Disagreement in patient and carer assessment of functional abilities after stroke

A Systematic Quality Review of Single-Case Experimental Designs Using Acceptance and Commitment Therapy in Adult Clinical Populations

Recent publications within Contextual Behavioral Science provided a rationale for the expansion of intervention efficacy research using methods that capture idiographic factors and processes. We conducted a systematic review of the use and quality of single-case experimental designs (SCED) within the Acceptance and Commitment Therapy (ACT) literature in adult clinical populations. The systematic review was conducted according to PRISMA guidelines and the databases CINAHL, MEDLINE, PsycINFO, PsycArticles and OpenGrey were searched for peer-reviewed articles. Further studies were sought through review of reference lists of all full text studies. Studies were assessed against What Works Clearinghouse (WWC) single-case design standards. Twenty-six studies met eligibility criteria and were conducted within research teams all implementing multiple-baseline designs. Twenty-four studies did not meet WWC standards with most failing to ensure a degree of concurrence across participants. The extent of randomisation methods was also captured. The review highlights the sparsity of SCEDs within ACT literature in clinical populations and current methodological practices. Limitations of the review and implications for future research are discussed.

Samarasekera N, Lerpiniere C, Perry LA, Moullaali TJ, J.M. Loan J, Wardlaw JM, Al‐Shahi Salman R. Association between Computed Tomographic Biomarkers of Cerebral Small Vessel Diseases and Long-Term Outcome after Spontaneous Intracerebral Hemorrhage

OBJECTIVE

A study was undertaken to assess whether cerebral small vessel disease (SVD) computed tomographic (CT) biomarkers are associated with long-term outcome after intracerebral hemorrhage.

METHODS

We performed a prospective, community-based cohort study of adults diagnosed with spontaneous intracerebral hemorrhage between June 1, 2010 and May 31, 2013. A neuroradiologist rated the diagnostic brain CT for acute intracerebral hemorrhage features and SVD biomarkers. We used severity of white matter lucencies and cerebral atrophy, and the number of lacunes to calculate the CT SVD score. We assessed the association between CT SVD biomarkers and either death, or death or dependence (modified Rankin Scale scores = 4-6) 1 year after first-ever intracerebral hemorrhage using logistic regression, adjusting for known predictors of outcome.

RESULTS

Within 1 year of intracerebral hemorrhage, 224 (56%) of 402 patients died. In separate models, 1-year death was associated with severe atrophy (adjusted odds ratio [aOR] = 2.54, 95% confidence interval [CI] = 1.44-4.49, p = 0.001) but not lacunes or severe white matter lucencies, and CT SVD sum score ≥ 1 (aOR = 2.50, 95% CI = 1.40-4.45, p = 0.002). Two hundred seventy-seven (73%) of 378 patients with modified Rankin Scale data were dead or dependent at 1 year. In separate models, 1-year death or dependence was associated with severe atrophy (aOR = 3.67, 95% CI = 1.71-7.89, p = 0.001) and severe white matter lucencies (aOR = 2.18, 95% CI = 1.06-4.51, p = 0.035) but not lacunes, and CT SVD sum score ≥ 1 (aOR = 2.81, 95% CI = 1.45-5.46, p = 0.002).

INTERPRETATION

SVD biomarkers on the diagnostic brain CT are associated with 1-year death and dependence after intracerebral hemorrhage, independent of known predictors of outcome. ANN NEUROL 2021;89:266-279.

Haematopoietic stem cell transplantation for severe combined immunodeficiency: Long-term health outcomes and patient perspectives

AIM

To examine the long-term follow-up and health outcomes of patients who have undergone haematopoietic stem cell transplant (HSCT) for severe combined immunodeficiency (SCID).

METHODS

Through a structured questionnaire, we examined follow-up arrangements and long-term health outcomes in 22 children who have had a successful HSCT for SCID during the period of 1984-2012 at the Sydney Children's Hospital, Sydney, Australia.

