Stroke Survivor and Caregiver Perspectives on Post-Stroke Visual Concerns and Long-Term Consequences

Are Optometrists Prepared to Be Involved in Post-Stroke Rehabilitation?

BACKGROUND/OBJECTIVES

Stroke survivors often experience various visual consequences that impact their daily life and may benefit from visual interventions. However, some of these usually go unaddressed as optometrists are rarely included in the post-stroke care pathway. Yet, optometrists are interested in contributing to the care of these patients. This survey evaluated the readiness of optometrists in diagnosing and managing visual disorders specific to stroke survivors.

METHODS

A questionnaire was developed by the researchers, pilot tested by 5 research optometrists and 15 community optometrists, and modified based on the feedback. Practicing optometrists were invited to complete the anonymous online survey through optometric organizations in Canada, the US, Hong Kong, India, and the UK.

RESULTS

Most respondents displayed strong knowledge, but 61.6% indicated that enhancing their knowledge would be helpful. The majority (87%) agreed that stroke is related to an increased incidence of falls. Participants' knowledge regarding the natural history of post-stroke visual disorders was poorer. There were also inconsistencies regarding what optometrists considered ideal interventions and what they undertook in practice. More than 50% of respondents reported that the quality of published evidence on post-stroke visual consequences was low or nonexistent.

CONCLUSIONS

Overall, survey respondents displayed sufficient knowledge. However, there are areas of uncertainty in their knowledge, which in many cases correspond to real gaps in the available evidence. There is a need to identify and remediate these gaps to enable optometrists to deliver quality optometric care as collaborative members of the post-stroke professional team, which would eventually improve the rehabilitation of stroke survivors.

Association between glaucoma and stroke: A bidirectional mendelian randomization study

Purpose

Observational studies have reported positive associations between glaucoma and stroke; however, controversial results exist. Importantly, the nature of the relationship remains unknown since previous studies were not designed to test causality. Therefore, we aimed to investigate the possible causal relationships between glaucoma and stroke.

Methods

Our two-sample Mendelian randomization (MR) encompassed multi-ethnic large-scale genome-wide association studies with more than 20000 cases and 260000 controls for glaucoma, and more than 80000 cases and 630000 controls for stroke. Individual effect estimates for each SNP were combined using the inverse-variance weighted (IVW) method. To avoid potential pleiotropic effects, we adjusted the main results by excluding genetic variants associated with metabolic factors. The weighted median and MR-Egger methods were also used for the sensitivity analysis.

Results

Our MR analysis revealed that glaucoma and its subtypes, including primary open-angle glaucoma and primary angle-closure glaucoma, exhibited no causal role in relation to any stroke (AS), any ischemic stroke (AIS), large-artery atherosclerotic stroke (LAS), small-vessel stroke (SVS), or cardioembolic stroke (CES) across MR analyses (all P ​> ​0.05). The null associations remained robust even after adjusting for metabolic-related traits and were consistent in both the European and Asian populations. Furthermore, reverse MR analyses also did not indicate any significant causal effects of AS, AIS, LAS, or CES on glaucoma risk.

Conclusions

Evidence from our series of causal inference approaches using large-scale population-based MR analyses did not support causal effects between glaucoma and stroke. These findings suggest that the relationship of glaucoma management and stroke risk prevention should be carefully evaluated in future studies. In turn, stroke diagnosis should not be simply applied to glaucoma risk prediction.

Meeting the need for post-stroke vision care in Australia: a scoping narrative review of current practice

PURPOSE

Determine current vision care pathways and practices for stroke survivors in Australia and internationally, focusing on identifying reoccurring gaps in these pathways and unmet care needs.

METHOD

A scoping narrative review was conducted to identify literature related to post-stroke vision care practices and perspectives of patients and health professionals.

RESULTS

A total of 16193 articles were retrieved and 28 deemed eligible for inclusion. Six were Australian, 14 from the UK, four from the USA, and four from within Europe. Post-stroke vision care is largely unstandardized, with substantial inconsistency in the use of vision care protocols, who executes them and at what point in post-stroke care they are utilised. Health professionals and stroke survivors expressed that unmet care needs were primarily a result of lack of education and awareness regarding post-stroke eye problems. Other gaps in care pathways related to the timing of vision assessment, provision of ongoing support, and the integration of eye-care specialists into the stroke team.

