A systematic review of the impact of stroke on social support and social networks: associated factors and patterns of change

Solution Focused brief therapy In post-stroke Aphasia (SOFIA Trial): protocol for a feasibility randomised controlled trial

Background: Around a quarter of people post stroke will experience aphasia, a language disability. Having aphasia places someone at risk of becoming depressed and isolated. There is limited evidence for effective interventions to enhance psychological well-being for this client group. A potential intervention is Solution Focused Brief Therapy (SFBT), which supports a person to build meaningful, achievable change through focusing on a person’s skills and resources rather than their deficits. The SOFIA Trial aims to explore the acceptability of SFBT to people with varying presentations of aphasia, including severe aphasia, and to assess the feasibility of conducting a future definitive trial investigating clinical and cost effectiveness. Methods: The trial is a single-blind, randomised, wait-list controlled feasibility trial with nested qualitative research and pilot economic evaluation comparing SFBT plus usual care to usual care alone. The study will recruit 32 participants with aphasia who are ≥6 months post stroke. All participants will be assessed on psychosocial outcome measures at baseline, three, and six months post randomisation by assessors blinded to treatment allocation. Participants will be randomly assigned to intervention group (start intervention immediately post randomisation) or wait-list group (start intervention six months post randomisation). Wait-list group will additionally be assessed nine months post randomisation. The intervention consists of up to six SFBT sessions delivered over three months by speech and language therapists. Participants and therapists will also take part in in-depth interviews exploring their experiences of the study. The pilot economic evaluation will use the EQ-5D-5L measure and an adapted Client Service Receipt Inventory. People with aphasia have been involved in designing and monitoring the trial. Discussion: Given the high levels of depression and isolation, there is a need to investigate effective interventions that enhance the psychological wellbeing of people with aphasia. Trial registration: ClinicalTrials.gov NCT03245060 10/08/2017.

The Importance of the Built Environment in Person-Centred Rehabilitation at Home: Study Protocol

Health services will change dramatically as the prevalence of home healthcare increases. Only technologically advanced acute care will be performed in hospitals. This-along with the increased healthcare needs of people with long-term conditions such as stroke and the rising demand for services to be more person-centred-will place pressure on healthcare to consider quality across the continuum of care. Research indicates that planned discharge tailored to individual needs can reduce adverse events and promote competence in self-management. However, the environmental factors that may play a role in a patient's recovery process remain unexplored. This paper presents a protocol with the purpose to explore factors in the built environment that can facilitate/hinder a person-centred rehabilitation process in the home. The project uses a convergent parallel mixed-methods design, with ICF (International Classification of Functioning, Disability and Health) and person-environment theories as conceptual frameworks. Data will be collected during home visits 3 months after stroke onset. Medical records, questionnaires, interviews and observations will be used. Workshops will be held to identify what experts and users (patients, significant others, staff) consider important in the built environment. Data will be used to synthesise the contexts, mechanisms and outcomes that are important to support the rehabilitation process at home.

Psychosocial interventions for stroke survivors, carers and survivor-carer dyads: a systematic review and meta-analysis

Objective: To evaluate the effectiveness of psychosocial interventions on depressive symptoms, anxiety symptoms, quality of life, self-efficacy, coping, carer strain and carer satisfaction among stroke survivors, carers and survivor-carer dyads. Data sources: MEDLINE, CINAHL, PsycINFO, SocINDEX, Cochrane Library, Web of Science and Scopus databases and the grey literature were searched up to September 2018. Methods: A systematic review and meta-analysis of randomized controlled trials of psychosocial interventions for stroke survivors, carers and survivor-carer dyads, compared to usual care. Outcomes measured were depressive symptoms, anxiety symptoms, quality of life, coping, self-efficacy, carer strain, and carer satisfaction. Results: Thirty-one randomized controlled trials (n = 5715) were included in the systematic review which found improvements in depressive symptoms, anxiety symptoms, quality of life and coping, though the number of trials assessing each outcome varied. A meta-analysis (11 trials; n = 1280) on depressive symptoms found that in seven trials psychosocial interventions reduced depressive symptoms in stroke survivors (SMD: -0.36, 95% CI -0.73 to 0.00; p = .05) and in six trials reduced depressive symptoms in carers (SMD: -0.20, 95% CI -.40 to 0.00; p = .05). Conclusion: Psychosocial interventions reduced depressive symptoms in stroke survivors and their carers. There was limited evidence that such interventions reduced anxiety symptoms, or improved quality of life and coping for stroke survivors and carers and no evidence that they improved self-efficacy, carer strain or carer satisfaction.

Preventing Chronic Emotional Distress in Stroke Survivors and Their Informal Caregivers

BACKGROUND/OBJECTIVE

Chronic emotional distress (e.g., depression, anxiety, post-traumatic stress) is common after stroke and interdependent between patients and their informal caregivers. We measured stroke survivors', caregivers', and neurocritical care nurses' views of primary drivers of distress during the stroke experience, and needs and preferences for the structure, topics, mode of delivery, and timing of an intervention to promote emotional recovery.

METHODS

We conducted semi-structured interviews with 24 patient-caregiver dyads within the Neuroscience Intensive Care Unit (Neuro-ICU). Additionally, we conducted two focus groups with 15 nurses. Interviews and focus groups were audio-recorded, transcribed, and coded using NVivo 11 (QSR International) software.

