Suicide. It really hurt.”
(Person 12, Interview 4, Aphasia Severity Rating: 1, Below mean years
since stroke)
Other contributing factors to participants’ low mood and anx­
iety after stroke included being isolated from previous friendship
groups, lack of support in the home with daily tasks, other life
stressors exacerbating their mental health, and feeling over­
whelmed and overstimulated throughout the day whilst engaging
in rehabilitation. Participants also mentioned that time was
important for recovering psychologically after a stroke. Some par­
ticipants reported that their mental health was most affected dur­
ing the earlier stages of their recovery and that it took years to
deal with their grief and reach acceptance. Some also noted that
there are days when their mental health is still impacted by a
stroke many years after their recovery.

One participant disclosed experiencing severe distress that cul­ “At the beginning I thought “why me” for three years and then after that
I was calm. I needed to wait a while before I calmed down. I had to wait
minated in suicidal ideation. This participant saw her distress as a and see.” (Gestures used – three fingers)
direct result of having her mental health needs neglected by hos­
(Person 3, Focus group 2, Aphasia Severity Rating: 1, Below mean years
pital staff. This participant also disclosed that these depressive
since stroke)
symptoms resulted in them disengaging entirely from their phys­
ical rehabilitation for several months, delaying their recovery “ … Slowly your mood and anxiety calms down, down, down on its own.”
significantly. (Person 10, Individual Interview, 2; Aphasia Severity Rating 3, Above mean
years since stroke)
Table 2. Participant demographics table.
Variable Mean range
Subtheme 2: dearth of psychological treatment options for
Mean age in years (SD) 62 (13.9) (43–82)
stroke survivors
Mean years since stroke (SD) 9.9 (10.6) (1–30)
Number of participants (N ¼ 12) Other focus group members also discussed feeling as though
Females 6 their mental health was neglected during their recovery in hospi­
Males 6 tals. Specifically, participants discussed that greater emphasis was
Type of stroke placed on physical rehabilitation compared to psychological
Haemorrhagic 4
Ischemic 8 rehabilitation. They reported that all their coping strategies were
English as first language 11 self-directed or given to them by their close family members.
Reported physical disability 9 Furthermore, they reported that their hospital psychologists were
Reported mood impairment 9 not trained in communicating with people with aphasia and so
Reported access to a carer 7
they were often denied the opportunity to express how they
Reported living alone 3
Regular users of technology 12 were feeling or why they were feeling depressed or anxious.
Reported no prior experience with relaxation 3 “ … I had to have my daughter come up and do relaxation with me in
Aphasia Severity Rating of 1 3 the hospital.” (Person 5, Focus group 1, aphasia severity rating: 1, above
Aphasia Severity Rating of 2 3 mean years since stroke)
Aphasia Severity Rating of 3 5
Aphasia Severity Rating of 4 1 “It’s such a stressful event in people are totally out of their comfort
zones … And yet, I was expected to toe the line as far as all the other

Table 3. Outline of core themes and associated sub-themes.

Core theme Description
Core theme 1: The importance and This theme explored participant’s
need for appropriate psychological experiences with their psychological
care after stroke. recovery after stroke.
Core theme 2: Perspectives This theme explored participants’
on relaxation. preferences for relaxation training
and the delivery of such
interventions. Participants also
suggested behavioural strategies to
improve treatment compliance.
Core theme 3: Perspectives on This theme explored participants’
developing a relaxation perceptions on barriers and
intervention. enablers to treatment adherence
and behavioural strategies to
enhance treatment compliance.
Subthemes
Subtheme 1: Mood disturbances are common and can
be severe after stroke.
Subtheme 2: Dearth of psychological treatment options
for stroke survivors
Subtheme 1. General positive views towards using
relaxation
Subtheme 2: Technology as a suitable medium for
relaxation therapy
Subtheme 3: Improving treatment compliance
Subtheme 1: Different preferences when using
relaxation strategies.
Subtheme 2: Acceptability of the Kalmer relaxation
intervention sample materials
6 R. EL-HELOU ET AL.
therapies went as far as doing everything put in front of me. At no stage
was guided relaxation, given any importance. I had to do it by myself by
looking at the window at clouds.”