RESULTS

Most children considered themselves healthy and 'cured' from SCID. Whilst many children enjoy relatively good bio-social health outcomes, specific negative health outcomes and absenteeism from school were perceived negatively. Two-thirds of children see their general practitioner or specialist regularly; however, there did not appear to be consistency with the nature of this follow-up.

CONCLUSION

The findings from our study highlight the complex bio-psychosocial health needs of post-HSCT SCID children and encourage SCID centres to consider a multidisciplinary approach to their follow-up. Further studies into the determinants of patients' perceptions of their health are needed.

Differences between patient and proxy reports in the assessment of disability after stroke

Objective : To determine whether the assessment of disability level including basic activities of daily living (ADL) and instrumental ADL varies between patients' and proxy respondents' reports, and to explore the factors influencing proxy agreement.

Design : Patient—proxy agreement study.

Setting : Hospital settings.

Subjects : Fifty-two stroke patients with mild or without cognitive impairments and their primary caregivers voluntarily participated in this study.

Main measures : The self-administered versions of the Barthel Index and Frenchay Activities Index were completed by the patients and their proxy respondents concurrently, yet separately, to assess the level of disability.

Results : The proxy agreement on total scores of the self-administered Barthel Index and self-administered Frenchay Activities Index demonstrated moderate to good agreement (self-administered Barthel Index: intraclass correlation coefficient (ICC) = 0.71; self-administered Frenchay Activities Index: ICC = 0.6). There were no significant differences between patient and proxy reports on self-administered Barthel Index and self-administered Frenchay Activities Index scores (paired

t = —0.22, P = 0.83; paired t = 0.88, P = 0.39, respectively). However, limits of agreement of patient and proxy reports on the self-administered Barthel Index and self-administered Frenchay Activities Index were notable. Stepwise regression analysis found no significant variables associated with proxy agreement.

Conclusions : These results indicate that it is appropriate for research purposes, but not appropriate for clinical usage, to use proxy reports to measure disability levels in patients with stroke. Furthermore, the two methods should not be used interchangeably to monitor patients because of the wide limits of agreement between patient and proxy reports on the self-administered Barthel Index and self-administered Frenchay Activities Index.

Measures used to assess burden among caregivers of stroke patients: a review

Objective: To describe measures used to evaluate the burden of caregiving experienced by caregivers of stroke patients and their clinimetric properties.

Design: A review of the literature was conducted to examine burden scales with regard to concept, feasibility, internal consistency, validity, reliability and responsiveness.

Results: The literature search resulted in 45 measures of caregiver outcomes, including 16 different measures of caregiver burden. About half of the scales were used only once and were not further described. Nearly all instruments measure the various dimensions of burden (competency, negative feelings, social relations, participation problems, physical and mental health and economic aspects), but not in the same proportions. Most measures showed good internal consistency, and validity was demonstrated for all measures except one. However, not much is known about the reliability and responsiveness of these measures.

Conclusions: No measure has proven superiority above others. Future research should focus on comparisons between existing instruments and on their reliability and responsiveness.

Reporting of neuropsychological dysfunction remains discrepant between individuals with traumatic brain injury and their close others up to five years post-injury

PURPOSE

The degree to which individuals with traumatic brain injury (TBI) and their close others share a common understanding and experience of post-injury neuropsychological changes is currently unclear. The aim of this preliminary study was to longitudinally examine levels of agreement between self and close other reports of neuropsychological dysfunction following TBI and explore factors associated with these agreement levels.

METHOD

Sixty-three people with TBI and their nominated close others independently completed the Structured Outcome Questionnaire at 1- and 5-years post-injury, reporting whether the person with TBI was experiencing any negative cognitive, behavioural or emotional changes compared to pre-injury.

RESULTS

Agreement levels between pair members ranged from chance to approximately 75% across neuropsychological domains and did not significantly change over 1- and 5-year time points. In the case of pair disagreement, close others were generally more likely to report difficulties. Pair disagreement was significantly associated with close other anxiety.