RESULTS AND CONCLUSIONS

The challenges and impacts of stroke most commonly reported by dyads were: uncertainty about future health, fear of recurrent strokes, negative emotions, and role changes post-stroke. Dyads and nurses agreed that resiliency skills such as mindfulness/focusing on the present, problem solving, gratitude/optimism, self-care, interpersonal communication and developing a supportive team of family, friends, and medical staff are beneficial to optimize recovery. The potential barrier to intervention delivery was accessibility, due to challenges of time and travel to appointments. Participants agreed that starting the intervention at hospitalization and continuing via live video after discharge is an ideal delivery modality. Stroke survivors, caregivers, and Neuro-ICU nurses believe that a resiliency skills-based intervention to prevent chronic emotional distress is necessary and urgent. This qualitative study provides valuable information on the challenges faced by dyads, intervention topics to prioritize, and strategies to maximize feasibility, acceptability, and effect.

The role of children and their socioeconomic resources for the risk of hospitalisation and mortality - a nationwide register-based study of the total Swedish population over the age 70

Background

Previous studies have shown that mortality in old age is associated with both number of children and their socioeconomic resources. The underlying mechanisms are unclear, as well as when during the process of health deterioration the advantage of parents over non-parents arises. This study aims to examine how the number of children and their socioeconomic resources are associated with different health outcomes among their parents, namely the hazard for i) first hospitalisation, ii) re-admission, iii) mortality after first hospitalisation, and iv) overall mortality.

Method

This longitudinal cohort study includes all individuals born 1920–1940 who were living in Sweden at age 70 years (890,544 individuals). Individuals were linked to their offspring and spouse using administrative registers and followed for up to 25 years. Associations were estimated using multivariable Cox models adjusted for index persons’ education and income, marital status, their partners’ education, and age at first birth.

Results

In this study, having children was associated with reduced mortality risk of their parents, but not with the risk of being hospitalised, which increased as number of children increased. A higher education of children was protective for all parental outcomes independent of number of children and their financial resources. In fact, income of the children was only weakly associated with the health of their parents.

Conclusions

The benefit of having children compared to childlessness for health in old age seems to arise once individuals have become ill rather than before. Children’s education is important for parental health and mortality, in fact more important than the number of children itself in this Swedish cohort.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1134-y) contains supplementary material, which is available to authorized users.

The impact of aphasia on Internet and technology use

Purpose: This study compared Internet use post-stroke in people with aphasia (n = 25) and without aphasia (n = 17). The purpose was to understand how people with aphasia were using the Internet and to investigate the impact of aphasia on their use.Materials and methods: A face-to-face supported questionnaire explored the use of technologies, types of Internet use, traditional and Internet communication, the perception of abilities, and possible barriers to acquiring or improving Internet skills. Descriptive and inferential statistics were used to analyze the data.Results: Internet use ranged from fully independent to by proxy across both groups. Most participants perceived their aphasia as a barrier, but for the majority, it was not the sole reason for failing to acquire or improve skills. Aphasia was related to difficulties with technology-based written communication. Educational attainment was related to participant's feelings about their own skills. Whilst aphasia was important, analysis revealed that age was a stronger predictor of Internet use per se.Conclusions: It is clear that aphasia often negatively affects Internet use and proficiency. However, this research clearly demonstrates that it is important to consider the influence of factors such as age, proxy use, education, and previous technology use and experience.Implications for rehabilitationPost-stroke aphasia contributes negatively to Internet use, particularly in the use of online communication tools such as email and messaging services.Sub-groups of people with aphasia are likely to be more vulnerable to exclusion from the benefits of the Internet; specifically, older people and those with lower levels of educational attainment.It is common for both older adults with and without aphasia to use the Internet via a proxy. Independent use may not always be the desired goal within rehabilitation.People with aphasia may perceive their age and disability as barriers to using the Internet and may lack confidence in their own ability or potential.

Loss of friendship following traumatic brain injury: A model grounded in the experience of adults with severe injury

Relationships make important contributions to wellbeing and maintenance of self-worth. For those who sustain traumatic brain injury (TBI), life is frequently characterized by declining interpersonal relationships. The aim of this study was to understand the post-injury experience of friendship from the perspective of adults with severe TBI. Participants were 23 adults who had sustained severe TBI on average 10 years earlier; the majority was between 25 and 45 years old. The experience of friendship was explored using a convergent mixed methods design (quantitative self-report measures and in-depth interviews). Qualitative analysis of interview transcripts employed open and focussed coding to reveal themes and categories. Participants nominated on average 3.35 (SD 2.19) friends. When paid carers and family members were excluded, the mean dropped to 1.52 (SD 1.38). Exploratory correlations between number of friends and quality of life, depression and strong-tie support revealed significant associations of moderate to large effects. The post-injury experience of friendship was broadly conceptualized as "going downhill" with four overlapping phases: losing contact, being misunderstood, wanting to share and hanging on. Participants' stories illustrated how rehabilitation can focus on friendship by supporting established relationships and facilitating access to activities that afford interpersonal encounters and opportunities to share experiences.