(Person 1, Focus group 1, aphasia severity rating: 4, above mean years
since stroke)
Participants also discussed the need to normalise care for men­
tal health concerns after stroke. It was agreed that psychological
rehabilitation should be given equal importance to other physical
rehabilitation, such as speech therapy, physiotherapy, occupa­
tional therapy, etc. Furthermore, participants discussed the need
to normalise depression and anxiety after stroke to help remove
feelings of shame associated with mood impairments through
psychoeducation. Specifically, participants reported needing to be
informed about both the biological and environmental causes of
mood problems after stroke and information on the range of
“holistic” treatments and therapies available outside of pharmaco­
logical interventions.
“It is important for people not to blame themselves if they have a
diagnosis of depression and anxiety after stroke.”
(Person 2, Focus group 1, Aphasia Severity Rating:2, Above mean years
since stroke) (This statement was typed in the ZoomTM chat)
“ … if you’ve been diagnosed … it’s not your fault, your brain has had an
injury and there’s a lot of stuff that’s going on up there that’s impacting
and affecting your body so all those unseen issues … I just think we need
to help take a load off that person.”
(Person 1, Focus Group 1, Aphasia Severity Rating: 4, Above mean years
since stroke)
Core theme 2: perspectives on relaxation
This second core theme explores participants’ diverse experiences
with using relaxation before the study. Most participants reported
having tried various relaxation strategies and experiencing a wide
range of benefits from ongoing practice. The small number of
participants who had not tried relaxation or who found it difficult
to practice also shared their experiences. Finally, participants dis­
cussed using technology for relaxation therapy to improve access
to psychological interventions for people after stroke.
Subtheme 1: general positive views towards using relaxation
Within the data, there were a variety of experiences of using relax­
ation. Whilst the majority of participants used/had used relaxation
strategies regularly as part of their recovery, a minority of partici­
pants had no experience with using relaxation strategies and did
not know the meaning of the term. Those who had tried relaxation
strategies had enjoyed yoga, mindfulness, or imaginal relaxation.
Those who had tried relaxation reported experiencing a range of
mental health benefits from it. For example, participants used
relaxation to reduce physiological symptoms of anxiety and stress,
to keep them grounded, productive, and to help them “think
more clearly.” One participant reported that relaxation enabled
them to live authentically and that they had been using relaxation
consistently for years to improve their daily functioning.
“It can make you think things out more clearly, it just ahh everyone
should probably have it, not just because you had a stroke, I just think it’s
a good thing.”
(Person 3, Focus group 2, Aphasia Severity Rating: 2, Below mean years
since stroke)
“It keeps me calm.”
(Person 4, Focus group 1, Aphasia Severity Rating; 1, Below mean years
since stroke)
“Yoga helps me to calm myself and slow down my heart rate.”
(Person 9, Individual interview, Aphasia Severity Rating: 3, Below mean
years since stroke). (Gestures: Participant pointed to his heart)
It was also reported that using relaxation strategies during
their recovery not only improved their psychological well-being
but helped improve their physical health and rehabilitation out­
comes. Particularly, one focus group member reported that mind-
body relaxation helped with their restricted mobility. Others
reported that relaxation helped them to sleep at night, which in
turn had benefits for their overall physical health. One participant
reported that they had been using relaxation before their stroke
to manage another chronic health issue and continued to use it
after stroke to manage their sleep difficulties.
“Yeah, so mind body relaxation really helps with my rehabilitation, with
mobility and is an important part of my rehab.”
(Person 4, Focus group 1, Aphasia Severity Rating: 1, Below mean years
since stroke).
“I use the calm app every night before bed to help me sleep.”
(Person 9, Individual interview, Aphasia Severity Rating: 3, Below mean years
since stroke). (Participant held his phone up to the camera to show the app)
All participants reported that the current relaxation strategies
they used hadn’t been modified for people with aphasia. Thus,
some participants with more severe impairments found their
experiences of using relaxation to be too challenging because the
recordings they used were not communicatively accessible.
Specifically, some relaxation activities were too long, the pacing
of instructions was too fast, and often the language used was too
complex. One participant reported that they found unstructured
relaxation tasks boring and noted stroke survivors may struggle
to concentrate during practice. It was agreed that unmodified
relaxation strategies may be too cognitively demanding for those
with stroke-related cognitive and communication impairments.
“I don’t know why, but I remember many times I was trying to use the
strategies a long time ago and it was hard for me, I was thinking about
other things and was bored.”
(Person 2, Focus group 1, Aphasia Severity Rating: 2, Above mean years
since stroke).
