The trajectory of minor stroke recovery for men and their female spousal caregivers: literature review

Physiotherapists' and occupational therapists' experiences with cross-sectoral coordination of rehabilitation for people with mild stroke - a qualitative interview study

PURPOSE

To meet the needs of people with mild stroke, multidisciplinary, person-centred, cross-sectoral rehabilitation is internationally recommended. However, there seem to be gaps in the rehabilitation process. The aim of this study was to investigate how occupational therapists and physiotherapists experience working in cross-sectoral rehabilitation for people with mild stroke.

MATERIALS AND METHODS

Data were generated through interviews with occupational therapists and physiotherapists working in four different Danish rehabilitation settings. Four group interviews and two individual interviews with a total of 19 participants were conducted. Ricoeur's theory of interpretation was used to interpret and discuss the data.

RESULTS

Four themes were identified: the risk of overlooking symptoms: better safe than sorry; varying degrees of involvement of people with mild stroke; spontaneous involvement of relatives; and contextual challenges for coherence in the rehabilitation process.

CONCLUSION

The therapists experienced challenges in coordinating rehabilitation across sectors due to the timing of the needs assessment and contextual challenges. They used a preventive strategy of sending a plan or referral for later re-assessment. The therapists involved people with mild stroke to varying degrees. They involved relatives spontaneously. For successful rehabilitation, ongoing assessment, recognition of collaboration factors and relative involvement are essential.

Effect of very early supported discharge versus usual care on activi-ties of daily living ability after mild stroke: a randomized controlled trial

OBJECTIVE

To examine the ability to perform basic and instrumental activities of daily life after very early supported discharge vs usual discharge and referral routine during the first year after mild stroke.

DESIGN

A secondary analysis of data from the Gothenburg Very Early Supported Discharge randomized controlled trial.  Patients: A total of 104 patients (56% men; mean (standard deviation) age 75 (11) years) who had experienced a first stroke classified as mild.

METHODS

The primary outcome was the Activities of Daily Living Taxonomy score. Stroke Impact Scale (activities of daily living, and mobility) scores was a secondary measure. Patients were randomized to either very early supported discharge with 4 weeks of home rehabilitation provided by a multidisciplinary stroke team, or a control group discharged according to usual routine (referral to primary care when needed). Assessments were performed at discharge, 4 weeks post-discharge, and 3 and 12 months post-stroke.

RESULTS

Instrumental activities of the Activities of Daily Living Taxonomy scores (the lower the better) in the very early supported discharge and control groups were median 4 and 6 (p = 0.039) at 4 weeks post-discharge and 3 and 4.5 (p = 0.013 at 3 months post-stroke, respectively. Stroke Impact Scale (Mobility) median scores (the higher the better) in the very early supported discharge and control groups at 3 months were 97 and 86 (p = 0.040), respectively. There were no group differences in the 2 outcomes at 12 months post-stroke.

CONCLUSION

Compared with usual discharge routine, team-based rehabilitation during the first month at home is beneficial for instrumental activity in the subacute phase, in patients with mild stroke. One year post-stroke both groups show equal results.

Lasting impairments following transient ischemic attack and minor stroke: a systematic review protocol

Introduction

The focus on medical management and secondary prevention following Transient Ischemic Attack (TIA) and minor stroke is well-established. Evidence is emerging that people with TIA and minor stroke can experience lasting impairments as fatigue, depression, anxiety, cognitive impairment, and communication difficulties. These impairments are often underrecognized and inconsistently treated. Research in this area is developing rapidly and an updated systematic review is required to evaluate new evidence as it emerges. This living systematic review aims to describe the prevalence of lasting impairments and how they affect the lives of people with TIA and minor stroke. Furthermore, we will explore whether there are differences in impairments experienced by people with TIA compared to minor stroke.

Methods

Systematic searches of PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Libraries will be undertaken. The protocol will follow the Cochrane living systematic review guideline with an update annually. A team of interdisciplinary reviewers will independently screen search results, identify relevant studies based on the defined criteria, conduct quality assessments, and extract data. This systematic review will include quantitative studies on people with TIA and/or minor stroke that report on outcomes in relation to fatigue, cognitive and communication impairments, depression, anxiety, quality of life, return to work/education, or social participation. Where possible, findings will be grouped for TIA and minor stroke and collated according to the time that follow-up occurred (short-term < 3 months, medium-term 3-12 months, and long-term > 12 months). Sub-group analysis on TIA and minor stroke will be performed based on results from the included studies. Data from individual studies will be pooled to perform meta-analysis where possible. Reporting will follow the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) guideline.

Perspectives

This living systematic review will collate the latest knowledge on lasting impairments and how these affect the lives of people with TIA and minor stroke. It will seek to guide and support future research on impairments emphasizing distinctions between TIA and minor stroke. Finally, this evidence will allow healthcare professionals to improve follow-up care for people with TIA and minor stroke by supporting them to identify and address lasting impairments.

Outcomes in Patients with Minor Stroke: Diagnosis and Management in the Post-thrombectomy Era

In the era of mechanical thrombectomy and better preventative strategies, a higher number of patients are being discharged home from the hospital with the so-called minor strokes. This has significantly changed the landscape of stroke recovery. Unfortunately, while symptoms may be categorized as mild compared to individuals with higher NIH Stroke Scale scores, the physical, cognitive, and emotional sequelae can be disabling and result in failure to return to work and poor quality of life in a population with significant potential to recover fully. In this review, we discuss the current state of minor stroke, the most common pattern of resulting deficits, what is known about the underlying pathophysiology that leads to a relatively global pattern of impaired cognition following an infarct in any location, and special considerations for treatment based on this population's unique needs. Raising awareness of the current morbidity associated with minor stroke, the need for a uniform definition that allows for comparisons of individuals across studies, and further research focused on this population to optimize outcomes, has the potential to significantly improve recovery.

