In search of self after stroke: a longitudinal qualitative study in the context of client-centred rehabilitation

PURPOSE

The aim was to illuminate the experiences of stroke survivors returning to everyday life in the year following stroke, in the context of client-centred rehabilitation.

METHODS

Four men who participated in a client-centred rehabilitation program were followed during the first year after stroke. Semi-structured interviews were conducted, allbut the first in the participants' home. The data were analysed using a grounded theory approach.

RESULTS

The results revealed a process with the overarching core category; The "new" self becomes reality through challenging everyday experiences, and five main categories driving the process: 1) Striving for structure in a "new" chaotic world, 2) Homecoming an ambiguous experience, 3) Reaching the "new" self through reflections of self-understanding, 4) Socialising in new circumstances, and 5) Realising a new reality.

CONCLUSIONS

While in hospital, stroke survivors can have unrealistic expectations. When at home they can begin to realise their actual capacity . To find a "new" self after a stroke can involve time-consuming and taxing processes of reflections of self-understanding. Engagement in self-selected meaningful and valued activities can support stroke survivors' reconstruction of the "new" self but not all stroke survivors may succeed in finding their "new" self during the first year after stroke.

Integrating consequences of stroke into everyday life - Experiences from a long-term perspective

BACKGROUND

Occupational engagement encompasses both objective and subjective aspects of occupation. Long-term follow-up studies indicate that stroke can have a negative impact on the ability to perform IADL. Less is known about the subjective experiences of occupational engagement and how engagement may evolve after stroke.

OBJECTIVE

To explore stroke survivors' experiences of occupational engagement and how engagement changed over time and across contexts.

MATERIAL AND METHODS

Repeat, semi-structured interviews 15-18 years post-stroke, analysed using thematic analysis. Eight out of nine participants were classified as having had a mild stroke at onset.

RESULTS

The analysis resulted in five themes that together formed the main theme 'It takes time - integrating consequences of stroke into everyday life by engaging in occupation, using internal resources and adapting to context'. This illustrated how occupational outcome was the result of a continuous process in which occupational engagement was a way of gradually integrating consequences of stroke into everyday life.

CONCLUSION AND SIGNIFICANCE

Occupational engagement plays an important part in the process of moving on with life and can serve as both goal and means of achieving desired outcomes after stroke. Interventions that focus on enabling opportunities for occupational engagement in valued occupations and support the use of abilities and internal resources can reduce the impact of stroke in everyday life.

Activities in Daily Living: The development of a new client-centred ADL intervention for persons with stroke

BACKGROUND

An intervention that contains several interacting components can be defined as a complex intervention. This intervention was developed in accordance with the Medical Research Council (MRC) guidance for complex interventions.

AIM

To describe the development, theoretical framework, and content of a client-centred activities in daily living intervention (CADL) for people with stroke.

MATERIAL AND METHODS

Different steps were used; identifying the evidence base, identifying/developing theory and the modelling process and outcomes in the development of the CADL. The remodelling of the process and content of the intervention that emerged are defined.

RESULTS

Findings from a series of qualitative studies of people with stroke demonstrated the need to develop an ADL intervention based on the clients' lived experiences. The theoretical framework is based on empirical research, theories about human occupation and client-centredness. The CADL is applying an occupational and phenomenological perspective in order to enable agency in daily activities and participation in everyday life among persons with stroke.

CONCLUSIONS AND SIGNIFICANCE

The article can be used as an example of how to present the development and theoretical framework of a new complex intervention in occupational therapy.

A client-centred ADL intervention: three-month follow-up of a randomized controlled trial

Objective

The aim was to study a client-centred activities of daily living (ADL) intervention (CADL) compared with the usual ADL intervention (UADL) in people with stroke regarding: independence in ADL, perceived participation, life satisfaction, use of home-help service, and satisfaction with training and, in their significant others, regarding: caregiver burden, life satisfaction, and informal care.

Methods

In this multicentre study, 16 rehabilitation units were randomly assigned to deliver CADL or UADL. The occupational therapists who provided the CADL were specifically trained. Eligible for inclusion were people with stroke treated in a stroke unit ≤3 months after stroke, dependent in ≥two ADL, not diagnosed with dementia, and able to understand instructions. Data were collected at inclusion and three months thereafter. To detect a significant difference between the groups in the Stroke Impact Scale (SIS) domain “participation”, 280 participants were required. Intention-to-treat analysis was applied.

Results

At three months, there was no difference in the outcomes between the CADL group (n = 129) and the UADL group (n = 151), or their significant others (n = 87/n = 93) except in the SIS domain “emotion” in favour of CADL (p = 0.04).

Conclusion

The CADL does not appear to bring about short-term differences in outcomes and longer follow-ups are required.

Place Integration through Daily Activities 1 Year after Stroke

Actions link meaning to particular places over time. This study examined how familiar places, in turn, inspired or influenced actions in the rehabilitation process for individuals who had experienced stroke. The aim of this study was to describe the meanings of actions in different places during 1 year of rehabilitation after stroke. The interview data were longitudinal and collected on four occasions during the first year after stroke (e.g., at 1, 3, 6, and 12 months). Seven categories emerged from the data analysis using a constant comparative method: (1) workplace in mind, (2) experiences at home enabling reflection, (3) rehabilitation setting creates uncertainty, (4) retrieving inspiration from familiar places, (5) matching the complexity of tasks across places, (6) understanding the reality by confrontation, and (7) on the way to place integration. From these themes, a core or overarching theme emerged: the desire for place integration inspires engagement in rehabilitation. The central finding in this study revealed a strong relationship between the desire to be reintegrated into familiar places, such as work and home, and motivation to engage in rehabilitation. Further, this desire for place integration was a constant driving force over the year that motivated the participants to find activities on their own that matched the task demands at their workplaces.

The Meaning of Occupational Gaps in Everyday Life in the First Year after Stroke

This longitudinal study identified how occupational gaps were characterized in people's lived experiences of performing everyday occupations during the first year after stroke. Four participants were interviewed four times during the year after stroke. The data were collected and analyzed using the Empirical, Phenomenological, Psychological method. Five main characteristics were identified: (1) encountering occupational gaps in formerly taken-for-granted activities, (2) striving to narrow gaps in desired occupations, (3) recognizing oneself in doing, (4) searching for a new sense of self through doing, and (5) creating strategies to enable doing. The findings show the importance of being able to preserve some sense of self in everyday doings after a life course disruption caused by stroke. Important implications for clinical practice include sensitivity to clients' experiences during this process, enablement of experiences in occupations promoting recognition, and support of clients in recapturing desired occupations.