CONCLUSIONS

Agreement between self and close others remains limited up to 5-years post-injury which questions the practice of using these reports interchangeably in research and clinical practice. Preliminary findings suggest some association between pair disagreement and close other psychological function; however, further research is warranted. Implications for Rehabilitation Reporting of neuropsychological dysfunction between individuals with TBI and their close others is not sufficiently reliable to warrant interchangeable use within research or clinical practice. Including both individuals with TBI and their close others in clinical assessments will facilitate a more holistic understanding of the client's difficulties and their relationships with those close to them. Preliminary findings indicate that disagreement between individuals with TBI and their close others may be associated with close other anxiety. Clinicians should be aware of the potential for disagreement to impact on the psychological health of close others.

Community Reintegration After Stroke

A systematic review of the literature from 1970-2002 was conducted to highlight the issues facing stroke survivors and their families upon integration into the community. Areas of interests were social support, caregiver burden and depression, family interactions, family education intervention, social and leisure activities post stroke, and leisure therapy. Four studies were selected for detailed reviews of the effectiveness of social support, 10 studies for family education intervention, and 3 studies for leisure therapy post stroke. There was evidence that improved social support as an intervention improves outcomes and that an active educational-counseling approach has a positive impact on family functioning post stroke. However, consensus regarding leisure therapy was not achieved. This article also stresses the impact of caring for a stroke survivor and the effect it has on family functioning and caregiver burden.

Supported cognitive-behavioural self-help versus treatment-as-usual for depressed informal carers of stroke survivors (CEDArS): study protocol for a feasibility randomized controlled trial

BACKGROUND

Increased life expectancy has resulted in a greater provision of informal care within the community for patients with chronic physical health conditions. Informal carers are at greater risk of poor mental health, with one in three informal carers of stroke survivors experiencing depression. However, currently no psychological treatments tailored to the unique needs of depressed informal carers of stroke survivors exist. Furthermore, informal carers of stroke survivors experience a number of barriers to attending traditional face-to-face psychological services, such as lack of time and the demands of the caring role. The increased flexibility associated with supported cognitive behavioral therapy self-help (CBTsh), such as the ability for support to be provided by telephone, email, or face-to-face, alongside shorter support sessions, may help overcome such barriers to access. CBTsh, tailored to depressed informal carers of stroke survivors may represent an effective and acceptable solution.

METHODS/DESIGN

This study is a Phase II (feasibility) randomized controlled trial (RCT) following guidance in the MRC Complex Interventions Research Methods Framework. We will randomize a sample of depressed informal carers of stroke survivors to receive CBT self-help supported by mental health paraprofessionals, or treatment-as-usual. Consistent with the objectives of assessing the feasibility of trial design and procedures for a potential larger scale trial we will measure the following outcomes: a) feasibility of patient recruitment (recruitment and refusal rates); (b) feasibility and acceptability of data collection procedures; (c) levels of attrition; (d) likely intervention effect size; (e) variability in number, length and frequency of support sessions estimated to bring about recovery; and (f) acceptability of the intervention. Additionally, we will collect data on the diagnosis of depression, symptoms of depression and anxiety, functional impairment, carer burden, quality of life, and stroke survivor mobility skill, self-care and functional ability, measured at four and six months post-randomization.

DISCUSSION

This study will provide important information for the feasibility and design of a Phase III (effectiveness) trial in the future. If the intervention is identified to be feasible, effective, and acceptable, a written CBTsh intervention for informal carers of stroke survivors, supported by mental health paraprofessionals, could represent a cost-effective model of care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN63590486.

Optimising outcome assessment to improve quality and efficiency of stroke trials

Substantial progress has been made in treatment of stroke and much of this has been driven by large scale, multi-centre, randomised controlled trials. Although stroke is a frequent cause of mortality, stroke-related disability and functional decline is of equal or greater concern to patients and carers. Thus, to prove efficacy of an intervention for stroke, we need robust methods of describing recovery. Various functional assessment scales are available, the tool recommended as trial end point by many specialist societies and regulatory authorities is the modified Rankin Scale (mRS). We will use the mRS as exemplar to discuss contemporary research around functional assessment for stroke trials, including recent work around structured assessments, assessor training and end point adjudication panels. We will present an overview and critique of these studies and give examples where strategies to improve mRS assessment are impacting on the quality of stroke clinical trials.