Accelerating Stroke Recovery: Body Structures and Functions, Activities, Participation, and Quality of Life Outcomes From a Large Rehabilitation Trial

BACKGROUND

Task-oriented therapies have been developed to address significant upper extremity disability that persists after stroke. Yet, the extent of and approach to rehabilitation and recovery remains unsatisfactory to many.

OBJECTIVE

To compare a skill-directed investigational intervention with usual care treatment for body functions and structures, activities, participation, and quality of life outcomes.

METHODS

On average, 46 days poststroke, 361 patients were randomized to 1 of 3 outpatient therapy groups: a patient-centered Accelerated Skill Acquisition Program (ASAP), dose-equivalent usual occupational therapy (DEUCC), or usual therapy (UCC). Outcomes were taken at baseline, posttreatment, 6 months, and 1 year after randomization. Longitudinal mixed effect models compared group differences in poststroke improvement during treatment and follow-up phases.

RESULTS

Across all groups, most improvement occurred during the treatment phase, followed by change more slowly during follow-up. Compared with DEUCC and UCC, ASAP group gains were greater during treatment for Stroke Impact Scale Hand, Strength, Mobility, Physical Function, and Participation scores, self-efficacy, perceived health, reintegration, patient-centeredness, and quality of life outcomes. ASAP participants reported higher Motor Activity Log-28 Quality of Movement than UCC posttreatment and perceived greater study-related improvements in quality of life. By end of study, all groups reached similar levels with only limited group differences.

CONCLUSIONS

Customized task-oriented training can be implemented to accelerate gains across a full spectrum of patient-reported outcomes. While group differences for most outcomes disappeared at 1 year, ASAP participants achieved these outcomes on average 8 months earlier (ClinicalTrials.gov: Interdisciplinary Comprehensive Arm Rehabilitation Evaluation [ICARE] Stroke Initiative, at www.ClinicalTrials.gov/ClinicalTrials.gov . Identifier: NCT00871715).

Motivators and barriers to using information and communication technology in everyday life following stroke: a qualitative and video observation study

Purpose: Information and communication technology devices have become a ubiquitous part of everyday life and a primary means of communication. The aim of this study was to describe the experience of information and communication technology and to explore the barriers and motivators to its use following stroke.Materials and methods: This observational study used semi-structured individual interviews and video observation of information and communication technology device use with six people, four men, and two women age 60-82 years with upper limb disability following stroke. They were analyzed using thematic analysis.Results: Three themes were identified that relate to barriers: (i) Sensory and motor impairments; (ii) Limited vision and impaired speech; and (iii) Device-specific limitations. Six themes were identified as motivators: (i) Connect with others; (ii) Provide safety; (iii) Facilitate reintegration; (iv) Reinforce technology adoption; (v) Leisure activities; and (vi) Contribute to the rehabilitation process.Conclusion: All participants used some form of information and communication technology daily to promote safety, enable daily activities, and social interaction, and to a lesser extent engage in leisure and rehabilitation activities. Barriers to information and communication technology use were primarily related to stroke related impairments and device-specific requirements, which limited use, particularly of smartphones. These barriers should be addressed to facilitate the use of information and communication technology devices.Implications for rehabilitationThis research suggests that;People with stroke are highly motivated to use information and communication technology devices in daily activitiesStroke-specific and age-related impairments limit the use and functionality of information and communication technology devices for people with strokeInformation and communication technology devices do not appear to be promoted or used in the rehabilitation or as assistive technologies.

Neuronavigated theta burst stimulation for chronic aphasia: two exploratory case studies

The present study reports the findings of a 10-day neuronavigated continuous theta burst stimulation (cTBS) over the right pars triangularis for two individuals with chronic aphasia after a single left hemispheric stroke. Baseline language and quality of life measures were collected prior to the treatment study, post-treatment and at 3-month follow up. Therapy was tolerated well by both participants and no side effects were noticed during and after treatment. Results from one individual showed potential for positive change in performance in comprehension and expressive language both post-treatment and at the follow-up stage. Also, a trend towards improvement post-treatment was noticed in discourse and sentence productivity, and grammatical accuracy. In the follow up stage, grammatical accuracy showed a trend towards improvement; discourse productivity decreased and; sentence productivity skills showed mixed results. Results from the other participant showed potential for positive change in comprehension post-treatment, that was maintained at the follow-up stage. However, a decline in expressive language post-treatment and at follow-up, stronger post-treatment, was noticed. Regarding quality of life measurements, participant one appeared to have improved as his performance increased in the overall, physical and communication domains, but decreased slightly in the psychosocial domain. The second participant improved in the physical and communication domains and declined overall and in the psychosocial domains. Findings from this study indicate that cTBS over the right pars triangularis may have the potential to improve various language skills in patients suffering from chronic aphasia post-stroke. However, the potential benefits of this fast, non-invasive brain stimulation protocol on improvement of language abilities post-stroke need further exploration.

Development of a novel positive psychology-based intervention for couples post-stroke

OBJECTIVE

Stroke provides challenges for survivors and partner caregivers. Stroke survivors and caregivers are interconnected in their emotional health, including depression, a common stroke sequelae. The purpose of this study was to develop and test the feasibility of a dyadic positive psychology-based intervention (PPI) for couples coping poststroke.

