The Impact of Mild Stroke on Meaningful Activity and Life Satisfaction

An ecological approach to activity after stroke: it takes a community

BACKGROUND

Biopsychosocial recovery from stroke is remarkable for some individuals, but the majority of stroke survivors have difficulty resuming activities. Even survivors with mild disability become disengaged.

METHODS

Situational analysis grounded theory and ecological models were used to examine the barriers and facilitators to choice of everyday activities of stroke survivors aged 50 to 64 years.

RESULTS

Resuming activities was an iterative process of scaffolding small tasks into activities through bargaining for access to practical support and inclusion into social situations. Although participants geared up to manage their condition and access activities, for the most part they were not in charge of the services and supports they required. They had little control over who was accepted to rehabilitation, for which services they qualified or disability policies.

CONCLUSIONS

There are layers of interactions between individuals and multiple factors in their environments that influence participation. Low poststroke activity levels may be amenable to intervention. Further research should consider the following: (1) participation in activities through the lens of all levels of the socioecological model; (2) the impact of disability and aging-related stigma; (3) the results of ad hoc community navigation; and (4) the effects of restrictive health and disability policies on meaningful activity.

Variability in the use of intravenous thrombolysis for mild stroke: experience across the SPOTRIAS network

BACKGROUND

Current guidelines do not define the lower severity threshold for thrombolysis. In this study, we describe the variability of treatment of mild stroke patients across a network of academic stroke centers.

METHODS

Stroke centers within the Specialized Program of Translational Research in Acute Stroke (SPOTRIAS) prospectively collect data on patients treated with intravenous recombinant tissue plasminogen activator (IV rt-PA), including demographics, pretreatment National Institutes of Health Stroke Scale (NIHSS) scores, and in-hospital mortality. We examined the variability in proportion of total tissue plasminogen activator-treated patients in the NIHSS categories (0-3, 4-5, or ≥ 6) and associated outcomes.

RESULTS

A total of 2514 patients with reported NIHSS scores were treated with IV rt-PA between January 1, 2005 and December 31, 2009. The proportion of patients with mild stroke (NIHSS scores of 0-3) who were treated with IV rt-PA varied substantially across the centers (2.7-18.0%; P < .001). There were 5 deaths in the 256 treated with an NIHSS score of 0-3 (2.0%). The proportion of treated patients across the network with an NIHSS score of 0 to 3 increased from 4.8% in 2005 to 10.7% in 2009 (P = .001).

CONCLUSIONS

There is substantial variability in the proportion of treated patients who have mild stroke across the SPOTRIAS centers, reflecting a paucity of data on how to best treat patients with mild stroke. Randomized trial data for this group of patients are needed to clarify the use of rt-PA in patients with the mildest strokes.

The association between major depression, health behaviors, and quality of life in adults with stroke

AIM

The study aims to examine the association between major depression, healthcare behaviors, and quality of life indices among adults with stroke.

METHODS

Data from 5869 participants with stroke in the 2006 Behavioral Risk Factor Surveillance Survey were examined. Multiple logistic regression was used to assess the independent association between depression status, self-care and preventive health behaviors, and quality of life indices, after accounting for relevant covariates.

RESULTS

In multivariate models, individuals with major depression were less likely to engage in physical activity (odds ratio 0·41; 95% confidence interval 0·29, 0·56) than those without major depression. Women with major depression were also less likely to have received a mammogram in the past two-years (odds ratio 0·61; 95% confidence interval 0·40, 0·96 for women ≥ age 40 and odds ratio 0·58; 95% confidence interval 0·36, 0·72 for women ≥ age 50) and a pap smear in the past three-years (odds ratio 0·40; 95% CI 0·22, 0·72). In comparisons of quality of life, individuals with major depression were less likely to perceive their health as excellent/very good/good (odds ratio 0·36; 95% confidence interval 0·25, 0·53), to report being satisfied with life (odds ratio 0·13; 95% confidence interval 0·08, 0·20), and to report receiving needed social support (odds ratio 0·42; 95% confidence interval 0·28, 0·63). Individuals who were depressed were also more likely to report one or more poor physical and poor mental health days in the past 30 days (odds ratio 4·56; 95% confidence interval 3·08, 6·76 and odds ratio 10·97; 95% confidence interval 7·75, 15·52, respectively).