The association between discrepancy in illness representations on distress in stroke patients and carers

BACKGROUND

To investigate the association between the illness representations of recently diagnosed stroke patients and their carers and distress in the months after stroke.

METHOD

Forty-two stroke survivors and their carers were assessed at 3 months and 32 couples returned data at 6 months after stroke. Patients and carers completed the Illness Perceptions Questionnaire-Revised, Barthel Index, Significant Others Scale and General Health Questionnaire. Analyses were conducted using the Actor-Partner Interdependence Model.

RESULTS

Carers were more pessimistic than patients about the symptoms, timeline and consequences of the stroke. Patient distress was associated with both patient and carer illness representations at Time 1, and their own illness representations and discrepancy in the illness representations of patients and carers at Time 2. Carer distress was associated with their own illness representations at Time 1, but not the patient's illness representations. Discrepant illness representations were associated with higher carer distress at Time 1 but not Time 2.

CONCLUSION

Illness representations of stroke patients and carers have implications for adjustment for both partners. It is important to understand couples' views of stroke, as discrepancy was as strongly associated with patient and carer distress as was physical disability.

The palliative care needs of acute stroke patients: a prospective study of hospital admissions

BACKGROUND

despite a mortality rate of approximately 30% in acute stroke, little is known about the palliative care needs of this group of patients.

DESIGN

prospective study of 191 acute stroke patients admitted to hospital in England. Biographical, medical and stroke-related data were collected. Participants completed the Sheffield Profile for Assessment and Referral to Care (SPARC), a screening tool for referral to specialist palliative care.

FINDINGS

over 50% reported moderate to significant fatigue-related problems. Approximately 50% reported symptom-related problems (e.g. pain) or psychological distress (e.g. anxiety). Approximately 25% had concerns about death or dying, and 66% had concerns about dependence and disability. Over 50% were worried about the impact of stroke on family members. There were significant main effects of dependence (Barthel Index) (F(1,123) = 12.640 P = 0.001) and age (F(4,123) = 3.022 P = 0.020), and a significant three-factor interaction between dependence, age and co-morbidities (F(9,123) = 2.199 P = 0.026) in predicting total SPARC scores.

CONCLUSIONS

acute stroke patients have a high prevalence of palliative care needs. Acute stroke services should use the SPARC for needs assessment. Priority for assessment should be given to patients with a score of <15/20 on the Barthel Index, a tool already used in most stroke services.

Rehabilitation of stroke patients needs a family-centred approach

PURPOSE

To highlight the importance of the spouse in stroke rehabilitation. Stroke not only affects the patients, but also their families, but rehabilitation practice is still primarily focused on the patient only.

METHOD

Analysis of the position of the spouse and possible consequences of stroke for the spouse, based on the literature.

RESULTS

Three roles of spouses are described: (i) the role of caregiver, as the spouse often provides extensive and comprehensive care for the patient; (ii) the role of client, as this informal care may lead to physical and emotional strain; and (iii) the role of family member, as the stroke affects the interpersonal relationships within the family system, not least the emotional and sexual relationship between the partners. This analysis provides an understanding of problems experienced by spouses as roles conflict and identifies topics for assessment and interventions directed at the spouse in the acute phase, rehabilitation phase and chronic phase of stroke.

CONCLUSION

We support a family-centred approach in which the strengths and needs of all family members, the patient with stroke included, are considered throughout all phases of the rehabilitation process.