DESIGN

Community-dwelling couples consisted of 1 partner who had a stroke ≥6 months ago and a cohabiting partner caregiver. One or both partner(s) had to report depressive symptoms. The PPI consisted of 1 brief face-to-face training session and an 8-week self-administered intervention in which participants were instructed to engage in at least 2 activities alone and 2 together each week. Two dyads were randomly assigned to a waitlist control to test feasibility of this process. Baseline, postintervention, and 3-month follow-up assessments and post-program feedback were obtained. Descriptive statistics were used to analyze sample characteristics, recruitment and retention rates, adherence, key pre- and postintervention outcomes, and satisfaction with the intervention.

RESULTS

Eleven of 20 couples responding to recruitment letters were enrolled in the study. Ten of 11 dyads completed the program. All participants engaged in activities for at least 6 of 8 weeks. Feedback data indicated participant satisfaction with the intervention, and key outcome measures demonstrated adequate variability.

CONCLUSIONS

The self-administered dyadic PPI is feasible for implementation with couples poststroke. The PPI represents a first step in a novel dyadic approach in this population. Recruitment, enrollment and attrition rates, and feedback will be used to inform a larger randomized trial. (PsycINFO Database Record

Examining the relationships between environmental barriers and leisure in community-dwelling individuals living with stroke

OBJECTIVE:

To characterize environmental barriers to leisure participation among individuals living with stroke; examine relationships between environmental barriers and leisure interest and satisfaction; and investigate participant factors associated with the perception of environmental barriers.

DESIGN:

Survey.

SETTING:

Community.

PARTICIPANTS:

Convenience sample of 51 community-dwelling adults less than six months post stroke.

INTERVENTIONS:

Not applicable.

MAIN OUTCOME MEASURE(S):

Craig Hospital Inventory of Environmental Factors-Short Form.

RESULTS:

Physical and structural environmental barriers were reported as the most frequent and large barrier to leisure participation ( n = 26 (51%) rated as "monthly or more," n = 12 (24%) rated as "big problem"). While attitude and support and policy barriers were not as commonly encountered, participants labeled these as "big problem(s)" (attitude and support n = 6 (12%), policy n = 7 (14%)). The presence of depressive symptoms was associated with the frequency in which attitudinal and support (rho = 0.50, P < 0.001), physical and structural (rho = 0.46, P < 0.001), and service and assistance (rho = 0.28, P = 0.04) barriers were reported, as well as magnitude of attitude and support barriers (rho = 0.48, P < 0.001). In multivariable regression analysis, depressive symptoms and walking capacity explained 21% of the variance of the frequency of attitude and support barriers ( P = 0.004), where depressive symptoms was an independent correlate ( P = 0.004). No other factors were associated with environmental barriers to leisure participation.

CONCLUSION:

Individuals with stroke report frequent and large physical and structural environmental barriers to leisure participation, which may be associated with the presence of depressive symptoms.

Nutrition, Energy Expenditure, Dysphagia, and Self-Efficacy in Stroke Rehabilitation: A Review of the Literature

While significant research has been performed regarding the use of thrombolytic agents and thrombectomy in the setting of acute stroke, other factors, such as nutritional status of stroke patients, is a less explored topic. The topic of nutrition is critical to the discussion of stroke, as up to half of stroke survivors may be considered malnourished at discharge. Dysphagia, old age, restricted upper limb movement, visuospatial impairment, and depression are all important risk factors for malnutrition in this cohort. The purpose of this review is to analyze current literature discussing neuroprotective diets, nutritional, vitamin, and mineral supplementation, dysphagia, and post-stroke coaching in stroke patients.

Relationship between perceived social support and patient-reported communication outcomes across communication disorders: a systematic review

BACKGROUND

Beyond the severity of voice, speech and language impairments, one potential predictor of communication success across adult populations with communication disorders may be perceived social support: the expectation that others will provide support if needed. Despite the preponderance of intervention approaches that assume a positive relationship between perceived social support and patient-reported communication success, the evidence base for these relationships is limited.

AIMS

The aim of this systematic review is to explore relationships between measures of perceived social support and patient-reported communication outcomes in adult populations with communication disorders.

METHODS & PROCEDURES

The PRISMA guidelines were followed in the conduct and reporting of this review. Electronic databases including PubMed, PsychINFO and CINAHL were systematically searched up to 19 May 2017. Additional data were obtained for two studies. All the included studies were appraised using the Critical Appraisal Skills Program (CASP) tools. Given the heterogeneous nature of the studies, data synthesis was narrative for the quantitative studies. A meta-ethnographic approach was used to synthesize qualitative data.

OUTCOMES & RESULTS

Eight quantitative and four qualitative studies met eligibility criteria. All quantitative studies met eight of eight quality criteria. For the qualitative studies, one study met nine of nine quality criteria; the remaining three studies met three, seven and eight quality criteria. Of the eight included quantitative studies, six independent data sets were used. Results revealed no significant relationships between perceived social support and communication outcomes in three studies (two aphasia with one data set, one Parkinson's disease), while perceived social support was a weak, but significant predictor in two studies (one multiple sclerosis, one head and neck cancer). Three additional studies (two aphasia with one data set; one Parkinson's disease) found that relationships were initially weak, but strengthened over time to become moderate. Results from qualitative studies (one head and neck cancer, two aphasia, one multiple sclerosis) revealed that perceived social support acted as a facilitator, and absent or misguided support acted as a barrier to communication outcomes. Skilful, responsive family members were able to facilitate better quality of communicative interactions, whereas lack of social support, or negative attitudes and behaviours of other people, were barriers.

