Perceived wellbeing of patients one year post stroke in general practice--recommendations for quality aftercare

Using Machine Learning to Study Factors Affecting Discharge Destination in Recovery Units

BACKGROUND

In recent years, machine learning has been developed in the medical community to construct multidimensional datasets consisting of many variables and perform simultaneous factor analysis.

OBJECTIVE

This study aimed to construct a multidimensional dataset of 50 items by incorporating supervised machine learning in a random forest algorithm to predict whether patients will be discharged home or to a facility after a stroke.

METHODS

Thirty patients hospitalized with cerebrovascular diseases who were subsequently discharged were considered as the study subjects. The dataset used for analysis consisted of attributes such as characteristics (three items), physical and cognitive functions (seven items), functional independence measure (FIM) (18 items), blood data (16 items), and social characteristics (six items). The discharge destination variable was either a home or a facility. Machine learning was used to extract factors important for this classification. The accuracy of the random forest was calculated by five-fold cross-validation. The mean decrease Gini, a measure of importance in classification, was calculated for each fold.

RESULTS

The results indicated that FIM, a measure of activities of daily living (ADL), and cognitive function, including memory, which strongly influenced the prediction equation, were important factors in the proposed algorithm. The results of the analysis revealed that the algorithm predicted home discharge or institutionalization with 87.1% accuracy.

CONCLUSION

Through this study, ADL and cognitive function were identified as important factors in predicting home discharge for patients with cerebrovascular disease.

Radial extracorporeal shock wave therapy as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients. A randomized controlled study

PURPOSE

To evaluate the effectiveness of radial extracorporeal shock wave therapy (r ESWT) as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients.

METHODS

100 eligible stroke patients with calf muscles spasticity were randomized into 2 groups. Group I: 50 patients exposed to rESWT 1.500 pulses, 0.10 mJ to 0.3mJ/mm2, with a frequency 4 Hz once weekly for one month. Group II: 50 patients exposed to Sham rESWT once weekly for one month. Clinical, electrophysiological & musculoskeletal ultrasound assessments were done for all patients.

RESULTS

After controlling baseline as covariate, the trend for modified Ashworth scale (MAS), Passive ankle dorsiflexion motion (PADFM), 10 meters walk test (10-MWT), and Ratio of maximum H reflex to maximum M response (H/M ratio) after one & two months was significantly different between the two groups, with improvement of all clinical and electrophysiological parameters in group I.

CONCLUSION

ESWT represents a useful non-invasive, additional modality for the reduction of foot spasticity and equinus deformity in stroke patients.

Stability of Psychological Well-being Following a Neurological Event and in the Face of a Global Pandemic

This study examined the stability of psychological well-being in people who have experienced a neurological event resulting in focal brain damage. Evidence suggests that psychological well-being is largely stable in healthy adult populations. However, whether such stability exists in neurological patients with acquired brain lesions is an open question. Given the trait-like characteristics of psychological well-being, we hypothesized that psychological well-being would be stable in neurological patients who are in the chronic epoch of recovery (≥3 months after the neurological event). Eighty participants (women = 40; age: M = 56, standard deviation ( SD) = 13) completed the Ryff Scales of Psychological Well-Being (PWBS) twice between 2016 and 2020 (Time 1 [T1] and Time 2 [T2]). The Ryff Scales measure various facets of well-being, including autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. Approximately half of participants completed their T2 assessment during the COVID-19 pandemic, creating an opportunity to investigate the effects of the pandemic on the stability of psychological well-being in a neurological population that may be particularly vulnerable to reduced well-being in this context. Pearson correlations and within-sample t-tests were conducted to examine the stability of self-reported well-being over time. Test–retest correlations ranged from .71 to .87, and no significant differences in well-being emerged across the two time points. Significant correlations between T1 and T2 were also evident in the subsample of participants who completed their second assessment during the COVID-19 pandemic. These findings provide evidence that long-term psychological well-being is remarkably reliable and consistent over time in patients who have experienced a major neurological event, even when an unprecedented global event occurred between measurement epochs. Treatment implications of these findings are discussed.

Persisting consequences of ischemic stroke after three months, assessed with the Stroke Impact Scale Version 3.0

INTRODUCTION

Acute ischemic stroke (AIS) has a significant impact on different aspects of the patient's life resulting in loss of independence and poor Health-related Quality of life (HR-QoL).

AIMS

This study aimed to evaluate the impact of AIS on HR-QoL during the first three months post-stroke in a defined Bulgarian population.