Despite using relaxation strategies daily and feeling benefits
from it, one participant reported that stroke survivors need more
than relaxation. The participant discussed the need for psycholo­
gists to upskill and learn to communicate with people who have
aphasia to understand why the person is anxious and depressed,
and to understand the root of their emotions. The person
reported feeling very isolated, frustrated, and panicked in the hos­
pital because the focus was solely on physical recovery, and no
one took the time to provide basic counselling. However, other
participants noted that they preferred relaxation as a psycho­
logical intervention because some stroke survivors are not able to
speak or may be too anxious to talk about their emotions. It was
also mentioned by another participant that they wanted to
receive supportive counselling from their family and friends and
preferred to have relaxation as a formal intervention for their
mood, rather than a talking-based therapy.
“Talking helped me … along with support groups.”
(Person 12, Individual Interview 4, Aphasia Severity Rating, 1, Below mean
years since stroke)
“The relaxation was useful but what would have been most useful was
having someone engage with me. Someone to bring forth what I was
panicking about that was really tricky. I have volunteered and worked
with homeless people and children and I’ve seen psychologists use all

these props to communicate with these people and I thought wouldn’t
that be great for people with aphasia, at an adult level obviously.”
(Person 1, Focus group 1, Aphasia Severity Rating: 4, Above mean years
since stroke)
“Yes, its good because people don’t talk about their emotions after
stroke … Some people are too scared to talk and write about how they
are feeling. People are not talking because it’s hard to talk even years
after their stroke.”
(Person 2, Focus group 1; Aphasia Severity Rating, 2, Above mean years
since stroke)
Subtheme 2: technology as a suitable medium for relax­
ation therapy
Notably those participants who had tried relaxation, were already
using different technologies for practice. Mobile phone apps were
most common, followed by ZoomTM [56] group relaxation meet­
ings, others used YouTube videos, and artificial intelligence tech­
nology, such as being read to by virtual assistants, such as
Amazon AlexaTM [77]. Many of the participants were already
attending ZoomTM [53] relaxation groups for people with aphasia.
Whilst these groups were very enjoyable, they were considered
not to be held frequent enough for participants to benefit from
them. Thus, many participants reported they would like to have
guided relaxation tapes to use in the home. One participant
reported that travelling for psychological interventions was too
difficult, so the technology would make psychological treatment
more accessible.
“ … Distance was a problem for me, I couldn’t get to the groups.”
(Person 3; Focus group 1, Aphasia Severity Rating: 2, Above mean years
since stroke)
Core theme 3: perspectives on developing a relaxation
intervention
The final theme is centred around co-designing the intervention
and ways to improve uptake of the relaxation therapy.
Participants discussed their preferences, and opinions and pro­
vided feedback to create or revise sample intervention materials.
Whilst participants had a diversity of preferences and needs, this
highlighted to the researchers, the need for variety and choice in
the intervention. Participants also discussed barriers to treatment
adherence and provided behavioural strategies to mitigate
these barriers.
Subtheme 1: different preferences when using relax­
ation strategies
Preferences for the type of relaxation strategy varied amongst
group members. For those with physical disabilities, progressive
muscle relaxation proved challenging, and they preferred imaginal
relaxation techniques. However, other participants who had diffi­
culties with concentration preferred a structured task like progres­
sive muscle relaxation. Some participants with physical disabilities
still reported that they would derive benefit from progressive
muscle relaxation despite having paralysis on one side of their
body. They reported imagining their muscles tensing and releas­
ing during the exercise.
Furthermore, participants reported having different preferences
for when they would like to relax and for how long. Some
reported they use relaxation before they go to sleep, others
reported they like to use relaxation regularly throughout their
day. One participant reported that relaxation once a fortnight was
DEVELOPMENT OF “KALMER” RELAXATION INTERVENTION 7
enough for them while others reported needing it every day or a
few times per week. Those who reported they would use it less
often believed this was related to them being too busy with their
other rehabilitation appointments.
“I would do it every day if you’re new to relaxation and if it was
immediately after your stroke.”
(Person 5; Focus group 1, Aphasia Severity Rating: 2, Below mean years
since stroke).
“If someone is having speech therapy it would be good to have it maybe
three times a week.”
(Person 1, Focus group 2, Aphasia Severity Rating: 3, Below mean years
since stroke)
“Four times a week is excellent. I don’t know if others will agree but for
me it’s important, it will help people sleep better and accept some of the
more permanent changes in their life.”