Scoping 'sex' and 'gender' in rehabilitation: (mis)representations and effects

BACKGROUND

Researchers have highlighted a large-scale global unmet need for rehabilitation. While sex and gender have been shown to interact with each other and with other social and structural factors to influence health and wellbeing, less is known about how sex and gender shape rehabilitation participation and outcomes within health systems.

METHODS

Using an intersectional approach, we examine literature that explores the relationship between sex and/or gender and rehabilitation access, use, adherence, outcomes, and caregiving. Following a comprehensive search, 65 documents met the inclusion criteria for this scoping review of published literature. Articles were coded for rehabilitation-related themes and categorized by type of rehabilitation, setting, and age of participants, to explore how existing literature aligned with documented global rehabilitation needs. Responding to a common conflation of sex and gender in the existing literature and a frequent misrepresentation of sex and gender as binary, the researchers also developed a schema to determine whether existing literature accurately represented sex and gender.

RESULTS

The literature generally described worse rehabilitation access, use, adherence, and outcomes and a higher caregiving burden for conditions with rehabilitation needs among women than men. It also highlighted the interacting effects of social and structural factors like socioeconomic status, racial or ethnic identity, lack of referral, and inadequate insurance on rehabilitation participation and outcomes. However, existing literature on gender and rehabilitation has focused disproportionately on a few types of rehabilitation among adults in high-income country contexts and does not correspond with global geographic or condition-based rehabilitation needs. Furthermore, no articles were determined to have provided an apt depiction of sex and gender.

CONCLUSION

This review highlights a gap in global knowledge about the relationship between sex and/or gender and rehabilitation participation and outcomes within health systems. Future research should rely on social science and intersectional approaches to elucidate how gender and other social norms, roles, and structures influence a gender disparity in rehabilitation participation and outcomes. Health systems should prioritize person-centered, gender-responsive care, which involves delivering services that are responsive to the complex social norms, roles, and structures that intersect to shape gender inequitable rehabilitation participation and outcomes in diverse contexts.

Social Isolation Among Spousal and Adult-Child Caregivers: Findings From the Canadian Longitudinal Study on Aging

OBJECTIVES

The caregiving outcomes of spousal and adult-child caregivers are widely studied since they are the most common source of support provided to adults. However, the literature on social isolation among spousal and adult-child caregivers is very limited. In order to further elaborate and specify unique caregiving outcomes, this study focuses on social isolation, both longitudinally and comparatively between spousal and adult-child caregivers.

METHODS

This study was based on the Baseline and Follow-up 1 data from the Canadian Longitudinal Study on Aging. A total of 5,226 participants (1,293 spousal caregivers and 3,933 adult-child caregivers) were selected. The Linear mixed models were used to examine the effect of caregiver type and caregiving intensity on social isolation over the course of survey.

RESULTS

Spousal and adult-child caregivers reported greater social isolation over time, and spousal caregivers exhibited a steeper increase in social isolation from Baseline to Follow-up 1 than adult-child caregivers. Also, an increase in caregiving hours resulted in greater social isolation. Finally, male spousal or adult-child caregivers were more likely to be socially isolated over time than their female counterparts.

DISCUSSION

The findings of this study contribute to the existing literature on caregiving outcomes by demonstrating an association between family caregiving and social isolation. The results indicate a strong need for intervention programs that aim to enhance social connectedness among family caregivers, and especially for those who perform intensive caregiving, are older age, and are from a lower socioeconomic status.

Effect of cohabiting partners on the development of posttraumatic stress symptoms after emergency department visits for stroke and transient ischemic attack

OBJECTIVE

Partners can be beneficial for patients experiencing stressful health events such as a stroke/transient ischemic attack (TIA). During such events, however, partners may exacerbate early distress. The present study tested whether having a cohabiting partner modified the association between patients' early perceptions of threat (e.g., feeling vulnerable, helpless) and longer-term posttraumatic stress symptoms (PTSS).

METHODS

Participants (N = 328) were drawn from an observational cohort study of patients evaluated for stroke/TIA at an urban academic hospital between 2016 and 2019. Participants self-reported emergency department (ED) threat perceptions and PTSS secondary to the stroke/TIA at three days and one month post-event.

RESULTS

Cohabiting partner status modified the association of ED threat with early PTSS. Patients with a cohabiting partner exhibited a positive association between ED threat and early PTSS, B = 0.12, p < .001; those without a cohabiting partner did not, B = 0.04, p = .067. A cohabiting partner was protective only for patients who initially reported low levels of ED threat, as patients with a cohabiting partner who reported low levels of ED threat also had lower early PTSS, B = -0.15, p = .016; at high levels of ED threat, a cohabiting partner was not protective, B = -0.02, p = .68. ED threat was associated with PTSS at one month, B = 0.42, p < .001, but cohabiting partner status did not modify the association.

CONCLUSIONS

ED threat perceptions were positively associated with early PTSS only for patients with a cohabiting partner. For patients who do not initially experience a stroke/TIA event as threatening, cohabiting partners may help patients maintain psychological equanimity.

