Background Walk ‘n Watch (WnW) is a structured, progressive walking exercise intervention developed for Canadian inpatient stroke rehabilitation. Although its mechanisms align with UK guidance for intensive walking therapy, stroke rehabilitation in the UK is delivered predominantly in the community. This change in service context has implications for safety, feasibility, and fidelity, necessitating structured pre-implementation intervention adaptation to support delivery.

Methods A prospective adaptation process used ADAPT guidance. A multidisciplinary coalition and learning collaborative (UK clinicians, clinical- academics, people with lived experience, and Canadian WnW developers) participated in stakeholder co-production activities. Informed by ADAPT steps 1-2, co-production focused on rationale, core components, contextual mapping and planning adaptations. Discussions were analysed through rapid deductive mapping using Consolidated Framework for Implementation Research (CFIR) domains. Candidate fidelity-consistent adaptations were refined by the learning collaborative. Conceptual outputs of the process were synthesised.

Results Three intervention core components were confirmed: 1) prioritised, high-volume, weight-bearing walking-related activities at moderate effort; 2) structured progression of steps based on performance on a walking test (e.g. Six-Minute Walk Test); 3) objective monitoring of steps and cardiovascular intensity. Several contextual determinants across CFIR domains were likely to influence UK community implementation. Fidelity-consistent modifications to the adaptable periphery were specified across four areas: 1) therapy & practice, 2) environment & safety, 3) monitoring & feedback, and 4) workflow & documentation. Adaptations included hybrid supervision, planned out-of-session practice, and monitoring using validated proxies. A WnW Adaptation Model was produced.

Conclusions This paper provides a transparent pre-implementation adaptation of WnW for delivery within UK community stroke rehabilitation. Anchoring adaptations to intervention mechanisms and principles through co-production and implementation science frameworks, this work establishes a foundation for piloting and hybrid effectiveness–implementation evaluation. The WnW Adaptation Model offers support for future implementation efforts. Discussion positions adaptation as a pragmatic means for applying optimisation principles.

PLAIN LANGUAGE TITLE Adapting the Walk ‘n Watch walking exercise programme for home-based stroke rehabilitation in the UK: A structured step-by-step process

Background Walk ‘n Watch (WnW) is a structured exercise programme that helps people improve their walking. It was originally developed for people recovering from stroke in hospital in Canada. While the approach fits well with United Kingdom (UK) recommendations for intensive therapy, stroke rehabilitation in the UK often takes place at home. Because of this difference, WnW needs careful adaptation for safe and effective delivery.

Methods Published ADAPT guidance was used to adapt WnW. UK therapists, researchers, people with stroke, and Canadian WnW developers undertook adaptation activities. Together, they identified which parts of WnW were essential, explored differences between the Canadian and UK settings, and planned changes. Discussions were reviewed using an established framework to develop adaptations that kept the most important parts of WnW intact (fidelity-consistent adaptations). The adaptation process was summarised.

Results Three essential intervention parts were confirmed: 1) prioritised, high-volume, weight-bearing walking-related activities at moderate effort; 2) structured progression of steps based on performance on a walking test; 3) objective monitoring of steps and cardiovascular intensity. Several factors were likely to influence delivery in the UK community. Changes focused on four areas: 1) therapy & practice, 2) environment & safety, 3) monitoring & feedback, and 4) workflow & documentation. They included using both in-person and online sessions, planning safe between session practice, and using non-digital monitoring. A WnW Adaptation Model was produced.

Conclusions This paper clearly describes the steps taken to adapt WnW for delivery in UK community stroke rehabilitation. By working closely with stroke experts and using established research frameworks, the adapted programme keeps the most important parts of WnW while allowing it to fit into real-life. The WnW Adaptation Model offers support for further testing and may assist others looking to adapt WnW. Discussion offers perspective on how adaptation aligns with optimising interventions.

The authors have declared no competing interest.

Dr. Suzanne Ackerley [Senior Clinical and Practitioner Research Award, NIHR306254] is funded by the NIHR for time contributing to this project. The views expressed in this publication are those of the authors and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.

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