(Person 2, Focus group 1, Aphasia Severity Rating, 2, Above mean years
since stroke)
“I could do it every day.”
(Person 12; Individual Interview 4, Aphasia Severity Rating 1, Below mean
years since stroke).
Subtheme 2: acceptability of the Kalmer relaxation intervention
sample materials
Most participants had positive reactions to the “Kalmer” interven­
tion sample materials that were demonstrated. Following conver­
sations about their preferences, they reported liking the revised
versions of the intervention’s logo, and name and particularly
liked the relaxation scripts they listened to. All of the participants
agreed that they would use the “Kalmer” relaxation scripts except
one participant who reported that they had already found relax­
ation strategies that worked best for them. This particular partici­
pant, whose aphasia was mild, still acknowledged that the
intervention could greatly benefit stroke survivors, particularly
during their early stages of recovery. Furthermore, the participant
encouraged the development of a bespoke relaxation product
specifically designed for the stroke population.
“Because I’ve got my own relaxation strategies that work. I probably
wouldn’t use it however I can see it would be very beneficial to get it out
there for people in hospital or just recently discharged or people who are
keen to start up relaxation targeted at people living with stroke.”
(Person 1, Focus group 1, Aphasia Severity Rating: 4, Above mean years
since stroke)
Importantly, the majority of participants reported that the
intervention would benefit stroke survivors throughout all stages
of their recovery as both a preventative measure and a treatment
to reduce anxiety and depressive symptoms. Interestingly, those
participants who had never tried relaxation and had not reported
significant depressive or anxiety symptoms reported really enjoy­
ing the imaginal relaxation tapes they listened to and could see
themselves benefitting from daily relaxation exercises in the after­
noon to “clear their mind,” regulate their mood and cope with
everyday stressful situations.
“It took a while to get going but then boom it got me … ”
(Person 3, Focus group 2, Aphasia Severity Rating, 3, Below mean years
since stroke).
“Doesn’t matter if they are happy or sad it still would benefit people
with aphasia.”
(Person 12, Individual interview: Aphasia Severity Rating: 1, Below mean
years since stroke).
8 R. EL-HELOU ET AL.
“Oh, it was just beautiful.”
(Person 11, Individual interview; Aphasia Severity Rating: 4, Below mean
years since stroke)
“I could do it every day … .”
(Person 12, Individual interview: Aphasia Severity Rating: 1, Below mean
years since stroke).
After listening to several audio samples of potential interven­
tion material that had been recorded by professional voice artists,
all participants reported needing a less formal and more natural
tone, with a moderate pace and extra time to transition to the
next movement in the relaxation strategy. Participants were also
asked to change specific words in the relaxation scripts for
example the word “tense” was not liked, and the word “tighten”
was preferred. They also expressed that they would need a variety
of settings for the imaginal relaxation task and gave examples,
such as “campfire,” “waterfall,” and a “mountain.” Additionally, the
importance of having a variety of relaxation strategies to choose
from was discussed as every individuals’ preference would vary.
“I think make it slower for the imaginal relaxation.”
(Person 9, Individual Interview 1, Aphasia Severity Rating:3, Below mean
years since stroke)
“A variety of different relaxation strategies would be good.”
(Person 1, Focus group 2: Aphasia Severity Rating: 3, Below mean years
since stroke)
“Using the word tense is associated with feeling sore.”
(Person 2, Focus group 2, Aphasia Severity Rating: 1, Below mean years
since stroke)
Interestingly, all participants disliked the instructional anima­
tions used to accompany the relaxation scripts as they felt they
needed something more realistic to help ground them. They
reported that they would prefer a recording of a real person
doing the tense and release movements. Following this advice,
the researcher (REH) created a demonstration video of herself
completing a progressive muscle relaxation exercise. This was
viewed positively by all focus group members. However, some
participants noted that visual cues may be redundant given most
participants would be closing their eyes to complete the tasks.
One participant reported that they would feel less isolated watch­
ing a stroke survivor with physical disabilities performing the
relaxation exercises and said it would give them a sense of
“camaraderie,” particularly during the early stages of
their recovery.
Subtheme 3: improving treatment compliance
Barriers to practicing relaxation consistently were identified by
focus group members. Specifically, a lack of time due to attending
medical appointments and other physical and speech rehabilita­
tion appointments was considered the greatest barrier. Others
reported feeling very tired after their busy day and simply not
wanting to engage in any activities once home. One participant
mentioned that people with stroke may find it difficult to remem­
ber to practice their relaxation.