CONCLUSION

Further research is needed into current Australian post-stroke vision care to accurately assess whether the needs of stroke survivors are being met. Available evidence indicates that in Australia, there is a requirement for well-defined protocols for vision screening, education, management, and referral of stroke survivors.

Lifespace and occupational participation following acquired brain injury during driving disruption: a mixed methods study

PURPOSE

To examine the lifespace of participants referred for occupational therapy driving assessment following acquired brain injury, to understand how, why, where and with whom access and participation in community-based occupations is occurring during the period of driving disruption.

MATERIALS AND METHODS

The mixed methods, convergent research design utilised a travel diary and Lifespace Mobility Assessment-Composite quantitative elements and semi-structured interviews analysed qualitatively with an interpretive description lens.

RESULTS

Forty-eight participants (56.25% male) aged between 26 and 65 years, left home on average once/day, primarily to conduct instrumental activities of daily living, health management, and social participation community-based occupations. Most reported restricted lifespace (54.2%) requiring assistance to conduct community occupations (68.1%). Support was primarily provided by family members (80.3%). Analysis of semi-structured interviews (n = 15) created three themes that shaped participant occupational experience during driving disruption: (i) changes to occupational participation; (ii) reliance on others for community access and participation; and (iii) trying to move forward.

CONCLUSION

The period of driving disruption following the onset of acquired brain injury is a time of occupational disruption which restricts lifespace, changing how, why, where and with whom participation in community-based occupations occurs. Rehabilitation facilitating occupational adaptation process to enhance community access capacity is indicated.

'If we don't assess the patient's vision, we risk starting at the wrong end': a qualitative evaluation of a stroke service knowledge translation project

BACKGROUND

Visual impairments (VIs) affect 60% of stroke survivors and have negative consequences for rehabilitation and quality of life poststroke. Symptoms of VIs post stroke are difficult to identify for stroke survivors and health care professionals without using a structured vision assessment. In this study, we qualitatively evaluate the implementation outcomes after implementing a structured visual assessment with the Competence, Rehabilitation of Sight after Stroke Vision (KROSS) assessment tool in stroke care services.

METHODS

This is a qualitative study comprising four focus group interviews. The health care personnel (HCP) involved in the implementation or with experience using the KROSS assessment tool in practice were invited to participate. We used Proctor et al.'s definitions of implementation outcomes as a framework, which informed the interview guide and analysis. We used a deductive - inductive content analysis, as described by Elo and Kyngäs.

RESULTS

The participants found the structured vision assessment with the KROSS tool as being acceptable; they expressed a motivation and intention to use the new routine in practice. They believed it was important to assess their patient's visual function because it influenced other rehabilitation activities and activities of daily living. Most of the participants reported having adopted the vision assessment in their practice, except for those participants from the home care services who experienced that they have few stroke survivors to follow up on. The assessment was believed to be more appropriate to perform within the rehabilitation services where there is more of a focus on functional assessments. Although vision assessment was new to all the participants, they felt that they improved their vision assessment skills by regularly using the assessment tool. Together with sufficient instructions and supervision, they believed that vison assessment was feasible for their practise. Including the vison assessment in the existing routines and systems was important to promote sustainable implementation.

CONCLUSION

Implementing a structured vision assessment with the KROSS tool in health care services was experienced as acceptable and feasible. The new routine led to increased attention towards poststroke VIs and increased collaboration with vision experts. Tailoring the routine to each practice and how they organise their work can support the integration of a vision assessment in their routines. To promote better vision care poststroke vision assessment and follow up should be included in the stroke care pathways.