METHODS

A total of 150 patients with AIS - 50 with thrombolytic and 100 with non-thrombolytic therapy, were enrolled in a hospital-based study at a tertiary care referral center for neurological disorders in Bulgaria. The HR-QoL of stroke survivors was assessed with the Stroke Impact Scale 3.0 on discharge, in the first and the third-month post-stroke.

RESULTS

The overall HR-QoL remained significantly reduced during the observation period. The most affected domains in the third-month were Participation, Hand function, Mobility, Strenght, and Activities of daily living (ADL). Improvement in all HR-QoL domains was found, most pronounced up to the first-month post-stroke. The higher age, NIHSS and mRS scores were associated with worse SIS 3.0 scores. Left-hemispheric AIS was associated with worse Memory and Communication outcomes, while Right-hemispheric lesions had a higher impact on the Emotions. Large-artery occlusion determined diminished Strenght scores, whereas cardioembolism impacted Communication and ADL domains. Contrarily, lacunar stroke showed more favourable outcomes in all domains.

CONCLUSION

There is the utmost need to focus on the long-term effects of ischemic stroke, due to the rising number of patients who live with the consequences of stroke. Stroke treatment should not be directed exclusively to acute stroke care or prevention, but also to optimizing the post-stroke functioning and Quality of life.

Quality of life after ischaemic stroke—accent on patients with thrombolytic therapy

Background

Intravenous thrombolysis is a widely approved treatment method for acute ischemic stroke (AIS). Nevertheless, there is a growing interest in its impact on functional outcomes and Health-related Quality of life (HR-QoL). We aimed to evaluate and compare the HR-QoL in patients receiving intravenous thrombolysis (IVT) and in those without thrombolytic therapy during the first 3-month post-stroke in a defined Bulgarian population.

Results

Patients treated with IVT have simillar functional outcomes and HR-QoL on the third month as the group with conservative treatment, besides their higher NIHSS on admission. Patients with IVT had better self-assessed recovery after the AIS. The higher NIHSS and mRS scores and the lower HR-QoL on discharge are reliable predictors for a poor functional outcome on the third month. A door-to-needle of 60 min or less, and the absence of pathological neuroimaging findings 24-h post IVT predict more beneficial HR-QoL outcome.

Conclusion

There were no significant differences in HR-QoL and functional outcomes between the groups. Nevertheless, IVT is a treatment option with great importance for improving the clinical outcomes after ischemic stroke, which should be performed in well selected patients.

Integrating community participation in the transition of older adults from hospital to home: a scoping review

INTRODUCTION

Benefits of community participation and physical activity for the health and wellbeing of older adults are well documented. This review aims to answer the question; "How is community participation considered for older adults in the transition from hospital to home?"

MATERIALS AND METHODS

This scoping review searched key databases using subject headings and keywords. Two independent reviewers selected studies based on a systematic procedure. Inclusion criteria were adults aged ≥60 years, transitioning from hospital to home, reporting on community participation, inclusive of leisure activities, social activities, and physical activity.

RESULTS

Of 2206 initial unique articles, 19 met inclusion criteria. Articles covered a range of diagnoses, most frequently stroke, hip replacement, or fracture. Numerous measures of community participation were reported, identifying "low" and "reduced" community participation in ten studies. Measures of physical activity, health-related quality of life, sleep quality, and loneliness were variable. Five studies reported interventions and four reported improved components of community participation. Numerous barriers to community participation were identified, with recommendations for future transition care services considered.

CONCLUSION

There are considerable barriers to promoting community participation in transition care services for older people. Older adults need information to prepare for returning home from hospital and to regain valued leisure and social activities for health-related quality of life.IMPLICATIONS FOR REHABILITATIONCommunity participation is an important component of healthy ageing which health professionals should consider beyond discharge.Levels of mobility and endurance should be considered in terms of facilitating community participation for older adults.Transition care services should provide adequate information to prepare individuals expectations of returning home following hospital stay, whilst attempting to maintain valued leisure and social activities.

Frequency of anxiety after stroke: An updated systematic review and meta-analysis of observational studies

BACKGROUND

Anxiety is a common and distressing problem after stroke.

AIMS

To undertake an updated systematic review and meta-analysis of observational studies of anxiety after stroke and integrate the findings with those reported previously.