“I’ve got a very busy week from when I wake up. My physical rehab is
more of a priority for me at the moment. As soon as I get home, I can
rest. So maybe at the end of the day might be helpful, I’ll wait and see
though, it’s hard, I’m very tired by the end of the day.”
(Person 2, Focus group 2: Aphasia Severity Rating: 1, Below mean years
since stroke) (Participant pointed to calendar with lots of appointments).
Suggestions for increasing treatment compliance for people
with aphasia were made. For example, participants reported that
using strategies, such as “email reminders” or conducting relax­
ation “in group settings” would likely increase compliance and
hold people accountable. Additionally, some focus group mem­
bers suggested that participants with busy schedules should com­
plete relaxation first thing in the morning or right before sleep.
One group member suggested that the intervention incorporate
simple and accessible technologies, such as a website with all
relaxation scripts uploaded on a single home page. They reported
that these hosting websites should be easily accessible for people
with aphasia on their ipads, smartphones, or laptops. Participants
discouraged using “outdated” technologies, such as DVDs or CDs
as not many people would have access to DVD/CD players
at home.
It was emphasised that participants should be made aware
that “it takes time” to see improvements in mood and become
skilled in relaxation and to not “give up” early on in relaxation
training. Importantly, it was agreed amongst focus group partici­
pants that research trial participants would need a good rationale
for completing relaxation and information on the importance of a
holistic approach to recovery after stroke.
“ … It takes times to improve maybe in six months, sometimes people are
slowly learning about becoming less anxious and accepting of their
limitations and you do not know where you will be at the end of the
relaxation. You need time, you must wait slowly until you get better.
Overtime things do get better.”
(Person 2, Focus group 1; Aphasia Severity Rating:2, Above mean years
since stroke)
“I think you need to emphasise that it is important as all the rest of
treatments. If you’re looking at your recovery in a wholistic way and just
giving that point … I know some people won’t agree but it’s worth
a shot.”
(Person 1, Focus group 1: Aphasia Severity Rating: 4, Above mean years
since stroke)
Finally, participants emphasised that all users should be
informed that the treatment was co-designed by stroke survivors
specifically for people with aphasia. It was considered that having
stroke survivors support the implementation of the intervention
would further enhance treatment adherence. Most importantly,
participants were most appreciative of being consulted in the
design of the “Kalmer” intervention. They wished to have an
active role in all phases of their treatment and recovery.
“In looking towards the final product, letting people know that consulting
with stroke survivors and people with lived experience of stroke have
contributed to the development of this video and even to the point of
saying it’s been borne out of the knowledge that there haven’t been
enough effective treatments. I was always interested in being included in
the bigger picture of my treatment and not just be on the receiving end
of something that was just given to me, give the reason, give me the why,
you know, I’m an intelligent person treat me like one or I’ll feel like less of
a person.”
(Person 1, Focus group 1: Aphasia Severity Rating: 4, Above mean years
since stroke).
Meaningful change
Focus group participants had varying opinions as to what symp­
toms are important for a relaxation intervention to target. Most
participants agreed that it was more important for the “Kalmer”
intervention to target anxiety rather than depression. Participants

also had varying beliefs when discussing what constitutes a min­
imal clinically meaningful improvement on outcome measures.
One group said they would like to see an improvement of seven
points on the anxiety outcome measure and three on the depres­
sion outcome measure, while the other group reported a reduc­
tion in symptoms by one point on both measures would still
make the intervention worth doing. Other participants reported
that they could not determine what minimum improvement score
they would deem worthwhile, as scores on outcome measures
would depend on what “stage the person was at during their
recovery” and they believed people’s mood typically improves
over time as they learn to accept all of the stroke-related changes
in their life.
Discussion
Anxiety after stroke is common [6,7], and people with aphasia are
not only more vulnerable to these disorders but also have worse
outcomes than those without impairments [12,13]. Stroke audit
data shows that psychological care after stroke is limited and
inadequate [14] and the evidence base for treatment efficacy for
stroke survivors is poor and not inclusive of stroke survivors with
aphasia [15,19–21]. While relaxation strategies have been shown
to be an acceptable, feasible, and beneficial treatment option
[30,33,37,38,65,66], a suitable intervention hasn’t been developed
or evaluated with and for people with aphasia [15,19]. As a first
step to address this knowledge gap in the literature, this study
aimed to consult with stroke survivors who have aphasia to co-
design a relaxation intervention.