Development of a DIY rehabilitation device for lower limb weakness in acute to subacute ischemic stroke

Many patients have significantly lower limb weakness after getting a stroke. Continuous regular physical therapy is essential to promote the improvement of the weakness and overall outcomes. Home rehabilitation provides motivation and enhances regular rehabilitation in stroke patients. The Do-It-Yourself (DIY) medical device is developed to fill the gap of unmet medical management needs and becomes increasingly applied in rehabilitation. The DIY device should support the concept of home rehabilitation in stroke patients. We designed and developed a low-cost, easy-to-use, DIY rehabilitation device to promote regular physical therapy in stroke patients with lower limb weakness. The methods and rationale of device development were described. The feasibility and safety of the device were also evaluated.•The DIY rehabilitation device for the lower limb is convenient and easy to assembly.•Regular home rehabilitation is enhanced with the DIY rehabilitation device.•The device is feasible and safe for physical therapy in stroke patients with lower limb weakness.

Barriers and Facilitators to Engagement in Rehabilitation Among Stroke Survivors: An Integrative Review

BACKGROUND

Approximately 795,000 Americans experience a new or recurrent stroke every year, and it remains one of the leading causes of disability worldwide. Patient engagement in rehabilitation and physical activity has been associated with improvements in functional outcomes during inpatient rehabilitation. There is limited knowledge of the barriers and facilitators to patients' engagement in stroke rehabilitation.

METHODS

An integrative review with a systematic approach was conducted to explore the current available literature on barriers and facilitators to patient engagement in stroke inpatient rehabilitation.

RESULTS

Twenty-five studies were included in the final review. Four major themes described the identified barriers and facilitators: (1) stroke impact, (2) self-efficacy, (3) therapeutic relationship, and (4) motivating factors. Individualized patient-centered goal setting was a commonly studied intervention found to successfully increase engagement.

CONCLUSION

Engagement in stroke rehabilitation is associated with improved patient outcomes. Using the identified themes from this review, nurses can develop focused interventions aimed at reducing barriers and increasing stroke patient engagement.

Barriers and facilitators to the implementation of a structured visual assessment after stroke in municipal health care services

BACKGROUND

Stroke is a leading cause of disability worldwide. Visual impairments (VIs) affect 60% of stroke survivors, and have negative consequences for rehabilitation and post-stroke life. VIs after stroke are often overlooked and undertreated due to lack of structured routines for visual care after stroke. This study aims to identify and assess barriers and facilitators to the implementation of structured visual assessment after stroke in municipal health care services. The study is part of a larger knowledge translation project.

METHODS

Eleven leaders and municipal interdisciplinary health care professionals participated in qualitative interviews. During two workshops, results from the interviews were discussed with 26 participants from municipal health care services and user representatives. Data from interviews and workshops were collected before the intervention was implemented and analyzed using content analysis.

RESULTS

The analysis identified individual and contextual barriers and facilitators. The individual barriers were related to the participants' experiences of having low competence of visual functions and vision assessment skills. They considered themselves as generalists, not stroke experts, and some were reluctant of change because of previous experiences of unsuccessful implementation projects. Individual facilitators were strong beliefs that including vision in stroke care would improve health care services. If experienced as useful and evidence based, the new vision routine would implement easier. Contextual barriers were experiences of unclear responsibility for vision care, lack of structured interdisciplinary collaboration and lack of formal stroke routines. Time constraints and practical difficulties with including the vision tool in current medical records were also expressed barriers. Contextual facilitators were leader support and acknowledgement, in addition to having a flexible work schedule.

CONCLUSIONS

This study shows that improving competence about VIs after stroke and skills in assessing visual functions are particularly important to consider when planning implementation of new vision routines in municipal health care services. Increased knowledge about the consequences of living with VIs after stroke, and the motivation to provide best possible care, were individual facilitators for changing clinical practice. Involving knowledge users, solutions for integrating new knowledge in existing routines, along with easily accessible supervision in own practise, are essential facilitators for promoting a successful implementation.

Impact of visual impairment following stroke (IVIS study): a prospective clinical profile of central and peripheral visual deficits, eye movement abnormalities and visual perceptual deficits

AIM

This study evaluates the spectrum of visual impairment in stroke survivors.

METHODS

The Impact of Visual Impairment after Stroke (IVIS) study is a multi-centre, acute stroke unit, prospective epidemiology study. Comprehensive visual examination was offered to all stroke survivors.