CONCLUSIONS & IMPLICATIONS

While perceived social support may affect communication outcomes in adults with communication disorders, current measures may not adequately capture these constructs. Results have implications for future research and interventions for speech and language therapists.

Cultural adaptation and psychometric testing of The Scenario Test UK for people with aphasia

BACKGROUND

This study explores the psychometric properties of The Scenario Test UK, a culturally adapted version of the Dutch original (The Scenario Test) developed by van der Meulen et al. in 2010, which evaluates functional, daily-life communication in aphasia. The Scenario Test assesses communication in an interactive context with a supportive communication partner.

AIMS

To evaluate the reliability (internal consistency, interrater and test-retest reliability) and construct validity (convergent, discriminant and known-groups validity) of The Scenario Test UK.

METHODS & PROCEDURES

The Scenario Test UK and other language, cognition and praxis assessments were administered to persons with aphasia after stroke (3+ months post-stroke) and to non-aphasic controls. Participants were recruited primarily through community stroke groups. Measures were completed in an interview format. Standard psychometric criteria were used to evaluate reliability and construct validity.

OUTCOMES & RESULTS

A total of 74 participants with aphasia and 20 participants without aphasia took part in The Scenario Test UK. The test showed high levels of reliability. Internal consistency (Cronbach's α = 0.92), interrater reliability (ICC = 0.95) and test-retest reliability (ICC = 0.96) were excellent. Interrater agreement in scores on the individual items ranged from good to excellent (κ = 0.41-1.00) for all but two items (item 4c κ = 0.38, item 6c κ = 0.36). The test demonstrated good levels of convergent (ρ = 0.37-0.75) and discriminant validity (ρ = -0.04 to 0.23). There was strong evidence for known groups validity (U = 132.50, p < .001), with those with aphasia scoring significantly lower [median (interquartile range-IQR) = 47 (39.8-51.0)] than those without aphasia [53 (52-54)].

CONCLUSIONS & IMPLICATIONS

The data support the reliability and validity of the Scenario Test UK as an assessment of functional, daily-life communication for persons with aphasia. Further testing is needed in independent samples on the measure's psychometric properties, including its sensitivity to change. Pending this testing, The test can be used as an assessment tool to evaluate communication skills with people with aphasia, to guide goal setting for therapy and to measure outcomes in response to therapy.

Depressive symptoms in stroke patients treated and non-treated with intravenous thrombolytic therapy: a 1-year follow-up study

INTRODUCTION

This is a prospective study, first to compare the frequency of depressive symptoms in stroke survivors treated, and non-treated, with intravenous thrombolysis and second, to explore relationships between post-stroke depression (PSD) and stroke treatment modalities, taking into account other possible determinants of PSD, including post-traumatic stress symptoms.

METHODS

Groups of 73 thrombolysed and 73 non-thrombolysed patients matched for age and gender were examined at 3 and 12 months after discharge. PSD was assessed using the Beck Depression Inventory. Post-traumatic stress symptoms (PTSS), disability and social support were assessed with the Impact of Event Scale-Revised, the Barthel Index and the Berlin Social Support Scale.

RESULTS

At 3 months, PSD was present in 23.3% of the thrombolysed and 31.5% in the non-thrombolysed groups (p = 0.265). At 12 months, the frequencies were 29.2 and 20.6% (p = 0.229). Logistic regression of the combined group of thrombolysed and non-thrombolysed patients indicated that at 3 months, the adjusted predictors of PSD were disability (OR 24.35), presence of PTSS (OR 9.32), low social support (OR 3.68) and non-thrombolytic treatment (OR 3.19). At 12 months, the predictors were disability (OR 15.78) and low education (OR 3.61).

LIMITATIONS

The use of a questionnaire for the detection of depression, the relatively small sample size and a significant drop-out rate could limit the interpretation of these results.

CONCLUSIONS

(1) Thrombolysed and non-thrombolysed stroke survivors had similar frequency of depressive symptoms although the thrombolysed patients had more severe neurological deficits in the acute phase. It can be assumed that if thrombolysis had not been used, depressive symptoms would have been more frequent. (2) Lack of the rt-PA treatment was associated with three-time greater odds of screening for PSD at 3 months post-stroke, after adjustment for other PSD correlates. (3) Therefore, thrombolytic therapy seems to have a positive, but indirect, effect on patients' mood, especially in the first months after stroke. (4) All stroke patients, irrespective of the method of treatment, should be monitored for the presence of depression.