SUMMARY OF REVIEW

Multiple databases were searched in May 2018 and 53 new studies were included following dual independent sifting and data extraction. These were combined with 44 previous studies to form a combined data set of 97 studies, comprising 22,262 participants. Studies using interview methods were of higher quality. Rates of anxiety by interview were 18.7% (95% confidence interval 12.5, 24.9%) and 24.2% (95% confidence interval 21.5, 26.9%) by rating scale. Rates of anxiety did not lower meaningfully up to 24 months after stroke. Eight different anxiety subtypes were also reported.

CONCLUSIONS

This review confirms that anxiety occurs in around one in four patients (by rating scale) and one in five patients (by interview). More research on anxiety subtypes is needed for an informed understanding of its effects and the development of interventions.

Shock Waves as a Treatment Modality for Spasticity Reduction and Recovery Improvement in Post-Stroke Adults - Current Evidence and Qualitative Systematic Review

Purpose

This systematic review examines intervention studies using extracorporeal shock wave therapy (ESWT) application in post-stroke muscle spasticity with particular emphasis on the comparison of two different types of radial (rESWT) and focused shock waves (fESWT).

Methods

PubMed, PEDro, Scopus, and EBSCOhost databases were systematically searched. Studies published between the years 2000 and 2019 in the impact factor journals and available in the English full-text version were eligible for inclusion. All qualified articles were classified in terms of their scientific reliability and methodological quality using the PEDro criteria. The PRISMA guidelines were followed and the registration on the PROSPERO database was done.

Results

A total of 17 articles were reviewed of a total sample of 303 patients (age: 57.87±10.45 years and duration of stroke: 40.49±25.63 months) who were treated with ESWT. Recent data confirm both a subjective (spasticity, pain, and functioning) and objective (range of motion, postural control, muscular endurance, muscle tone, and muscle elasticity) improvements for post-stroke spasticity. The mean difference showing clinical improvement was: ∆=34.45% of grade for fESWT and ∆=34.97% for rESWT that gives a slightly better effect of rESWT (∆=0.52%) for spasticity (p<0.05), and ∆=38.83% of angular degrees for fESWT and ∆=32.26% for rESWT that determines the more beneficial effect of fESWT (∆=6.57%) for range of motion (p<0.05), and ∆=18.32% for fESWT and ∆=22.27% for rESWT that gives a slightly better effect of rESWT (∆=3.95%) for alpha motor neuron excitability (p<0.05). The mean PEDro score was 4.70±2.5 points for fESWT and 5.71±2.21 points for rESWT, thus an overall quality of evidence grade of moderate (“fair” for fESWT and “good” for rESWT). Three studies in fESWT and four in rESWT obtained Sackett’s grading system’s highest Level 1 of evidence.

Conclusion

The studies affirm the effectiveness of ESWT in reducing muscle spasticity and improving motor recovery after stroke.

Measures used to assess impact of providing care among informal caregivers of persons with stroke, spinal cord injury, or amputation: a systematic review

PURPOSE

(1) To identify measures used to evaluate the impact of caregiving among caregivers of persons with stroke, spinal cord injury, and amputation; and (2) to systematically evaluate their clinimetric properties reported in validation studies.

MATERIALS AND METHODS

Two separate systematic reviews (Embase, PsycINFO, CINAHL, Pubmed/Medline) were conducted. COSMIN guidelines were used to assess clinimetric properties and methodological quality of studies.

RESULTS

(1) 154 studies published between 2008 and May 2019 were included, in which 48 measures were used, mostly describing negative impact. Thirty measures were used only once and not further described. (2) In general, structural validity, internal consistency, and hypothesis testing were often investigated. Reliability, cross-cultural and criterion validity to a lesser extent, and scale development and content validity were rarely described. Tests of measurement error and responsiveness were exceptional. Most supporting evidence was found for the Zarit Burden Interview Short Form, Caregiver Burden Scale and Positive Aspects of Caregiving Questionnaire.

CONCLUSIONS

There is a wide variety of impact of caregiving measures. The present study provided a detailed overview of what is known about clinimetric characteristics of 18 different measures repeatedly used in research. The overview provides clinicians a guidance of appropriate measure selection.

PROSPERO REGISTRATION

CRD42018094796IMPLICATIONS FOR REHABILITATIONClinicians should be aware that information about measure development and clinimetric properties for most measures used to assess impact of informal caregiving is incomplete.Most supporting evidence was found for the Zarit Burden Interview Short Form, Caregiver Burden Scale and Positive Aspects of Caregiving Questionnaire.This overview of clinimetric properties provides clinicians guidance for selection of an appropriate measure.