CONCLUSIONS

In adults with stroke, major depression is associated with decreased engagement in stroke-specific and gender-specific self-care and preventive health behaviors, as well as a broad range of quality of life indices.

The impact of mild stroke on participation in physical fitness activities

Objective. To compare participation in moderate to high intensity physical activities in persons before and after a mild stroke. Methods. We used data from the Cognitive Rehabilitation and Research Group to examine changes in moderate to high intensity physical activity participation in persons who had a mild stroke as defined by an NIH Stroke Scale score of less than 6 (N = 127). Using the Activity Card Sort, we compared the participants' high-demand leisure activity (leisure activities that are moderate to high intensity physical activities) participation at 6-months after stroke with their prestroke level. Results. We found a significant decrease in numbers of high-demand leisure activities in all participants and in each demographic group after mild stroke. Conclusion. These results suggest that persons after mild stroke are not retaining the high-demand leisure activities they were doing prior to their stroke. Health professionals must promote participation in high-demand leisure activities in patients with mild stroke as a tool to enhance health and fitness.

Validity, responsiveness, and clinically important difference of the ABILHAND questionnaire in patients with stroke

OBJECTIVE

To investigate the criterion-related validity, responsiveness, and clinically important differences of the ABILHAND questionnaire in patients with stroke.

DESIGN

Validation and clinimetric study.

SETTING

Three medical centers.

PARTICIPANTS

Patients with stroke (N=51).

INTERVENTIONS

A total of 51 patients with stroke received 1 of 3 upper extremity rehabilitation programs for 4 weeks.

MAIN OUTCOME MEASURES

The ABILHAND and the criterion measures, including the Stroke Impact Scale (SIS), FIM, Nottingham Extended Activities of Daily Living (NEADL), and accelerometers, were administered at pretreatment and posttreatment. The score of the ABILHAND, given in logits, was based on the conversion of the ordinal score into a linear measure of ability.

RESULTS

Correlation coefficients (Pearson r) were moderate to large between the ABILHAND and SIS physical domains (.54-.66), fair to moderate between the ABILHAND and FIM-motor and NEADL (.28-.48), and moderate between the ABILHAND and accelerometer data (.45-.54). The responsiveness of the ABILHAND was large (standardized response mean=1.27). The minimal clinically important difference range for the ABILHAND was .26 to .35, and 51.0% of the patients showed a positive change that exceeded the lower bound of a clinically important difference after intervention.

CONCLUSIONS

The results support that the ABILHAND is an appropriate outcome measure for assessing upper extremity performance in daily activities in patients with stroke and is sensitive to detect change after rehabilitative interventions. The change score of a patient with stroke on the ABILHAND should reach .26 to .35 logits points to be regarded as a clinically important change.

Rehabilitation, Disability, and Participation Research: Are Occupational Therapy Researchers Addressing Cognitive Rehabilitation After Stroke?

I reviewed articles published in the American Journal of Occupational Therapy (AJOT) in 2009 and 2010 to assess (1) whether research was published in the practice area of rehabilitation, disability, and participation and (2) the evidence being produced in an underdeveloped subcategory of this practice area: cognitive rehabilitation after stroke. The review revealed one intervention effectiveness study that addressed cognitive rehabilitation poststroke published in the 2-year period. Further analysis of outside repositories of evidence in this area revealed that although some evidence supports rehabilitation approaches for people with cognitive dysfunction after a stroke, little research has been devoted to this practice area. The poststroke cognitive intervention approaches in use have been shown to have little or no effect on improving everyday life activity. Occupational therapy has a key research and practice role with the poststroke population, and occupational therapists should be at the forefront in developing the science to support the effectiveness of their services.