Experiences and resistance strategies utilized by fathers of children with cancer

This study examines the experiences of fathers of children diagnosed with cancer. In this grounded theory study, participating fathers were qualitatively interviewed using a theoretical sampling approach. Results indicate fathers to be profoundly affected by their child's condition of cancer. Fathers' experiences include isolation and heightened sadness and uncertainty. Paternal roles comprise providing family support, sufficient resources, and seeking to maintain family stabilization. Post-diagnosis lived experience is described to hold new meaning as fathers reconcile the presence of childhood cancer within the life of their child and family. Strategies of resistance are demonstrated as fathers combat the devastating impacts of cancer through a commitment to family integration, healthy personal lifestyle and attitudes, support seeking, spirituality, and reframing of priorities. An emerging model is presented, as are implications for practice and recommendations.

Proxy and self-report agreement on the Stroke and Aphasia Quality of Life Scale-39

BACKGROUND AND PURPOSE

Health related quality of life outcomes are increasingly used to measure the effectiveness of stroke interventions. People with severe aphasia after stroke may be unable to self-report on such measures, necessitating the use of proxy respondents. We explored the level of agreement between people with aphasia (PWA) and their proxies on the Stroke and Aphasia Quality of Life Scale (SAQOL-39) and whether this agreement is influenced by demographic variables and proxy levels of depression and carer strain.

METHODS

People with chronic aphasia (> or = 6 months post stroke) were recruited through the UK national charity for PWA. They were interviewed on the SAQOL-39 and their nominated proxies were interviewed on the SAQOL-39, the General Health Questionnaire and the Caregiver Strain Index. Proxy respondents had to be > or = 18 years of age, see the person with aphasia at least twice a week and have no known severe mental health problems or cognitive decline.

RESULTS

50 of 55 eligible pairs (91%) took part in the study. Proxies rated PWA as more severely affected than PWA rated themselves. The SDs of the difference scores were large and the difference was significant for three of the four SAQOL-39 domains and the overall mean (p < or = 0.01). However, the bias as indicated by effect sizes was small to moderate (0.2-0.5). The strength of the agreement was excellent for the overall SAQOL-39 and the physical domain (intra-class correlation coefficient ICC 0.8), good for the psychosocial and communication domains (0.7) and fair for the energy domain (0.5). Demographic variables and proxy's mood and carer strain did not affect the level of agreement.

CONCLUSIONS

For group comparisons, proxy respondents who are in frequent contact with people with chronic aphasia can reliably report on their health related quality of life, using the SAQOL-39. Although there are significant differences between PWA and proxy responses, the magnitude of this difference is small to moderate.

Pain and depression in caregivers affected their perception of pain in stroke patients

OBJECTIVES

Informal caregivers often serve as proxy raters of Health-Related Quality of Life (HRQL) when patients cannot report on their own behalf. Caregiver depression has been associated with bias in proxy ratings, but few studies have examined the role of caregiver pain. The aim of this study was to determine if caregiver depressive symptoms and/or pain systematically affected patient-proxy agreement on patient HRQL after stroke.

STUDY DESIGN AND SETTINGS

Secondary data analysis of 95 stroke patients and their caregivers (dyads) at 6 months poststroke. Caregiver depressive symptoms were measured by Center for Epidemiologic Studies Depression Rating Scale, and pain was measured using EQ-5D. Using multivariate regression, we examined the effect of caregiver depressive symptoms and pain on patient-proxy difference scores on Health Utilities Index 3 (HUI3) attributes and Short Form-36 domains of vitality and social functioning.

RESULTS

Caregiver depressive symptoms and pain were associated with significant differences in patient-proxy scores on HUI3 pain (P<0.05). Depressed caregivers underestimated pain experienced by patients, and caregivers with pain overestimated patient pain. Additionally, an interaction between caregiver depressive symptoms and pain was identified.

CONCLUSION

Presence of pain and depressive symptoms in caregivers can significantly affect perceptions of pain in stroke patients. Results suggest that caregivers with pain and/or depression may provide more biased proxy assessments of pain.