Best Practices for The Interdisciplinary Rehabilitation Team: A Review of Mental Health Issues in Mild Stroke Survivors

Individuals with mild strokes are generally considered fully functional and do not traditionally receive rehabilitation services. Because patients with mild stroke are assumed to have a good recovery, they may have deficits in other areas, including mental health, that are not addressed. As a result, patients with mild stroke are unable to meet quality of life standards. In addition, healthcare professionals are likely unaware of the potential mental health issues that may arise in mild stroke. To address this gap in knowledge, we review the evidence supporting mental health evaluation and intervention in mild stroke. Specifically, we review comorbid diagnoses including depression, anxiety, fatigue, and sleep disturbances and their potential effects on health and function. Finally, we conclude with general recommendations describing best practice derived from current evidence.

A Systematic Review of Semantic Feature Analysis Therapy Studies for Aphasia

PURPOSE

The purpose of this study was to review treatment studies of semantic feature analysis (SFA) for persons with aphasia. The review documents how SFA is used, appraises the quality of the included studies, and evaluates the efficacy of SFA.

METHOD

The following electronic databases were systematically searched (last search February 2017): Academic Search Complete, CINAHL Plus, E-journals, Health Policy Reference Centre, MEDLINE, PsycARTICLES, PsycINFO, and SocINDEX. The quality of the included studies was rated. Clinical efficacy was determined by calculating effect sizes (Cohen's d) or percent of nonoverlapping data when d could not be calculated.

RESULTS

Twenty-one studies were reviewed reporting on 55 persons with aphasia. SFA was used in 6 different types of studies: confrontation naming of nouns, confrontation naming of verbs, connected speech/discourse, group, multilingual, and studies where SFA was compared with other approaches. The quality of included studies was high (Single Case Experimental Design Scale average [range] = 9.55 [8.0-11]). Naming of trained items improved for 45 participants (81.82%). Effect sizes indicated that there was a small treatment effect.

CONCLUSIONS

SFA leads to positive outcomes despite the variability of treatment procedures, dosage, duration, and variations to the traditional SFA protocol. Further research is warranted to examine the efficacy of SFA and generalization effects in larger controlled studies.

Post-stroke social networks, depressive symptoms, and disability in Tanzania: A prospective study

Background Evidence suggests that social networks improve functional recovery after stroke, but this work has not been extended to low- and middle-income countries (LMICs). Post-stroke depression interferes with functional outcome but is understudied in LMICs. Aims To determine the relationships between social networks, disability, and depressive symptoms in patients surviving 90-days post-stroke in Dar es Salaam, Tanzania. Methods Participants ≥ 18 years, admitted ≤ 14 days of stroke onset, were enrolled. Disability was measured using the modified Rankin Scale, social networks by the Berkman-Syme social network index, and depressive symptoms by the Patient Health Questionnaire-9 (PHQ-9) by telephone interview at 90 days. A Kruskal-Wallis test or Spearman's correlation coefficient was used to assess the associations between social networks, depressive symptoms, and disability. Results Of 176 participants, 43% (n = 75) died, with an additional 11% (n = 20) lost to follow-up by 90 days. Among 81 survivors, 94% (n = 76, 57% male, average age 54 years) had complete information on all scales (mean and median follow-up time of 101 and 88 days). Thirty percent (n = 23, 41.9%, 95% confidence interval 20.2) had at least mild depressive symptoms (PHQ-9 ≥ 5 points). Nearly two-thirds (n = 46, 61%) reported ≥ 3 close friends. A higher social network index score was associated with fewer depressive symptoms (p < 0.0001) and showed a trend towards significance with lower disability (p = 0.061). Higher depressive symptom burden was correlated with higher disability (r = 0.52, p < 0.0001). Conclusion Post-stroke social isolation is associated with more depressive symptoms in Tanzania. Understanding social networks and the associated mechanisms of recovery in stroke is especially relevant in the context of limited resources.

Social Network Trajectories in Myocardial Infarction Versus Ischemic Stroke

BACKGROUND

Changes in social networks are rarely examined before and after various diseases because of insufficient data. CHS (The Cardiovascular Health Study) offers an opportunity to compare social network trajectories surrounding well-adjudicated myocardial infarction (MI) or stroke events. We tested the hypothesis that social networks will be stable after MI and decrease after stroke.

METHODS AND RESULTS

We examined trajectories of the Lubben Social Network Scale score (LSNS, range 0-50) before and after vascular events over 11 years. The LSNS assesses engagement in family networks, friends' networks, and social supports. We used a linear mixed model with repeated measures and fixed effects to compare the change in social network score before and after events in 395 people with MI and 382 with ischemic stroke. Over a mean of 12.4 years of follow-up for MI and 11.1 years for stroke, we examined an average of 4 social network scores for each participant. We controlled for sociodemographics, baseline cognitive function, and comorbidities. The participants' mean age was 73.5, 51% were women, and 88% were non-Hispanic white. After MI, the social network trajectory remained stable compared with the baseline trajectory (-0.06 points per year, adjusted P=0.2356). After stroke, the social network trajectory declined compared with the baseline trajectory (-0.14 points per year, adjusted P=0.0364).

CONCLUSIONS

Social networks remained stable after MI and declined after stroke. This small and persistent decline after adjustment for potential confounders is notable because it deviates from stable network trajectories found in CHS participants and is specific to stroke.