Exploring changing needs following minor stroke

Medical advances have led to many of the severe consequences of stroke being averted. Consequently, more people are being discharged from hospital following treatment for what is classed as minor stroke. The needs of people with minor stroke have received little research attention. The aim of the current study was to conduct an exploratory prospective needs analysis to document the unmet health, rehabilitation and psychosocial needs of a recently hospitalised minor stroke cohort approximately 2 weeks (T1) and 2 months (T2) post-hospital discharge. An exploratory cohort design was used to explore the unmet health, service and social needs of 20 patients with minor stroke. Participants completed questionnaires (Survey of Unmet Needs and Service Use, Mayo-Portland Adaptability Inventory-4, Exeter Identity Transition Scales, RAND 36-Item Health Survey 1.0) at T1 and T2. Nine participants reported unmet needs at T1 and seven participants reported unmet needs at T2. Between T1 and T2, there was a significant improvement in perceived role limitations due to physical health. Participation in society was significantly better at T2. In conclusion, patients with minor stroke report health, service and social needs that are unmet by existing services. This patient cohort urgently requires co-ordinated services to detect and manage these unmet needs.

Disrupted biographies: making sense of minor stroke after hospital discharge

PURPOSE

To explore how people with minor stroke make sense of the stroke in the first weeks following hospital discharge to home.

MATERIALS AND METHODS

A qualitative descriptive approach using semi-structured interviews with 17 participants with minor stroke at approximately 2 weeks post-hospital discharge was used to explore their experiences of the early stage of recovery. Interview transcripts were analysed using qualitative content analysis.

RESULTS

Three main themes were derived from the analysis 1) Reconciling personal reactions, 2) Emotional introspection after the stroke, and 3) Navigating the social side of stroke.

CONCLUSIONS

Although participants had different experiences of minor stroke, there were common elements. The first weeks post-hospital discharge were a time of questioning and reconciling the stroke for many participants. Adjusting to post-stroke impairments and the impact of these on social participation was also prominent. There is a critical need for education about what to expect prior to discharge from hospital with minor stroke and a designated discharge pathway to avoid the development of secondary post-stroke issues in the community.IMPLICATIONS FOR REHABILITATIONPeople with minor stroke may experience ongoing post-stroke disabilities following discharge home.The transition period is characterised by questioning and reconciling what has happened by people with minor stroke.Information about what to expect prior to discharge from hospital for people with minor stroke and their families is essential.There is a critical need for a designated discharge pathway with follow up for people with minor stroke and their families.

Meeting unmet needs following minor stroke: the SUN randomised controlled trial protocol

Background

Whilst there are comprehensive guidelines for the rehabilitation of people with severe impairments from stroke, there has been less attention on the health and rehabilitation needs of people with minor stroke. Our study will assess whether a new multi-component service pathway using an integrated model based around primary care will reduce unmet need following minor stroke compared with usual care 1 and 3 months post-hospital discharge.

Methods

One hundred ten patients with minor stroke will be recruited within a parallel, randomised controlled trial design comparing a new service pathway and usual care.

The new service pathway will comprise a self-management kit, customised General Practitioner checklist, and a series of minor stroke educational topics. Participants will complete assessments pre-hospital discharge and 1 and 3 months later. The primary outcome measure will be the Survey of Unmet Needs and Service Usage. Secondary outcome measures will include assessments of ability, adjustment and participation; social group connectedness; return to work; health-related quality of life; and perceptions of the new service pathway (intervention group only). Mixed model repeated measures will be used to analyse within and between group differences at each time point. Return to work will be analysed using Chi square tests. Perceptions of the new service pathway will be analysed qualitatively.

Dissemination of results

The project will produce an evidence-based, multicomponent service pathway for minor stroke patients, applicable to other health services nationally and internationally. Dissemination will include publications and presentations.

Trial registration

Prospectively registered - Australian New Zealand Clinical Trials Registry (ACTRN12619000133134p) 30 January 2019.

The lived experience of supporting people with mild stroke

Background: Mild stroke occurrences are rising and in order to comprehensively understand the experience of this health phenomenon, the context in which people with mild stroke live must be explored. Spouses are an important part of the lives of this population, but their experiences are yet to be fully understood.Aims/Objectives: To answer the question: "What is the essence of the mild stroke experience from the perspective of spouses during the first 9-months after acute hospital discharge, in Australia?"Materials and Methods: Qualitative study involving four spouses at 9-months post-acute hospital discharge for their family member. Interpretative phenomenological analysis used to analyze interview transcripts.Results: Two themes identified: (1) Activities gained but time lost, and (2) Small changes but big impacts. The first theme portrays the increase in daily activity that spouses experienced due to caregiving related activities, which impacted on their occupational participation. The second highlights the impact that people with mild strokes' behavioral and emotional changes can have on spouses.Conclusions and Significance: Whilst spouses generally return to their daily routines after a family members' mild stroke, some will experience increased time pressures and occupational disruptions. Health providers should prepare spouses for behavioral and emotional changes in people with mild stroke.

"Just got to live life as it comes": A case study of the spousal-dyad longitudinal mild stroke transitional experience

Objective: To longitudinally explore the transition home for a spousal dyad following mild stroke, in the context of a mild stroke-specific health service. Research Design: A case study approach, using an Interpretative Phenomenological Analysis (IPA), was identified as suitable for this study, as it enabled the essence of the phenomenon to be examined. Method: Participants were purposively chosen from a Randomised Control Trial (RCT), to reflect the average age, gender and marital status of the mild stroke population. The participants were a male (age 64) and his wife (age 62). Participants received the RCT intervention. Semi-structured interviews were completed separately with participants at 1-, 3-, 6- and 9- months post stroke. Results: Two themes were identified: (1) The Unexpected, Undesirable and Short-Lived, and (2) The New 'Normal'. The first theme reflects the confusion, adjustment and adaptation that occurred for the couple, especially during the first month at home. The second represents the couple's journey back to their everyday lives following hospital discharge, but also the questions and changes that remained present at 9-months post-discharge. Conclusions: Themes demonstrate an ongoing process of adjustment and the contextual nature of the transitional experience. Results also indicate the need to ensure that individuals have access to mild-stroke specific information across the transition continuum.