Concerns and anticipated challenges of family caregivers following participation in the neuropsychological feedback of stroke patients

Forty-five family caregivers participated in the feedback session on the neuropsychological test results of their close ones, victims of stroke. Following the feedback, the caregivers were presented with an open-ended list of concerns regarding the patients' level of functioning and care needs, and were asked to identify the concerns which they had and the challenge that they represented to them. A hierarchy of concerns was established based upon their frequency and the challenge that they represented. Results indicated that "making sure that the patient is safe at all times", "knowing what his/her future needs will be", "knowing what to do in specific situations in which the patient is unable to perform the task independently" and "dealing with the emotional aspects of the patient" are the caregivers' most prominent concerns. The hierarchy of concerns is discussed from the perspective of its relevance to clinical work and the need for clinicians to incorporate it in plans for rehabilitation.

Outcomes among family caregivers of aphasic versus nonaphasic stroke survivors

Adverse consequences are known to occur in family members responsible for providing care to stroke survivors. However, the differential effect of aphasic versus nonaphasic stroke on caregivers has not been well studied. This study compares selected outcomes (e.g., perceived task difficulty, depressive symptoms, and other negative stroke-related outcomes) among caregivers of aphasic (n = 46) and nonaphasic (n = 113) stroke survivors. Results indicated that caregivers of aphasic survivors perceived greater difficulty with tasks and had more negative stroke-related outcomes than caregivers of nonaphasic survivors. Communication with the survivor was rated as most upsetting and difficult by caregivers in the aphasic group, followed by managing behaviors. Lack of time for family and friends was evident. Female caregivers and caregivers of survivors with self-care deficits also perceived greater difficulty with tasks and negative outcomes. Comprehensive assessment of the unique needs of caregivers of aphasic survivors is suggested for more individualized nursing interventions.

Critical Appraisal and Review of the Rankin Scale and Its Derivatives

BACKGROUND AND PURPOSE

Efforts to reduce stroke burden require accurate assessment of outcomes in order to compare treatments. The Rankin Scale and its derivatives, the Modified Rankin Scale and the Oxford Handicap Scale, taken together, are among the most common outcome measures that have been used in stroke research. The aim of this study was to perform a critical appraisal of the clinimetric properties of these scales. It was also planned to review the use of these scales in a selection of articles to illustrate concerns raised by the critical appraisal.

SUMMARY OF REVIEW

A literature search was performed using electronic databases to locate relevant articles about the reviewed scales. The scales were appraised using a structured format regarding the following properties: purpose, development, presentation, language, method of administration, content validity, face validity, feasibility, construct validity, reliability, responsiveness, and generalizability. There are concerns in each of the appraised areas regarding the clinimetric properties of these scales.

CONCLUSION

Further work is needed to improve the clinimetric properties of the reviewed scales to ensure that they are more useful tools in determining the outcome of stroke. Alternatively, a newer global outcome scale with improved clinimetric properties may be a better option for future stroke research.

An evidence-based review of stroke rehabilitation

A comprehensive evidence-based review of stroke rehabilitation was created to be an up-to-date review of the current evidence in stroke rehabilitation and to provide specific conclusions based on evidence that could be used to help direct stroke care at the bedside and at home. A literature search using multiple data-bases was used to identify all trials from 1968 to 2001. Methodological quality of the individual randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) quality assessment scale. A five-stage level-of-evidence approach was used to determine the best practice in stroke rehabilitation. Over 403 treatment-based articles investigating of various areas of stroke rehabilitation were identified. This included 272 randomized controlled trials.

Further evidence for the agreement between patients with stroke and their proxies on the Frenchay Activities Index

OBJECTIVE

To determine item, subscale and total score agreement on the Frenchay Activities Index (FAI) between stroke patients and proxies six months after discharge from rehabilitation.

DESIGN

Prospective study design.

SETTING/SUBJECTS

Fifty patient-proxy pairs, interviewed separately, in the patient's residence.

MAIN OUTCOME MEASURES

Modified FAI using 13 items. Individual FAI items, subscales and total score agreement as measured by weighted kappa and intraclass correlation coefficients (ICC).