A systematic review of the methodological and practical challenges of undertaking randomised-controlled trials with cognitive disability populations

Approximately 10% of the world's population have a cognitive disability. Cognitive disabilities can have a profound impact on a person's social, cognitive or mental functioning, requiring high levels of costly health and social support. Therefore, it is imperative that interventions and services received are based upon a sound evidence-base. For many interventions for this population, this evidence-base does not yet exist and there is a need for more Randomised Controlled Trials (RCTs). The process of conducting RCTs with disabled populations is fraught with methodological challenges. We need a better understanding of these methodological barriers if the evidence-bases are to be developed. The purpose of this study was to explore the methodological and practical barriers to conducting trials with adults with cognitive disabilities. As a case example, the literature regarding RCTs for people with intellectual disabilities (ID) was used to highlight these pertinent issues. A systematic literature review was conducted of RCTs with adults with ID, published from 2000 to 2017. A total of 53 papers met the inclusion criteria and were reviewed. Some of the barriers reported were specific to the RCT methodology and others specific to people with disabilities. Notable barriers included; difficulties recruiting; obtaining consent; resistance to the use of control groups; engaging with carers, staff and stakeholders; the need to adapt interventions and resources to be disability-accessible; and staff turnover. Conducting RCTs with people with cognitive disabilities can be challenging, however with reasonable adjustments, many of these barriers can be overcome. Researchers are not maximising the sharing of their experience-base. As a result, the development of evidence-bases remains slow and the health inequities of people with disabilities will continue to grow. The importance of the MRC guidelines on process evaluations, together with implications for the dissemination of 'evidence-base' and 'experience-base' are discussed.

Supporting people with aphasia to 'settle into a new way to be': speech and language therapists' views on providing psychosocial support

BACKGROUND

People with aphasia are at risk of becoming depressed and isolated. Online surveys have found that the majority of speech and language therapists (SLTs) lack confidence in addressing the psychological needs of people with aphasia.

AIMS

To explore how SLTs conceptualize the scope of their role; barriers and facilitators to SLTs addressing psychosocial needs; and SLTs' experiences of specialist training and support, and working with mental health professionals (MHPs).

METHODS & PROCEDURES

Focus groups were conducted in stroke healthcare settings. Purposive sampling was used when selecting sites so as to capture a range of experiences. Results were analysed using framework analysis.

OUTCOMES & RESULTS

Twenty-three SLTs took part in six focus groups. Participants' psychosocial work included counselling-type interactions, psycho-education, working with families, facilitating peer support and training other healthcare professionals. There was lack of consensus on the scope of the SLT role. Many expressed a sense of conflict, both perceiving it as valuable to spend time addressing psychological well-being, while simultaneously feeling uneasy if they deviated from 'direct SLT' work. Barriers to addressing psychosocial well-being were: emotionally challenging nature of this work, particularly for those who felt unsupported; caseload and time pressures; attitudes of senior managers and commissioners; difficulties measuring and documenting more 'fluid' psychosocial work; and the complexity of the needs and backgrounds of some patients. Enabling factors were: specialist ongoing support; peer support from colleagues; experience; support of management; and personal belief. Specialist training was valued. It changed how participants viewed the therapist-client relationship (more client led); the assessment and goal-setting process; and gave them more confidence to acknowledge client emotions. However, many felt that there was a need for ongoing specialist advice, and to be able to see approaches modelled for this client group. In terms of MHPs, a subset of stroke-specialist clinical psychologists worked directly with people with marked aphasia and families, as well as supporting the multidisciplinary team to provide holistic care. However, a main theme was that participants perceived many MHPs did not consider people with aphasia as 'appropriate candidates' for psychological input.

CONCLUSIONS & IMPLICATIONS

All participants cared about the emotional well-being of their clients; however, they identified a number of barriers to people with aphasia receiving appropriate psychological support. A cultural shift, whereby psychological care for people with aphasia is seen as valuable, feasible and necessary, delivered collaboratively by SLTs, MHPs and the wider team, may improve services.

"I've got somebody there, someone cares": what support is most valued following a stroke?

PURPOSE

There is often a need for increased support following a stroke. This study explored what types of support are provided by different network members and what support functions are most valued.

METHODS

Adults with first stroke were recruited from a stroke unit and participated in in-depth interviews 8-15 months poststroke. Framework Analysis was used to build thematic and explanatory accounts of the data.

RESULTS

Twenty-nine participants took part. Main themes to emerge were as follows: the spouse was the most important provider of support; children were a relatively stable source of support, although many participants expressed reservations about worrying a child; relatives and friends typically provided social companionship and emotional support rather than on-going practical support. The only universally valued support function was the sense that someone was concerned and cared. Other valued functions were as follows: social companionship including everyday social "chit chat"; practical support provided sensitively; and, for many, sharing worries and sensitive encouragement. The manner and context in which support was provided was important: support was easiest to receive when it communicated concern, and was part of a reciprocal, caring relationship.

CONCLUSIONS

As well as measuring supportive acts, researchers and clinicians should consider the manner and context of support. Implications for rehabilitation The manner in which support was provided mattered: support was easier to receive when it communicated concern. The spouse was the most important source of all support functions; children, relatives and friends were important providers of emotional and social companionship support. Researchers and clinicians should not only focus on what support is received, but also the context (e.g., contribution, reciprocity, quality of relationship) and manner (e.g., responsiveness, sensitivity) of the support.