RESULTS

1500 stroke admissions were recruited. 1204 stroke survivors had visual assessment. Reduced central vision was documented in 529, visual field loss in 308, ocular motility abnormalities in 533 stroke survivors, visual perception deficits in 59 stroke survivors and visual inattention in 315 stroke survivors. About half, regardless of visual impairment type, were visually asymptomatic. Recovery, whether full or partial, was best for central vision, ocular motility abnormalities and visual perception deficits (about 70% improvement) occurring over a mean follow-up period of 2-3 months.

CONCLUSIONS

Incidence of impaired central vision, visual field loss, ocular motility disorders and visual inattention was 29.4%, 24.8%, 39.3% and 26.2% respectively. Visual impairment was more likely to occur in more severe stroke and older stroke survivors. Asymptomatic cases raise concerns for acute stroke units where robust specialist vision screening is not routine. Those with partial/no recovery require specialist follow-up and management whilst the wide range of abnormalities highlight the need for specialist visual assessment acutely.Implications for rehabilitationVisual impairment is a common consequence of stroke.Incidence of visual impairment is about 60%.Significant numbers of stroke survivors are visually asymptomatic, highlighting the need for standardised vision assessments.Many stroke survivors have persistent long-term visual impairment, necessitating referral and access to specialist eye care services.

Use of the ICD-10 vision codes to study ocular conditions in Medicare beneficiaries with stroke

BACKGROUND

Ocular conditions are common following stroke and frequently occur in combination with pre-existing ophthalmologic disease. The Medicare International Statistical Classification of Diseases and Related Health Problems (ICD-10) coding system for identifying vision related health conditions provides a much higher level of detail for coding these complex scenarios than the previous ICD-9 system. While this new coding system has advantages for clinical care and billing, the degree to which providers and researchers are utilizing the expanded code structure is unknown. The purpose of this study was to describe the use of ICD-10 vision codes in a large cohort of stroke survivors.

METHODS

Retrospective cohort design to study national 100% Medicare claims files from 2015 through 2017. Descriptive data analyses were conducted using all available ICD-10 vision codes for beneficiaries who had an acute care stay because of a new stroke. The outcome of interest was ≥1 ICD-10 visual code recorded in the claims chart.

RESULTS

The cohort (n = 269,314) was mostly female (57.1%) with ischemic stroke (87.8%). Approximately 15% were coded as having one or more ocular condition. Unspecified glaucoma was the most frequently used code among men (2.83%), those over 85+ (4.80%) and black beneficiaries (4.12%). Multiple vision codes were used in few patients (0.6%). Less than 3% of those in the oldest group (85+ years) had two or more vision codes in their claims.

CONCLUSIONS

Ocular comorbidity was present in a portion of this cohort of stroke survivors, however the vision codes used to describe impairments in this population were few and lacked specificity. Future studies should compare ophthalmic examination results with billing codes to characterize the type and frequency of ocular comorbidity. It important to understand how the use of ICD-10 vision codes impacts clinical decision making, recovery, and outcomes.

"Invisible" visual impairments. A qualitative study of stroke survivors` experience of vision symptoms, health services and impact of visual impairments

BACKGROUND

Visual impairments (VIs) have a negative impact on life and affect up to 60% of stroke survivors. Despite this, VIs are often overlooked. This paper explores how persons with VIs experience vision care within stroke health services and how VIs impact everyday life the first 3 months post stroke.

METHODS

Individual semi-structured interviews were conducted with 10 stroke survivors 3 months post stroke, and analyzed using qualitative content analysis.

RESULTS

The main theme, "Invisible" visual impairments, represents how participants experience VIs as an unknown and difficult symptom of stroke and that the lack of attention and appropriate visual care leads to uncertainty about the future. VIs were highlighted as a main factor hindering the participants living life as before. The lack of acknowledgement, information, and systematic vision rehabilitation leads to feelings of being unsupported in the process of coping with VIs.

CONCLUSION

VIs are unknown symptoms pre stroke and sequelas after stroke that significantly affect everyday life. VIs and vision rehabilitation needs more attention through all phases of stroke health services. We request a greater awareness of VIs as a presenting symptom of stroke, and that visual symptoms should be included in stroke awareness campaigns. Further, we suggest increased competence and standardized evidence-based clinical pathways for VIs to advance all stroke health services including rehabilitation in order to improve outcomes and adaptation to future life for stroke survivors with VIs.