Clinical study of combined mirror and extracorporeal shock wave therapy on upper limb spasticity in poststroke patients

Mirror therapy is a simple, inexpensive, and patient-oriented method that has been shown to reduce phantom sensations and pain caused by amputation and improve range of motion, speed, and accuracy of arm movement and function. Extracorporeal shock wave therapy (ESWT) is a new, reversible, and noninvasive method for the treatment of spasticity after stroke. To investigate the therapeutic effect of the combination of mirror and extracorporeal shock wave therapy on upper limb spasticity in poststroke patients. We randomly assigned 120 patients into four groups: A, B, C, and D. All groups received conventional rehabilitation training for 30 min per day, five times a week, for 4 weeks. Moreover, participants in groups A, B, and C also added mirror therapy, ESWT, and a combination of mirror and ESWT, respectively, for 20 min per day. Motor recovery and spasticity were measured using Fugl–Meyer assessment and modified Ashworth scale. The differences in the Fugl–Meyer assessment and modified Ashworth scale scores in group C were significantly greater than those of group D at all observed time points after treatment and were significantly greater than those of groups A and B (P<0.05), but no significant differences were observed between groups A and B until 12 months. Upper extremity spasticity was improved by combined mirror and ESWT.

Adjusting after stroke: Changes in sense of purpose in life and the role of social support, relationship strain, and time

It is unclear how the onset of a major health condition, such as a stroke, may impact sense of purpose long-term and whether social factors influence this change. We examined changes in purpose in 716 stroke patients (M_age = 72.09 years, 52.5% female) who participated in the Health and Retirement Study between 2006 and 2014. Multilevel growth modeling indicated that recent stroke patients' sense of purpose declined over time relative to pre-stroke purpose, whereas those suffering stroke prior to baseline demonstrated relative stability. Furthermore, social support was associated with initial levels but not change in sense of purpose.

Quality of life, anxiety, depression and burden among stroke caregivers: A longitudinal, observational multicentre study

AIM

To longitudinally describe stroke caregivers' quality of life, anxiety, depression and burden and to identify predictors of stroke caregivers' quality of life, anxiety, depression and burden.

BACKGROUND

Caregivers have a key role in stroke survivor care and the first year of caregiving is the most challenging. To give tailored interventions, it is important to capture changes and identify predictors of caregiver quality of life, anxiety, depression and burden during the first year.

DESIGN

A 12-month longitudinal study. Data were collected between June 2013-May 2016.

METHODS

Changes in stroke caregiver quality of life, anxiety and depression and burden and their predictors were identified using linear mixed-effects models.

RESULTS

The caregivers (N = 244) were 53 years old and mostly female. Caregiver quality of life did not change significantly over the 12 months, anxiety and depression decreased up to 9 months and caregiver burden decreased from baseline to 3 months, then increased up to 9 months. Higher caregiver quality of life was predicted by caregiver younger age, higher education, living with a stroke survivor, survivor older age and higher physical functioning; higher anxiety and depression were predicted by older caregiver age and younger survivor age; higher burden was predicted by caregiver male gender, the caregiver not living with survivor and survivor lower physical functioning.

CONCLUSION

The first 9 months of caregiving are particularly problematic for caregivers. The trajectories of the above variables and their predictors may be useful for policy makers, clinicians, investigators and educators to give better care to stroke caregivers and their survivors.

Management of post-stroke mood and emotional disturbances

INTRODUCTION

Mood and emotional disturbances are common in stroke patients. Out of diverse post-stroke emotional disturbances, depression, anxiety, emotional incontinence, anger proneness, and fatigue are frequent and important symptoms. These symptoms are distressing for both the patients and their caregivers, and negatively influence the patient's quality of life. The emotional symptoms are not apparent and are therefore often neglected by neurologists. Their phenomenology, predicting factors, and pathophysiology have been under-studied, and are under-recognized. In addition, well-designed clinical trials targeting on these symptoms are rare. Areas covered: This review will describe some of the most common or relevant post-stroke mood and emotional disturbances. The phenomenology, factors or predictors, and presumed etio-pathogenesis will be described. Current pharmacological and non-pharmacological management strategies of these diverse emotional disturbances will be discussed based on different pathophysiological mechanisms. Expert commentary: It is fortunate that these mood and emotional disturbances can be treated by various methods, including pharmacological and non-pharmacological therapy. To administer the appropriate therapy, we must understand the similarities and differences in the pathophysiological mechanisms associated with these emotional symptoms.