Gateway to Recovery: A Comparative Analysis of Stroke Patients' Experiences of Change and Learning in Norway and Denmark

Objectives

The recovery process is reported by stroke survivors to be a change process fraught with crises and hazard. Interaction with health professionals and others may play a central role in establishing renewed control over life.

Research Questions

(1) How do patients handle and overcome experienced changes after stroke? (2) How do they experience the support to handle these changes during the first year after stroke? (3) How do the similarities and differences transpire in Danish and Norwegian contexts? Methodology. A qualitative method was chosen. Six patients from Denmark and five patients from Norway (aged 25-66) were followed up until one year after stroke, by way of individual interviews. The data were analyzed (using NVivo 11) by means of phenomenological analysis.

Findings

The participants described four main issues in the recovery process that impacted the experienced changes: (i) strategies and personal factors that promote motivation, (ii) the involvement of family, social network, and peers, (iii) professionals' support, and (iv) social structures that limit the recovery process. There was a diversity of professional support and some interesting variations in findings about factors that affected recovery and the ability to manage a new life situation between Central Denmark and Northern Norway. Both Norwegian and Danish participants experienced positive changes and progress on the bodily level, as well as in terms of activity and participation. Furthermore, they learned how to overcome limitations, especially in bodily functions and daily activities at home. Unfortunately, progress or support related to psychosocial rehabilitation was almost absent in the Norwegian data.

"Stuck in a loop of fear": a phenomenological exploration of carers' experiences supporting a spouse with acquired brain injury

PURPOSE

Family caregivers are important to facilitating the rehabilitation of individuals with brain injury. However, research shows spousal carers often reporting poorer health and well-being with psychosocial challenges including increased marital dissatisfaction. This study explores the accounts of participants caring for a spouse with brain injury.

MATERIALS AND METHODS

This study used semi-structured interviewing and interpretative phenomenological analysis.

RESULTS

One theme, "Living in and beyond the loop of fear", with two subheadings is reported. Participants' attempts to manage their fears prominently defined their early caregiving. Fears were aggravated by the vulnerability of their spouse's health which partially owed to brain injury sometimes having no symptoms prior to its onset. Consequently, participants anxiously strove to prevent further harm to their spouse's health due to what they perceived as the continued "hidden" threat of brain injury. Therefore, participants became hypervigilant, leaving themselves vulnerable to burnout. Over time, some participants modified care practices and managed fears using beliefs accepting their limits to protect their spouses' health.

CONCLUSIONS

Findings suggest that beliefs conducive to acceptance helped carers to develop more sustainable, less over-protective, care. Interventions to help carers develop similar beliefs could be provided in therapeutic settings. Recommendations for future research are made. Implications for Rehabilitation Caring for a long-term partner with acquired brain injury has considerable challenges which can threaten an individual's health and well-being. Our research reports on carers' experiences of anxiety which they managed through hypervigilant and overprotective practices which put them at risk of burnout. Consequently, we recommend the promotion of care beliefs that reframe caregiving: recognising the carer's limitations to safeguard a spouse, whilst accepting the vulnerability of the spouse's health. We propose that promoting such principles in therapeutic settings may better equip carers emotionally to provide sustainable care, something which could benefit the carer and spouse's rehabilitation alike.

Stroke survivors' long-term QALY-weights in relation to their spouses' QALY-weights and informal support: a cross-sectional study

Background

Healthcare interventions that have positive effects on the stroke survivors’ health-related quality of life (HRQoL) and quality-adjusted life-years (QALYs) might also have positive effects for their spouses in terms of improved HRQoL and/or reduced spousal informal support. However, knowledge about stroke survivors’ HRQoL and QALY and the consequences for their spouses’ HRQoL and QALY is limited. Therefore, the aim of this study was to describe the HRQoL and QALY-weights in dyads of stroke survivors in comparison with dyads of healthy controls, and to study the relationship between the stroke survivors’ QALY-weights and consequences for spouses in terms of QALY-weight and annual cost of informal support, using a long-term perspective.

Methods

Data on stroke survivors, controls, and spouses were collected from the seven-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). HRQoL was assessed by the SF-36, and the preference-based health state values were assessed with the SF-6D. The magnitude of the support was assessed with a study specific time-diary. An ordinary least squares (OLS) regression was used to estimate the association between stroke survivors’ and spouses’ QALY-weights. A two-part econometric model was used to estimate the association between stroke survivors’ QALY-weights and the time spent and cost of spouses’ informal support.

Results

Cohabitant dyads of 248 stroke survivors’ aged <70 at stroke onset and 245 controls were included in the study. Stroke survivors had lower HRQoL in the SF-36 domains physical functioning, physical role, general health, vitality (P < 0.001), and social functioning (P = 0.005) in comparison with their cohabitant spouses. There was no significant difference in HRQoL for the dyads of controls. The results from the regression analyses showed that lower QALY-weights of the stroke survivors were associated with lower QALY-weights of their spouses and increased annual cost of spousal informal support.

Conclusion

Our results show that the QALY-weights for stroke survivors had consequences for their spouses in terms of annual cost of spousal informal support and QALY-weights. Hence, economic evaluation of interventions that improve the HRQoL of the stroke survivors but ignore the consequences for their spouses may underestimate the value of the intervention.

Long-term QALY-weights among spouses of dependent and independent midlife stroke survivors

Purpose

The aim of this study was to investigate whether the dependency of midlife stroke survivors had any long-term impact on their spouses’ QALY-weights.

Method

Data on stroke survivors, controls, and spouses were collected from the 7-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke. Health-related quality of life was assessed by the SF-36, and the preference-based health state values were assessed with the SF-6D. Spouses of dependent and independent stroke survivors were categorized according to their scores on the modified Rankin Scale. An ordinary least squares regression analysis was used to evaluate whether the dependency of the stroke survivors had any impact on the spouses’ QALY-weights.