The key findings of this study highlight the importance of
developing a self-managed relaxation intervention suitable for
people who have aphasia. Notably, most participants reported
feeling that their psychological care after stroke was neglected by
health professionals and mostly self-directed. These findings are
supported by the Stroke Foundation audit data [14] and other
qualitative studies which found that most stroke survivors with
aphasia experienced inadequate psychological support during
rehabilitation [23,26,32,78]. Furthermore, other qualitative studies
with multi-disciplinary stroke health professionals found that psy­
chological rehabilitation after stroke is not always prioritised in
healthcare systems [23] and stroke health professionals have lim­
ited training and resources to support stroke survivors with apha­
sia experiencing mood problems [23,24]. Thus, developing and
implementing a self-managed technology-based relaxation inter­
vention, inclusive of people with severe aphasia, is a viable solu­
tion to the many barriers to treatment.
Notably, participants who did not experience significant anx­
iety or depressive symptoms, still reported that they would bene­
fit from using the “Kalmer” relaxation intervention. Thus,
relaxation interventions are not only seen as useful as a treatment
for anxiety but could have potential benefits for the overall well-
being of stroke survivors. This is further supported by other stud­
ies that have shown that relaxation is useful and enjoyable for
stroke survivors who do not have any diagnosed mental health
disorders [29,30,34]. Thus the “Kalmer” relaxation intervention
may be used also as a preventative intervention for this vulner­
able population [15,23]. These findings collectively highlight the
need for stroke survivors to have adequate and inclusive psycho­
logical treatments available and that future studies should focus
on the development and evaluation of such self-managed inter­
ventions for people with aphasia.
Importantly, the samples created for the “Kalmer” intervention,
were viewed positively and considered acceptable and feasible for
DEVELOPMENT OF “KALMER” RELAXATION INTERVENTION 9
older people and those with severe aphasia and physical disabil­
ities. In fact, most focus group members preferred technology-
based interventions to in-person relaxation therapy as undertak­
ing treatment from home was more accessible. This result is con­
sistent with the systematic review which found that technology-
based psychological interventions for stroke survivors achieve
high satisfaction and compliance rates [35]. Given “Kalmer’s”
potential acceptability for people with severe communication
impairments, this intervention may also have benefits for stroke
survivors with other cognitive impairments. Future research might
explore the potential of this intervention for stroke survivors with
mild to severe cognitive impairment.
When exploring the acceptability of the relaxation intervention
for stroke survivors with physical disabilities, some participants
reported that utilising progressive muscle relaxation would be
challenging for those with sensory loss and paralysis. However,
other participants believed such practices would help restore their
“mind-body connection.” Emerging research has shown that
patients with sensory loss and paralysis reportedly benefit from
practicing mindfulness of the body [79]. It was found that practic­
ing mindfulness of the body through visualisation and imaginal
techniques can increase both acceptance and awareness of the
body, even in places with reduced or no sensation [79–81].
Additionally, mindfulness of the body can also help individuals
with sensory loss and paralysis accept their disabilities and their
individual identities [79,80].
This study also explored “clinically meaningful change” to help
inform future evaluations of the “Kalmer” relaxation intervention.
The efficacy of most psychological treatments is currently eval­
uated based on statistically significant changes in pre and post-
outcome measures, however, there are limitations to only using
this method [82]. For example, such statistical analyses are not
sensitive to individual changes in symptoms following treatment
which are valuable and necessary for individualised treatment
planning as well as understanding the trajectory of a patient’s
mental illness and how a patient responds to treatment [82–85].
In this study, participants’ views on what improvement score
would be meaningful and valuable to them varied significantly
(one point through to a seven-point improvement) however it
was agreed by all focus group members that the outcome meas­
ures used appeared useful for detecting improvements. It was
beyond the scope of this study to reach a majority consensus on
meaningful change; further research is needed with a larger num­
ber of participants. Such research could determine meaningful
change for a clinical group using the Delphi method, whereby
participants provide their views on meaningful change anonym­
ously and then researchers present the group responsible for dis­
cussion where a consensus can then be reached [86]. Future
research should use these processes to help facilitate how to
score improvements after the “Kalmer” intervention is interpreted
and evaluated at both a clinical group and individual level [82].