Music Upper Limb Therapy-Integrated: An Enriched Collaborative Approach for Stroke Rehabilitation

Stroke is a leading cause of disability worldwide. It leads to a sudden and overwhelming disruption in one’s physical body, and alters the stroke survivors’ sense of self. Long-term recovery requires that bodily perception, social participation and sense of self are restored; this is challenging to achieve, particularly with a single intervention. However, rhythmic synchronization of movement to external stimuli facilitates sensorimotor coupling for movement recovery, enhances emotional engagement and has positive effects on interpersonal relationships. In this proof-of-concept study, we designed a group music-making intervention, Music Upper Limb Therapy-Integrated (MULT-I), to address the physical, psychological and social domains of rehabilitation simultaneously, and investigated its effects on long-term post-stroke upper limb recovery. The study used a mixed-method pre-post design with 1-year follow up. Thirteen subjects completed the 45-min intervention twice a week for 6 weeks. The primary outcome was reduced upper limb motor impairment on the Fugl-Meyer Scale (FMS). Secondary outcomes included sensory impairment (two-point discrimination test), activity limitation (Modified Rankin Scale, MRS), well-being (WHO well-being index), and participation (Stroke Impact Scale, SIS). Repeated measures analysis of variance (ANOVA) was used to test for differences between pre- and post-intervention, and 1-year follow up scores. Significant improvement was found in upper limb motor impairment, sensory impairment, activity limitation and well-being immediately post-intervention that persisted at 1 year. Activities of daily living and social participation improved only from post-intervention to 1-year follow up. The improvement in upper limb motor impairment was more pronounced in a subset of lower functioning individuals as determined by their pre-intervention wrist range of motion. Qualitatively, subjects reported new feelings of ownership of their impaired limb, more spontaneous movement, and enhanced emotional engagement. The results suggest that the MULT-I intervention may help stroke survivors re-create their sense of self by integrating sensorimotor, emotional and interoceptive information and facilitate long-term recovery across multiple domains of disability, even in the chronic stage post-stroke. Randomized controlled trials are warranted to confirm the efficacy of this approach. Clinical Trial Registration: National Institutes of Health, clinicaltrials.gov, NCT01586221.

What Factors Predict Who Will Have a Strong Social Network Following a Stroke?

PURPOSE

Measures of social networks assess the number and nature of a person's social contacts, and strongly predict health outcomes. We explored how social networks change following a stroke and analyzed concurrent and baseline predictors of social networks 6 months poststroke.

METHOD

We conducted a prospective longitudinal observational study. Participants were assessed 2 weeks (baseline), 3 months, and 6 months poststroke. Measures comprised the Stroke Social Network Scale (Northcott & Hilari, 2013), Medical Outcomes Study Social Support Survey (Sherbourne & Stewart, 1991), National Institutes of Health Stroke Scale (Brott et al., 1989), Frenchay Aphasia Screening Test (Enderby, Wood, Wade, & Langton Hewer, 1987), Frenchay Activities Index (Wade, Legh-Smith, & Langton Hewer, 1985), and Barthel Index (Mahoney, Wood, & Barthel, 1958). Analyses of variance and standard multiple regression were used to analyze change and identify predictors.

RESULTS

Eighty-seven participants (37% with aphasia) were recruited; 71 (16% with aphasia) were followed up at 6 months. Social network scores declined poststroke (p = .001). Whereas the Children and Relatives factors remained stable, the Friends factor significantly weakened (p < .001). Concurrent predictors of social network at 6 months were perceived social support, ethnicity, aphasia, and extended activities of daily living (adjusted R2 = .42). There were 2 baseline predictors: premorbid social network and aphasia (adjusted R2 = .60).

CONCLUSIONS

Social networks declined poststroke. Aphasia was the only stroke-related factor measured at the time of the stroke that predicted social network 6 months later.

Very early social support following mild stroke is associated with emotional and behavioral outcomes three months later

OBJECTIVE

To investigate whether social contact and support received during hospitalization for acute ischemic stroke predict depression and daily life functioning three months later.

DESIGN

Prospective observational study using Ecological Momentary Assessments to evaluate the number of social contacts as well as social support received from family, friends and medical staff within 24 hours following admission for stroke. Patients also monitored depression symptoms and behavior in real-time and in daily life contexts three months later.

SETTING

A university hospital acute stroke unit.

SUBJECTS

Thirty-four mild ischemic stroke patients.

INTERVENTIONS

None.

MAIN MEASURES

One-day Ecological Momentary Assessments immediately following stroke collected information concerning perceived social support, number of social contacts and depression symptoms. Ecological Momentary Assessments was repeated three months later and addressed depression levels as well as activities of daily living, such as working, cooking, shopping and housework.

RESULTS

The number of social interactions received at hospitalization did not predict three-month outcomes. However, a better quality of moral support from friends and family immediately after stroke was associated with decreases in later depression levels ( p = 0.041) and increases in activities of daily living ( p = 0.011). Material support from friends and family was associated with increases in activities of daily living ( p = 0.012). No effect was observed for support received from medical staff.

CONCLUSIONS

Patient perceptions of better support quality, and not quantity, immediately following mild stroke, are associated with better behavioral and emotional outcomes three months later.