Beliefs of rehabilitation professionals towards guided self-rehabilitation contracts for post stroke hemiparesis

Purpose To investigate the beliefs of physiotherapy students (ST), professionals (PT) and physicians (MD) about engaging patients with post-stroke hemiparesis into Guided Self-Rehabilitation Contracts (GSC), to increase their exercise intensity and responsibility level. Method A survey examining beliefs about post-stroke rehabilitation was completed by first (n = 95), second (n = 105), and third (n = 48) year STs; PTs (n = 129) and MDs (n = 65) in France. Results The belief about whether a patient may exercise alone varied between the professional groups with more STs and MDs finding it acceptable: 62% of PTs vs. 74% of STs (p = 0.005) and 79% of MDs (p = 0.02). For 93% of therapists (STs and PTs together), the caregiver may take part in physical therapy sessions. The appropriate weekly duration of exercises in chronic hemiparesis should be over 5 h for 19% of PTs, 37% of STs, and 51% of MDs (MDs vs. PTs, p < 0.005). After stroke, functional progress through rehabilitation is possible all lifelong for 11% of STs, 19% of PTs (p < 0.05, STs vs. PTs), and 29% of MDs (MD vs. PT, NS). Conclusions The strategy of asking patients to perform exercises alone, in the practice or at home, is still not accepted by a large proportion of physical therapy professionals as compared with students or with physicians. Most therapists still see a <5-h weekly duration of exercise as sufficient after stroke. Few therapists are ready to utilize the persistence of behavior-induced brain plasticity regardless of age or delay after the lesion.

What environmental factors influence resumption of valued activities post stroke: a systematic review of qualitative and quantitative findings

OBJECTIVE

Identify the environmental factors that influence stroke-survivors' reengagement in personally valued activities and determine what specific environmental factors are related to specific valued activity types.

DATA SOURCES

PubMed, CINAHL and PsycINFO were searched until June 2016 using multiple search-terms for stroke, activities, disability, and home and community environments.

REVIEW METHODS

An integrated mixed-method systematic review of qualitative, quantitative and mixed-design studies was conducted. Two researchers independently identified relevant studies, assessed their methodological quality and extracted relevant findings. To validly compare and combine the various findings, all findings were classified and grouped by environmental category and level of evidence.

RESULTS

The search yielded 4024 records; 69 studies were included. Most findings came from low-evidence-level studies such as single qualitative studies. All findings were consistent in that the following factors facilitated reengagement post-stroke: personal adapted equipment; accessible environments; transport; services; education and information. Barriers were: others' negative attitudes and behaviour; long distances and inconvenient environmental conditions (such as bad weather). Each type of valued activity, such as mobility or work, had its own pattern of environmental influences, social support was a facilitator to all types of activities. Although in many qualitative studies others' attitudes, behaviour and stroke-related knowledge were seen as important for reengagement, these factors were hardly studied quantitatively.

CONCLUSION

A diversity of environmental factors was related to stroke-survivors' reengagement. Most findings came from low-evidence-level studies so that evidence on causal relationships was scarce. In future, more higher-level-evidence studies, for example on the attitudes of significant others, should be conducted.

Extracorporeal Shock Wave Stimulation as Alternative Treatment Modality for Wrist and Fingers Spasticity in Poststroke Patients: A Prospective, Open-Label, Preliminary Clinical Trial

Objective. To evaluate the effectiveness of radial shock waves (rESW) for wrist and fingers flexors spasticity in stroke patients. Methods. Twenty patients with upper limb muscle spasticity were enrolled in the study and treated with a single session of rESW. The spasticity level of the radio carpal (RC) and finger (FF) joints was assessed using Modified Ashworth Scale (MAS). The resting bioelectrical activity of the flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) was examined using surface electromyography (sEMG). Trophic conditions were measured using infrared thermal (IRT) imaging. All measurements were conducted at baseline (t₀), immediately after rESW (t₁), and 1 (t₂) and 24 (t₃) hours following rESW. Results. Significant reduction in MAS was observed for the RC joint in t₁, as well as for the FF joints in t₁, t₂, and t₃. A significant decrease in sEMG was shown for the FCR muscle in t₁ and t₂, as well as for the FCU muscle in t₁ and t₃. Also, a significant increase in IRT value was observed in t₃ only. Conclusions. A single session of rESW could be an effective alternative treatment for reduction of limb spasticity and could lead to improvement of trophic conditions of the spastic muscles.