Result

Cohabitant dyads of 247 stroke survivors aged <70 at stroke onset and 245 dyads of controls were included in the study. Spouses of dependent stroke survivors (n = 50) reported a significant lower mean QALY-weight of 0.69 in comparison to spouses of independent stroke survivors (n = 197) and spouses of controls, (n = 245) who both reported a mean QALY-weight of 0.77. The results from the regression analysis showed that higher age of the spouse and dependency of the stroke survivor had a negative association with the spouses’ QALY-weights.

Conclusion

The QALY-weights for spouses of dependent midlife stroke survivors were significantly reduced compared to spouses of independent midlife stroke survivors. This indicates that the inclusion of spouses’ QALYs in evaluations of early treatment and rehabilitation efforts to reduce stroke patients’ dependency would capture more of the total effect in dyads of stroke survivors.

Long-term cost of spouses' informal support for dependent midlife stroke survivors

OBJECTIVES

Stroke is a major global disease that requires extensive care and support from society and relatives. The aim of this study was to identify and quantify the long-term informal support and to estimate the annual cost of informal support provided by spouses to their stroke surviving partner.

METHOD

Data were based on the 7-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke. One-third of the spouses stated that they provided support to their stroke surviving partner. The magnitude of the support was assessed with a study-specific time-diary and was estimated for independent and dependent stroke survivors based on the scores of the modified Rankin Scale. To deal with skewed data, a two-part econometric model was used to estimate the annual cost of informal support.

RESULT

Cohabitant dyads of 221 stroke survivors aged <70 at stroke onset were included in the study. Spouses of independent stroke survivors (n = 188) provided on average 0.15 hr/day of practical support and 0.48 hr/day of being available. Corresponding figures for spouses of dependent stroke survivors (n = 33) were 5.00 regarding practical support and 9.51 regarding being available. The mean annual cost of informal support provided for independent stroke survivors was estimated at €991 and €25,127 for dependent stroke survivor.

CONCLUSION

The opportunity cost of informal support provided to dependent midlife stroke survivors is of a major magnitude many years after stroke onset and should be considered in economic evaluations of health care.

Evidence for Ancestral Programming of Resilience in a Two-Hit Stress Model

In a continuously stressful environment, the effects of recurrent prenatal stress (PS) may accumulate across generations and alter stress vulnerability and resilience. Here, we report in female rats that a family history of recurrent ancestral PS facilitates certain aspects of movement performance, and that these benefits are abolished by the experience of a second hit, induced by a silent ischemia during adulthood. Female F4-generation rats with and without a family history of cumulative multigenerational PS (MPS) were tested for skilled motor function before and after the induction of a minor ischemic insult by endothelin-1 infusion into the primary motor cortex. MPS resulted in improved skilled motor abilities and blunted hypothalamic-pituitary-adrenal (HPA) axis function compared to non-stressed rats. Deep sequencing revealed downregulation of miR-708 in MPS rats along with upregulation of its predicted target genes Mapk10 and Rasd2. Through miR-708 stress may regulate mitogen-activated protein kinase (MAPK) pathway activity. Hair trace elemental analysis revealed an increased Na/K ratio, which suggests a chronic shift in adrenal gland function. The ischemic lesion activated the HPA axis in MPS rats only; the lesion, however, abolished the advantage of MPS in skilled reaching. The findings indicate that MPS generates adaptive flexibility in movement, which is challenged by a second stressor, such as a neuropathological condition. Thus, a second “hit” by a stressor may limit behavioral flexibility and neural plasticity associated with ancestral stress.

Patient with stroke: hospital discharge planning, functionality and quality of life

ABSTRACT Stroke still causes high levels of human inability and suffering, and it is one of the main causes of death in developed countries, including Portugal. Objective: analyze the strategies of hospital discharge planning for these patients, increasing the knowledge related to hospitalhome transition, discharge planning processes and the main impact on the quality of life and functionality. Method: integrative literature review using the PICOD criteria, with database research. Results: 19 articles were obtained, using several approaches and contexts. For quality of life, the factors related to the patient satisfaction with care and the psychoemotional aspects linked with functionality are the most significant. Conclusion: during the hospitalization period, a careful hospital discharge planning and comprehensive care to patients and caregivers - in particular the functional and psychoemotional aspects - tend to have an impact on the quality of life of patients.

Spouses of Stroke Survivors Report Reduced Health-Related Quality of Life Even in Long-Term Follow-Up

Background and Purpose—

The consequences for the family of stroke survivor are generally studied in a short-term perspective. The aim of this study was to assess long-term aspects of health-related quality of life among spouses of stroke survivors.

Methods—

Data on stroke survivors, controls, and spouses were collected from the 7-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). The health-related quality of life of spouses was assessed by the Short Form-36, and the characteristics of stroke survivors were assessed using the National Institutes of Health Stroke Scale, the Mini-Mental State Examination, the Hospital Anxiety and Depression Scale, the Barthel Index, and the modified Rankin Scale.

Results—

Dyads of 248 stroke survivors aged <70 at stroke onset and 245 dyads of matched controls were included. Spouses of stroke survivors and spouses of controls had a median age of 64 and 65, respectively; proportion of men was 35% and 34%, respectively. The spouses of stroke survivors reported lower scores in all the mental domains ( P =0.045; P <0.001), as well as in the domains of general health ( P =0.013) and physical role ( P =0.006), compared with the spouses of controls. Predictors of poor physical health of the spouses were their own age and the level of global disability of the stroke survivor. Predictors of poor mental health of the spouses were depressive symptoms, cognitive impairment, and global disability among the stroke survivors.