RESULTS

Excellent agreement was found for the total FAI (ICC 0.87, 95% confidence interval (CI) 0.78-0.93), and domestic (ICC 0.85, 95% CI 0.73-0.91) and outdoor (ICC 0.87, 95% CI 0.78-0.95) subscales, with moderate agreement found for the work/leisure subscale (ICC 0.63, 95% CI 0.34-0.78). For the individual FAI items, good, moderate, fair and poor agreement was found for five, three, four and one item, respectively. The best agreement was for objective items of preparing meals, washing-up, washing clothes, shopping and driving. The poorest agreement was for participation in hobbies, social outings and heavy housework. Scoring biases associated with patient or proxy demographic characteristics were found. Female proxies, and those who were spouses, scored patients lower on domestic activities; male patients, and those who were younger, scored themselves higher on outdoor activities and higher patient FIM scores were positively correlated with higher FAI scores.

CONCLUSIONS

While total and subscale agreement on the FAI was high, individual item agreement varied. Proxy scores should be used with caution due to bias.

Patient knowledge and expectations for functional recovery after stroke

OBJECTIVE

Understanding the causes and outcomes of stroke is important for stroke survivors and may affect their success in rehabilitation and their risk of recurrent stroke; therefore, this study was performed to assess the knowledge and expectation of functional recovery in stroke patients undergoing acute inpatient rehabilitation.

DESIGN

Survey study of 50 consecutive stroke patients undergoing inpatient rehabilitation at a single urban rehabilitation hospital.

RESULTS

Forty-six percent of participants were able to correctly identify whether they had sustained a cerebral infarct or hemorrhage. Rehabilitation length of stay was, on average, 1 wk longer than anticipated by patients. Patients overestimated their functional abilities on initial assessment and at discharge compared with staff assessments, with some improvement in accuracy for discharge predictions. Ninety-four percent of participants expected to be discharged home, and most achieved this goal. Although no participant anticipated discharge to a nursing home, 10% of patients were discharged to this location.

CONCLUSIONS

Knowledge of stroke and its treatment was limited, and expectations for recovery tended to exceed actual accomplishments. There are significant areas of opportunity for enhanced educational efforts for stroke patients undergoing inpatient rehabilitation.

Evolution of the caregiving experience in the initial 2 years following stroke

Relationships between stroke survivor and family caregiver factors and the caregiver's health-related quality of life (HRQL) and overall quality of life (QoL) were examined in 97 dyads during the first and second years after stroke. Compared to age- and sex-matched population norms, caregivers scored significantly lower on the mental subscales of HRQL, and differences were greater for women than for men. Caregiver characteristics (older age, less burden, and fewer physical symptoms) were associated with better HRQL (mental summary scale) in the first year, with similar findings in the second year. Moderate stroke survivor physical impairment and caregiver characteristics (younger age and better HRQL) were associated with better QoL in the first year. During the second year poorer caregiver physical and mental health and caring for a stroke survivor with communication difficulties were associated with diminished QoL.

Family member knowledge and expectations for functional recovery after stroke

OBJECTIVE

To assess the stroke knowledge and expectations for recovery among the family members of stroke patients in an acute rehabilitation hospital.

DESIGN

Survey study of 50 family members of stroke patients undergoing inpatient rehabilitation at a single urban rehabilitation hospital.

RESULTS

Sixty percent of participants were able to identify whether their family member had sustained a cerebral hemorrhage or infarct; 48% were able to identify at least one treatment provided to their family member for his or her stroke. The average length of stay predicted by participants closely matched the average patient length of stay. Participants tended to overestimate the functional abilities of their family member with a stroke, both on initial assessment and discharge. This overestimation was more substantial for discharge functional ability than for initial assessment. Participants were able to predict discharge location with substantial accuracy (82% agreement, kappa = 0.41).

CONCLUSIONS

The knowledge of stroke etiology and functional outcome of family members of individuals undergoing rehabilitation after stroke shows significant limitations. Participants' ability to predict functional outcome on discharge was worse than their knowledge of current functional status. Participant predictions of length of stay and discharge disposition were areas of relative strength. Further efforts are needed to enhance the knowledge level of family members of patients undergoing rehabilitation after stroke.