Predicting length of stay in patients admitted to stroke rehabilitation with high levels of functional independence

PURPOSE

In Ontario, stroke patients with relatively mild functional deficits are admitted to inpatient rehabilitation programmes. Despite apparently minor impairments, many of these patients remain in rehabilitation for prolonged periods of time. The objective of the present study is to identify variables that predict length of stay (LOS) within this population of high functioning stroke patients.

METHODS

Stroke patients with Functional Independence Measure (FIM™) scores ≥100 admitted to a specialised inpatient rehabilitation programme in Ontario, Canada, from April 2005 to March 2008 were included in this study. Data from the National Rehabilitation Reporting System and chart review were used. Associations with LOS were examined among 25 potential predictor variables using bivariate correlations. Significantly correlated (p <0.002) variables were entered into a multiple linear regression.

RESULTS

Twenty-four percent (n = 134) of patients admitted during the study period were identified as presenting with mild functional deficits. These patients had a mean admission age of 63.5 (SD 14.6) years, a mean admission FIM score of 109.9 (SD 6.6) and a mean LOS of 22.3 (SD 10.5) days. FIM motor and cognitive subscale scores, Mini Mental State Exam scores and five single items assessing orientation, financial independence, and verbal, written and auditory communication ability were significantly correlated with LOS. The regression model, which included all eight variables, explained 60% of the variance associated with LOS (r = 0.80).

CONCLUSIONS

For patients admitted to stroke rehabilitation programmes with mild functional impairment, 60% of the variance in LOS can be explained by a small number of variables indicative of deficits in the areas of motor function, cognition and communication.

Occupations of Older Adults: A Cross Cultural Description

Participation in everyday occupations influences people's health and well-being. To enable individuals to do the activities they want and need to do is the main concern of occupational therapy practice. Many daily occupations are universal, but they also depend on culture. The development of the Activity Card Sort in eight countries has offered the opportunity to describe occupations across cultures. In the developmental process of culturally relevant versions of the Activity Card Sort by occupational therapists in each country, the instrument versions included samples of older adults ( N = 468). These data are used in the current description with the aim of identifying central activities across cultures and central activities for Asian and Western cultures. Te n activities were identified as being central across cultures (i.e., more than half of the older adults in all eight countries performed them). They were the following: shopping in a store, doing grocery shopping, doing dishes, doing laundry, reading books or magazines, sitting and thinking, watching television, listening to radio or music, visiting with friends and relatives, and talking on the telephone. Further, 16 additional activities central to Asian culture and 18 activities central to Western culture were identified. The identification of central activities deepens knowledge of activities with cultural significance. This knowledge is needed in clinical practice and multicultural research. This description provides a starting point for further exploration of everyday occupations among older adults.

The psychology of stroke in young adults: the roles of service provision and return to work

Literature about the psychological consequences of stroke in those under 65 is reviewed focussing on services and work. Despite similarities, young and old survivors have different experiences and needs. These are attributable to the effects of stroke on age-normative roles and activities, self-image, and the young person's stage in the life-cycle, especially family and work. "Hidden" cognitive impairments, a disrupted sense of self, and the incongruity of suffering an "older person's" disease are salient. Young survivors benefit from services, but experience lack of congruence between their needs and service philosophy, methods, and aims, and consequently have unmet needs. Employment is psychologically salient, and the evidence about return rates, factors that affect return, and the adequacy of employment-related service provision is reviewed. Specific and general recommendations are made for increasing congruence between young survivors' needs and service provision and also for facilitating their return to work.

Executive Dysfunction Immediately after Mild Stroke

The purpose of this study was to determine the presence of executive function deficits immediately after mild stroke that are known to impact participation in home, work, and community life. Individuals with mild stroke who were discharged from the acute setting to the home with few or no rehabilitation services were assessed within 1 week after discharge using a cognitive battery. Using rigorous criteria to identify a specific deficit in executive function, results showed that 66% of the population (N = 35) scored in the deficit range on at least one of the four measures of executive function; 27% of the population (N = 14) scored in the deficit range on two or more measures. Although deficits post-stroke are sometimes known to spontaneously recover, cognitive dysfunction of this nature often becomes chronic. This group is typically discharged with little or no rehabilitation; by detecting these deficits in the acute stage of stroke care, occupational therapists can make appropriate rehabilitation and follow-up recommendations.