Conclusions—

The health-related quality of life of spouses of stroke survivors is reduced not only during the first years but also in the long-term perspective.

What Makes Family Caregivers Happy During the First 2 Years Post Stroke?

Background and Purpose—

This study aimed to identify aspects of the caregiving situation contributing to family caregivers’ psychological well-being.

Methods—

Longitudinal cohort study with structured quantitative interviews 1, 3, 6, and 12 months post stroke. A subset of participants also completed surveys 18 and 24 months post stroke. Participants included individuals hospitalized for their first stroke and their family caregivers. Psychological well-being was assessed by the Positive Affect Scale.

Results—

A total of 399 stroke survivor, caregiver dyads completed the 1-year follow-up and 80 dyads completed the second year of follow-up. Using mixed effects modeling for longitudinal data, caregivers reported more psychological well-being when they provided more assistance to stroke survivors who had fewer symptoms of depression, better cognitive functioning, and who had more severe strokes. In addition, caregivers who maintained participation in valued activities had more mastery, gained personally providing care, were in better physical health, were older, and were from Quebec reported more psychological well-being. Caregivers followed for a second year post stroke reported better psychological well-being when caring for stroke survivors with fewer symptoms of depression and more severe strokes and when the caregivers had a greater sense of mastery and gained more personally providing care.

Conclusions—

Our findings contribute to the caregiver intervention development literature by identifying aspects of the caregiving situation that are associated with positive outcomes. Incorporating specific aspects, for example, strategies to enhance caregiver mastery into programs and services offered to caregivers may enhance their positive experiences with providing care and ultimately enhance the sustainability of the caregiving situation.

Advance care planning in stroke: influence of time on engagement in the process

PURPOSE

Individuals who experience stroke have a higher likelihood of subsequent stroke events, making it imperative to plan for future medical care. In the event of a further serious health event, engaging in the process of advanced care planning (ACP) can help family members and health care professionals (HCPs) make medical decisions for individuals who have lost the capacity to do so. Few studies have explored the views and experiences of patients with stroke about discussing their wishes and preferences for future medical events, and the extent to which stroke HCPs engage in conversations around planning for such events. In this study, we sought to understand how the process of ACP unfolded between HCPs and patients post-stroke.

PATIENTS AND METHODS

Using grounded theory (GT) methodology, we engaged in direct observation of HCP and patient interactions on an acute stroke unit and two stroke rehabilitation units. Using semi-structured interviews, 14 patients and four HCPs were interviewed directly about the ACP process.

RESULTS

We found that open and continual ACP conversations were not taking place, patients experienced an apparent lack of urgency to engage in ACP, and HCPs were uncomfortable initiating ACP conversations due to the sensitive nature of the topic.

CONCLUSION

In this study, we identified lack of engagement in ACP post-stroke, attributable to patient and HCP factors. This encourages us to look further into the process of ACP in order to develop open communication between the patient with stroke, their families, and stroke HCPs.

A systematic review of qualitative studies on adjusting after stroke: lessons for the study of resilience

PURPOSE

To synthesize qualitative studies on adjusting after stroke, from stroke survivors' and carers' perspectives, and to outline their potential contribution to an understanding of resilience.

METHODS

A systematic review of qualitative studies in peer reviewed journals from 1990 to 2011 was undertaken. Findings from selected studies were summarized and synthesized and then considered alongside studies of resilience.

RESULTS

Forty studies were identified as suitable. These suggested that the impact of stroke was felt on many dimensions of experience, and that the boundaries between these were permeable. Nor was stroke as an adverse "event" temporally bounded. Adjustment was often marked by setbacks and new challenges over time. Participants identified personal characteristics as key, but also employed practical and mental strategies in their efforts to adjust. Relationships and structural factors also influenced adjustment after stroke.

CONCLUSIONS

The impacts of stroke and the processes of adjusting to it unfold over time. This presents a new challenge for resilience research. Processes of adjustment, like resilience, draw on personal, inter-personal and structural resources. But the reviewed studies point to the importance of an emic perspective on adversity, social support, and what constitutes a "good" outcome when researching resilience, and to a greater focus on embodiment. Implications for Rehabilitation Stroke is a sudden onset condition which for around a third of people has long-term consequences. Stroke can cause a variety of physical and cognitive impairments, some of which may not be obvious to an outsider. As well as physical functioning, stroke can have a profound effect on survivors' sense of self and on their relationships. Stroke survivors' accounts suggest that relationships (including relationships with health care professionals) and structural factors (such as access to health services, employment possibilities and welfare systems) mediate efforts to adjust after stroke. While there is considerable overlap between notions of adjustment and resilience, the experiences of stroke survivors suggest further issues that need to be addressed in order to gain a more comprehensive understanding of resilience.

Revisioning, reconnecting and revisiting: the psychosocial transition of returning home from hospital following a stroke

PURPOSE

This study aimed to investigate and improve understanding of the experiences of patients and their carers during the first month at home following discharge from hospital, thereby enhancing appropriate care from a more informed perspective.

METHOD

In-depth interviews and self-report diaries were used to capture data from 12 patient/carer dyads. Four survivors with marked communication problems were included in this number, two requiring the use of pictures and diagrams to express their views. Interpretative phenomenological analysis (IPA) was used to capture and interpret survivor and carer experiences.

FINDINGS

Three superordinate themes were derived from the data. Stroke survivors and their carers described the first month at home as a very dynamic time, recounting a process that involved revisioning (re-examining their identity and the reality of their new situation, including an awareness of their own mortality), reconnecting (with important relationships and previous activities) and revisiting (their past lives, and the stroke event and hospital experience). These three activities assisted in making and finding sense in their new situation; participants' vision of their lives was revised and revisited as they attempted to reconnect with as much of their past selves and past activities as possible.