Strengths and limitations
This co-design study likely benefitted from the inclusion of partici­
pants whose preferences and experiences with relaxation varied
widely. Furthermore, participants had a variety of stroke-related
impairments and were all at various stages of their physical and
psychological recovery post-stroke. This study also explored par­
ticipants’ perspectives on how the relaxation intervention might
also effect depressive symptoms, useful given the rate of comor­
bid anxiety and depression [68]. This study also had some limita­
tions. It is important to acknowledge that participants
10 R. EL-HELOU ET AL.
volunteered to participate in this study out of interest and there­
fore may have already had a bias in favour of relaxation as an
intervention. Another consideration is that, on average, partici­
pants were 10 years post-stroke (range of 1–30 years post-stroke),
thus there may be some differences in opinions for survivors in
the acute phase of their stroke. Participants frequently reflected
on the acute phase of their stroke throughout their discussions
highlighting the importance of specifically considering this stage
in their stroke journey. Additionally, a relatively unstructured
approach to co-design was utilised than some that are available
[50]. However, it is worth noting that this can also be a strength
and the method did adhere to the basic principles of co-design
as outlined in the literature [46]. Finally, this study did not investi­
gate the impact of COVID-19 on the use of technology-based
relaxation interventions in people with aphasia, thus future devel­
opment and evaluation studies may wish to consider this.
It is important to note that a bias in this study’s participant
sample likely exists as this study was conducted online with par­
ticipants who had access to technology and were either inde­
pendent in their use of technology and/or had support to
participate. Other individuals with aphasia may not have sufficient
IT literacy to access the intervention. Research trials in the future
may therefore need to include IT support or involve carers to
overcome this potential barrier to treatment. In addition to this,
researchers may address previously identified barriers and facilita­
tors to internet use by people with aphasia, to help mitigate
digital exclusion [87]. Future trials may also wish to consider the
guidelines and resources developed by the Cognitive and
Learning Disabilities Accessibility Task Force, the Web Accessibility
Initiative, or the World Wide Web Consortium (i.e., W3C) to
improve accessibility for people with aphasia. Another potential
bias in this study’s sample may exist given participants volun­
teered to participate in this study. Thus, we cannot rule out that
participants with experience of relaxation may have been more
likely to participate in the study and more likely to display posi­
tive attitudes towards relaxation.
Future directions
Moving forward, Kalmer should be formally evaluated. Any inter­
vention trial should address the many barriers to treatment adher­
ence discussed in this paper. The barriers identified include lack
of time, lack of knowledge/education on relaxation, shame when
seeking treatment, and difficulties in remembering when to use
the intervention. A theoretical framework, such as the Behaviour
Change Wheel [88] might be used to develop behaviour change
techniques that target these identified barriers to ultimately
improve treatment adherence.
Importantly, one focus group member emphasised the need to
go beyond relaxation training to develop modified talking thera­
pies for people with aphasia. In addition to the development of
modified treatments, this would require psychological therapists
to be trained to communicate effectively with people who have
aphasia. Recent research has demonstrated preliminary evidence
to support the adaptation of talk-based psychological therapies
for people with aphasia, such as solution-focused therapy and
behavioural activation [89–91] but with a focus on depression as
a primary outcome. Such modified therapies might incorporate
Kalmer as an additional intervention component that explicitly
targets anxiety as often these disorders co-exist.
Conclusion
Stroke survivors with aphasia and anxiety lack suitable treatment
options. The “Kalmer” relaxation training has been refined based
on end-user feedback and deemed acceptable and feasible for
people stroke survivors including those with severe aphasia.
Disclosure statement
The authors report no conflicts of interest.
Funding
This research received a specific grant from the University of
Technology Sydney CTCS Grant Seed funds—to the Stroke and
Relaxation Trial.
ORCID
Rebecca El-Helou http://orcid.org/0000-0001-9462-9675
Brooke Ryan http://orcid.org/0000-0002-6053-7614
Ian Kneebone http://orcid.org/0000-0003-3324-7264
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 DEVELOPMENT OF “KALMER” RELAXATION INTERVENTION 13

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Have you tried relaxation before?
e1000393.
What have you tried?
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Is relaxation helpful?
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Sample intervention materials shown to participants.
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Would you use our relaxation videos?
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Can people with aphasia use this?
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What can we change?
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What else are we missing?
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What will get in the way of practice?
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How can we help with that?
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What overall score improvement would make this treatment
worthwhile on the BOA?
What overall score improvement would make this treatment
worthwhile on the SADQ-10?