Social activity contributes independently to life satisfaction three years post stroke

Objective: To determine social activity and life satisfaction three years post stroke and to investigate the contribution of social activity to life satisfaction controlled for the influence of demographic, physical and cognitive disabilities and social support.

Design: Cross-sectional study.

Subjects: One hundred and sixty-five patients with a stroke.

Main measures: The Life Satisfaction questionnaire (LiSat-9), the Social Support List – Interaction (SSL-12-I), the Barthel Index, the Mini-Mental State Examination (MMSE) and the Frenchay Activities Index.

Results: In total, 165 stroke patients participated, of whom 112 (67.9%) reported that they were satisfied with life as a whole. Socially inactive patients were significantly less often satisfied (50%, n = 26) than socially moderately (74.4%, n = 64) and socially highly active (81.5%, n = 22) patients. Lowest satisfaction ratings were found for sexual life (40.6%, n = 58). The socially inactive group was most satisfied with their partner relationship (85.1%, n = 40), the moderately and highly socially active group with their self-care ability (87.2%, n = 75 and 96.3%, n = 26, respectively). ADL and social activity were moderately correlated with life satisfaction. Social activity was found to explain an additional variance of the LiSat-9 total score (6.9%) and overall life satisfaction item (5.2%) after controlling for demographic variables, social support, ADL and cognitive functioning.

Conclusions: Three years post stroke, many patients report ongoing dissatisfaction with various life domains. Social activity was related to life satisfaction.

Predicting home and community walking activity in people with stroke

OBJECTIVE

To determine the ability of the 6-minute walk test (6MWT) and other commonly used clinical outcome measures to predict home and community walking activity in high-functioning people with stroke.

DESIGN

Cross-sectional.

SETTING

Outpatient physical therapy clinic.

PARTICIPANTS

Participants (N=32) with chronic stroke (n=19; >6mo poststroke) with self-selected gait speed (GS) faster than .40m/s and age-matched healthy participants (n=13).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

INDEPENDENT VARIABLES

6MWT, self-selected GS, Berg Balance Scale (BBS), lower extremity motor section of the Fugl-Meyer Assessment, and Stroke Impact Scale. Dependent variable: average steps taken per day during a 7-day period, measured using an accelerometer.

RESULTS

6MWT, self-selected GS, and BBS were moderately related to home and community walking activity. The 6MWT was the only predictor of average steps taken per day; it explained 46% of the variance in steps per day.

CONCLUSIONS

The 6MWT is a useful outcome measure in higher functioning people with stroke to guide intervention and assess community walking activity.

Returning to work after stroke: a review

This review focuses on the experiences and rehabilitation needs of working age, higher functioning stroke survivors in relation to their 'return to work'. It grew out of the poststroke experience of one of the authors and her realization of the inadequacy of services to facilitate return to work and optimal recovery from stroke. The authors' aim is to present a practice-oriented review that can provide information for future practice and research. Returning to work and sustaining employment are considered key aspects of rehabilitation and recovery by younger stroke survivors. From a psychosocial perspective, successful return to work can enhance recovery and life satisfaction by consolidating self-esteem, confidence and social identity. However, even higher functioning stroke survivors with minimal or no obvious physical disability may experience workplace challenges relating to their neurological condition. Appropriate rehabilitation would include specific preparation for return to work, education within the workplace to facilitate return to work, participation by the stroke survivor in all aspects of the management of their return to work, and an ongoing role for a stroke educator/workplace advocate. In conclusion, further research is required in this area to support stroke survivors in returning to and maintaining employment to achieve their poststroke potential. Thirteen recommendations arising from the existing literature and the lived experience of one of the authors are presented at the end of the review.