CONCLUSIONS

This study contributes to understandings through in-depth individual accounts of the psychosocial transition of returning home. Details of how people make sense of their altered situation can make a valuable contribution to research, and the knowledge base for care provision. Implications for Rehabilitation Supporting people to revision their future can assist with psychosocial transition following a stroke. Assisting patients to reconnect and reintegrate in a way that is meaningful to them is an important part of the rehabilitation support that can be offered by professionals, and can be informed by awareness of their vision of what the future may now hold. Offering people the opportunity to reflect on what has occurred, either verbally or in the form of a diary, can assist adjustment and help people to make sense of their changed situation.

Younger stroke survivors' experiences of family life in a long-term perspective: a narrative hermeneutic phenomenological study

The psychosocial consequences following a stroke are known to be challenging, influencing the stroke survivors' ability to participate in and carry out the taken-for-granted roles and activities in family life. This study explored how living with the consequences of stroke impacted on family life in the late recovery phase, that is, six months or more after stroke onset. Twenty-two stroke survivors aged 20–61 years were interviewed in-depth six months to nine years after stroke onset. The interviews were analyzed applying a narrative, hermeneutic phenomenological approach. The findings revealed challenges that varied with time, from an initial struggle to suffice in and balance the relationships and roles within the family early after the stroke, towards a more resigned attitude later on in the stroke trajectory. The struggles are summarized in two main themes: “struggling to reenter the family” and “screaming for acceptance.” Nonestablished people living with stroke and stroke survivors in parental roles seem to be particularly vulnerable. Being provided with opportunities to narrate their experiences to interested and qualified persons outside the home context might be helpful to prevent psychosocial problems.

Protective factors in patients aged over 65 with stroke treated by physiotherapy, showing cognitive impairment, in the Valencia Community. Protection study in older people (EPACV)

Background

Family function may have an influence on the mental health deterioration of the caregivers of dependent family members and it could have a varying importance on the care of dependents. Little attention has been paid to the preparation of minor stroke survivors for the recovery trajectory or the spouse for the caregiving role. Therefore, this study protocol intends to analyze the influence of family function on the protection of patients with stroke sequels needing physiotherapy in the family environment.

Methods/Design

This is an analytical observational design, prospective cohort study and using a qualitative methodology by means of data collected in the “interviews of life”. The study will be carried out by the Rehabilitation Service at Hospital of Elda in the Valencia Community.

All patients that have been diagnosed with stroke and need physiotherapy treatment, having a dependency grade assigned and consent to participate in the study, will undergo a monitoring of one year in order to assess the predictive factors depending on the dependence of the people affected.

Discussion

Our research aims to analyze the perception of caregivers, their difficulties to work, and the influence of family function. Moreover, it aims to register the perception of the patients with stroke sequel over the care received and whether they feel protected in their family environment.

Determining the needs, priorities, and desired rehabilitation outcomes of young adults who have had a stroke

Background. Guidelines state that young adults' (aged 18–55 years) rehabilitation needs and priorities following stroke are different from older adults'. However, there is a lack of evidence regarding young adults' perspectives of their needs and priorities. Aim. To gain an understanding of young adults' experience of stroke and associated rehabilitation needs, priorities, and desired outcomes. Methods. A qualitative approach was adopted, based on the phenomenology of Merleau-Ponty. Longitudinal data were gathered using unstructured interviews and analysed using phenomenological reduction. Results. Ten young adults took part in up to four interviews over two years. An overarching theme, Embodied Disorientation, and three subthemes: Mortal Body, Situated Body, and Embodied Perception of Difference, described the young adults' experience. A subsequent iterative process enabled tabulation of patient-centred rehabilitation needs, priorities, and outcomes. Conclusion. Rehabilitation professionals can use the evidence-based outcomes table to work with young adults to develop meaningful patient-centred goals and select appropriate interventions which align with identified needs and outcomes throughout the stroke recovery trajectory.

The correlates and course of depression in patients with lacunar stroke: results from the Secondary Prevention of Small Subcortical Strokes (SPS3) study

BACKGROUND

Little is known about post-stroke depression in patients with lacunar stroke due to cerebral small vessel disease. Our objectives were to describe the prevalence of depression, its correlates and to examine the course of depression over time in a cohort of patients with lacunar stroke, the majority of whom had mild functional disability.

METHODS

Depression was determined in participants in the international Secondary Prevention of Small Subcortical Strokes (SPS3) trial which is testing antiplatelet therapies and targets of blood pressure control in patients with lacunar strokes and assessing stroke recurrence and cognitive decline. Depression was evaluated using the Patient Health Questionnaire. Multivariable logistic regression models were fitted to examine the relationship between the covariates of interest and depression. Generalized estimating equations were used to examine the likelihood of depression over time, while accounting for the multiple measurements within each subject.

RESULTS

The prevalence of depression in 2,477 participants at approximately 4 months after stroke was 19%. Older age (OR 0.97; 95% CI 0.96-0.99), male gender (OR 0.62; 95% CI 0.48-0.80) and less cognitive impairment (OR 0.99; 95% CI 0.98-1.00) were independently associated with a lower risk of depression. Functional disability (OR 1.8; 95% CI 1.3-2.4), living with a spouse/family (OR 1.6; 95% CI 1.1-2.3) and risk factors for stroke (OR 1.2; 95% CI 1.0-1.3) were each independently associated with a higher risk of depression. Longitudinal modeling indicated that the likelihood of depression decreased by 1.12 times (95% CI 1.06-1.17) for each 1-year increase in time.