Active range of motion predicts upper extremity function 3 months after stroke

BACKGROUND AND PURPOSE

After stroke, 80% of patients experience acute paresis of the upper extremity and only approximately one-third achieve full functional recovery. Predicting functional recovery for these patients is highly important to provide focused, cost-effective rehabilitation. Our purpose was to examine if early measures of upper extremity active range of motion (AROM) could predict recovery of upper extremity function, and to describe the trajectory of upper extremity AROM recovery over time.

METHODS

Thirty-three subjects were tested at 1 month and then at 3 months after stroke. Upper extremity function was measured with 6 standardized clinical tests that were synthesized into a single, sensitive score for upper extremity function using principal component analysis. The ability to move each segment (AROM) was measured using a 3-dimensional electromagnetic tracking system.

RESULTS

Stepwise multiple regression revealed that AROM of the shoulder and middle finger segments taken at 1 month could predict 71% of the variance in upper extremity function at 3 months. All segments of the upper extremity recover similarly and no evidence of a proximal to distal gradient in motor deficits appeared over time.

CONCLUSIONS

Simple AROM measurements of the upper extremity taken within 1 month after stroke can be used to predict upper extremity function at 3 months. This information is important for determining the prognosis of upper extremity functional recovery.

Understanding the experience of stroke: a mixed-method research agenda

The use of both quantitative and qualitative strategies to examine a single research question has been a subject of considerable controversy and still remains a largely uncommon practice in the sociology of health and illness. Yet, when seeking to understand the meaning of a chronic disabling condition in later life from a social psychological perspective, a mixed-method approach is likely to provide the most comprehensive picture. This article provides an overview of the usefulness and appropriateness of a mixed-method approach to understanding the stroke experience. I comment on the current state of research on the experience of stroke, including epistemological and ontological orientations. Using real data examples, I address paradigmatic assumptions, methods of integration, as well as challenges and pitfalls in integrating methods. I conclude by considering future directions in this field of research.

Experiences of male patients and wife-caregivers in the first year post-discharge following minor stroke: a descriptive qualitative study

BACKGROUND

Most patients with minor stroke are discharged directly home from acute care, under the assumption that little will be required in the way of adaptation and adjustment because informal caregivers will manage the stroke recovery process. We explored male patients with minor stroke and their wife-caregivers' perceptions of factors affecting quality of life and caregiver strain encountered during the first year post-discharge.

METHODS

Data were obtained from responses to two open-ended questions, part of quality of life and caregiver strain scales administered to participants in a larger descriptive study. Conventional content analysis was used to assess narrative accounts of living with minor stroke provided by 26 male patients and their wife-caregivers over a period of 1-year post-discharge.

RESULTS

Two major themes that emerged from these data were 'being vulnerable' and 'realization'. Subthemes that arose within the vulnerability theme included changes to patients' masculine image and wife-caregivers' assumption of a hyper-vigilance role. In terms of 'realization' patients and their wife-caregivers shared 'loss' as well as 'changing self and relationships'. Patients in this study focused primarily on their physical recovery and their perceptions of necessary changes. Wife-caregivers were actively involved in managing the day-to-day demands that stroke placed on individual, family and social roles.

CONCLUSIONS

We conclude that patients and wife-caregivers expend considerable time and energy reestablishing control of their lives following minor stroke in an attempt to incorporate changes to self and their relationship into the fabric of their lives.

Predictors of life satisfaction among stroke survivors and spousal caregivers: a narrative review

Stroke is a major cause of disability and death worldwide. It affects 15 million people globally and 60% either die or are permanently disabled as a result of stroke. In a rapidly aging population, stroke is expected to continue to be a major concern for survivors, their families and health and social care providers. Most stroke survivors live in the community and are assisted by family caregivers, especially spouses. However, stroke-related impairments and poststroke depression interfere with recovery and result in impaired relationships and reduced life satisfaction for the survivors and their spouses. New interventions are needed to assist stroke survivors and their spouses to cope with the many physical, emotional and environmental changes that result after stroke and enable survivors to become reintegrated into the community.