CONCLUSIONS

One fifth of those in the SPS3 trial cohort reported depression that is sustained over time. Although this is lower than the prevalence reported for stroke in general, these results underscore the importance of early screening for post-stroke depression, treatment and follow-up to minimize the negative consequences associated with depression.

Increased residual disability among poststroke survivors and the repercussions for the lives of informal caregivers

PURPOSE

To analyze the associations between increased residual disability among poststroke survivors and the repercussions for their informal caregivers' lives, taking into account the latter's gender and education level.

METHODS

215 stroke survivors (64.5 years; 55.8% men) were recruited by one neurologist from each of the 22 French regions. Katz Index of Independence in Activities of Daily Living (Katz ADL) was mean 9.3, and 54% still had impairments in "more than two of the six neurological domains" of the American Heart Association Stroke Outcome Classification (AHA.SOC): motor, sensory, vision, affect, cognition, and language. The 215 caregivers (57.8 years; 72.1% women) completed a face-to-face questionnaire concerning their social (8 items), material (4 items), and emotional (8 items) repercussions.

RESULTS

Katz ADL and AHA.SOC were significantly related to social repercussions for caregivers. Lack of autonomy among stroke survivors (low Katz ADL) was associated with the material difficulties of most concern to caregivers: "I needed to move house" (odds ratio [OR] 1.16; 95% CI, 1.07-1.27) and "I cannot go out anymore" (OR 1.29; 95% CI, 1.16-1.44). Being a male caregiver was strongly associated with a feeling of injustice (OR 2.53; 95% CI, 1.07-6.00). A low educational level was linked to an increased feeling of fear (OR 2.61; 95% CI, 1.05-6.51) and a greater feeling of isolation (OR 6.49; 95% CI, 1.20-35.02).

CONCLUSION

Increased dependency post stroke leads to impoverishment in the caregiver's social relationships. Evaluating the emotional repercussions, particularly for men, is an important aspect of enabling survivors to continue to live at home. Innovative accompaniment and counseling services should be considered.

Recovering from a stroke: a longitudinal, qualitative study of older Norwegian women

AIM

To illuminate older women's experiences and the characteristics of the recovery process following a stroke.

BACKGROUND

Patients with stroke face serious challenges related to bodily changes, existential aspects and daily life after stroke. Few qualitative longitudinal studies have examined the recovery process from the perspective of the patient. Knowledge about older women's experiences in coping with life after a stroke is limited.

DESIGN

Prospective, longitudinal, case-study design.

METHODS

Six women aged 68-83 suffering from first-time stroke were recruited from two stroke units. Each participant was interviewed in-depth 12-14 times during the first two years post stroke. The interviews addressed how they experienced their body, their self-understanding, daily life and how this had changed over time. Most interviews took place in the participants' homes. Gadamer's philosophical hermeneutics informed the analyses.

RESULTS

Post stroke recovery was slow and complex and evolved through four distinct phases. In the first phase (0-2 months post stroke), the participants' main concerns were their bodily changes; in the second phase (2-6 months), activities of daily life; in the third phase (6-12 months), self-understanding and in the fourth phase (12-24 months), going on with life. The transition between phases was gradual.

CONCLUSION

Recovery from stroke evolves over time through four distinct phases, which differ depending on significant experiences and associated meanings. Psychological and social resources are equally critical in the women's process of recovery.

RELEVANCE TO CLINICAL PRACTICE

The four phases of rehabilitation suggest at what points various concerns require increased therapeutic attention. Psychological and social resources must be vitalised at an early phase similar to bodily resources. This knowledge may assist professionals in offering adequate help throughout the recovery process even beyond the established rehabilitation period.

The role of nursing in the rehabilitation of stroke survivors: an extended theoretical account

This article provides a critique and theoretical extension of a work that sought to describe the contribution of nurses to stroke rehabilitation. At the time, the role of nursing was considered important but therapeutically nonspecific. Stroke nursing research has increased significantly and so has research focusing on the patient experiences of the adjustment and rehabilitation processes following a stroke. These developments provide significant new insights that may refine and extend the original understanding of the role of nursing in stroke rehabilitation. This article proposes an extended theoretical framework of the role of nursing in stroke recovery and rehabilitation.

Family functioning is associated with depressive symptoms in caregivers of acute stroke survivors

OBJECTIVE

To determine whether family functioning is uniquely associated with caregiver depressive symptoms in the immediate aftermath of stroke.

DESIGN

Cross-sectional data from the baseline assessment of an intervention study for stroke survivors and their families.

SETTING

Neurology inpatient service of a large urban hospital.

PARTICIPANTS

Stroke survivors (n=192), each with a primary caregiver. The mean age of stroke survivors was 66 years, and most, 57%, were men (n=110). The mean age of caregivers was 57 years, and 73% (n=140) of the caregivers were women. Eighty-five percent of caregivers were white.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Measures were chosen to assess caregivers' depressive symptoms (Centers for Epidemiologic Studies Depression Scale), family functioning (Family Assessment Device), and additional factors such as health status (Medical Outcomes Study 36-Item Short-Form Health Survey) and stroke survivors' cognitive abilities (modified Mini-Mental State Examination) and functional impairments (FIM and Frenchay Activities Index).

RESULTS

Depressive symptoms were mild to moderate in 14% and severe in 27% of caregivers. Family functioning was assessed as unhealthy in 34% of caregiver-patient dyads. In statistical regression models, caregiver depression was associated with patients' sex, caregivers' general health, and family functioning.

CONCLUSIONS

Forty-one percent of caregivers experienced prominent depressive symptoms after their family member's stroke. Higher depression severity in caregivers was associated with caring for a man, and having worse health and poor family functioning. After stroke, the assessment of caregivers' health and family functioning may help determine which caregivers are most at risk for a depressive syndrome.

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.