The correlation between occupational performance and well-being in stroke patients

[Purpose] This study was performed to evaluate the occupational performance of stroke patients and their environment by occupational self-assessment and to investigate the relationship between occupational performance and well-being. [Subjects and Methods] This study enrolled ninety-two stroke patients who were receiving occupational therapy at a general hospital, a rehabilitation hospital, or a community welfare center in the cities of Busan and Gimhae, Republic of Korea. Occupational performance and well-being were investigated with Occupational Self-Assessment Version 2.2 and the Personal Well-being Index-Adult. [Results] Analysis of the correlation between occupational performance as assessed by the "Myself" and "My Environment" sections of Occupational Self-Assessment Version 2.2 and well-being revealed moderate positive correlation for both sections. [Conclusion] The relationship between occupational performance and well-being was identified. Further studies are needed to reveal whether improvement of occupational performance could affect well-being in various dimensions.

Effects of extracorporeal shock wave on upper and lower limb spasticity in post-stroke patients: A narrative review

BACKGROUND

Effective treatment strategies for post-stroke muscle spasticity are still a significant interdisciplinary issue and challenge for neurologists, neurosurgeons, physiatrists nurses and physiotherapists. Extracorporeal shock wave (ESW) treatment is a well-supported physical modality used in a wide range of musculoskeletal disorders. The list of justified indications for ESW treatment and scientific areas of investigations is continuously evolving and adapting to different pathologies, including spasticity after stroke.

OBJECTIVES

To analyze the relevant available research and clinical studies demonstrated that the treatment potentials and effectiveness of ESW procedure including mechanisms of the anti-spastic action within hypertonic muscles after stroke.

LITERATURE SEARCH

A computer research was performed using MEDLINE, PubMed, PEDro, CINAHL, and EMBASE databases. Assessment of eligibility of papers was determined by two independent reviewers. The inclusion criteria comprised: publication in peer-reviewed journals, studies published in the last 10 years, involving clinical trials, full-version available and written in English only.

DISCUSSION

A total of 91 articles were collected, 83 of which were non relevant. Ultimately, 8 clinical studies within a total of 195 patients met inclusion criteria for this review. Only one randomized controlled trial was found and then scored using the Cochrane-based assessment. The other studies involving were analyzed separately according to their methodological quality in a descriptive manner.

CONCLUSIONS

ESW was found to be safe and effective. The mechanism of ESW action is still under investigation.

Quality of life of stroke survivors and their informal caregivers: A prospective study

BACKGROUND

Health care improvements have led to increased survival among stroke patients; however, the disability level remains high. These patients require assistance from caregivers, particularly in the first year after stroke. Longitudinal studies of quality of life (QoL) and the factors associated with QoL for both patients and caregivers are limited.

OBJECTIVES

To describe the changes in QoL and determine the factors associated with QoL for both stroke patients and their informal caregivers in the first year after stroke.

METHODS

This multicenter prospective study was conducted in public hospitals in Mongolia. In this study, 155 first-time stroke patients and their 88 informal caregivers were followed up for 1 year. The WHOQOL-BREF questionnaire was used to assess QoL. The Barthel Index was administered to the patients at the baseline and after 1 year. A generalized estimating equation analysis was used to determine the factors associated with QoL.

RESULTS

The QoL of stroke patients in the domains of physical and environmental aspects improved significantly (p < 0.05) after 1 year; however, social relationship and psychological health declined, but the decline was not significant. Among caregivers, psychological health and social relationship domains improved significantly. Factors associated with low QoL among stroke patients were advancing age, male patients, being single and less improvements on BI score, and among caregivers were poor physical health and financial difficulties.

CONCLUSIONS

Efficient rehabilitation therapy for poststroke patients can improve their QoL. Disability training and financial support for caregivers of poststroke patients might be helpful; however, further research is required.

Clarifying the associations between anxiety, depression and fatigue following stroke

Both psychological distress and fatigue are common post stroke. Although there is recognition that the phenomena are related, the nature of the relationship is unclear.Cross-sectional study of 98 independently functioning participants within 2 years of stroke. Significant relationships were observed between fatigue and general anxiety, health-related anxiety and stroke-specific anxiety (r range from .31 to .37). In the final regression model, depression, pain and stroke-specific anxiety were significant, accounting for 32 per cent of the variance in fatigue scores (p < .001). The findings provide insight into the importance of anxiety-related factors post stroke, their relevance to our understanding of post-stroke fatigue and their implications for post-stroke intervention.

[Home after a stroke; 'that's when it really begins'. A qualitative study into the needs for aftercare of stroke patients after being discharged home]

AIM

To explore stroke patients needs of care after discharge from hospital or rehabilitation facility.

METHOD

Semi-structured interviews with twenty stroke patients and their partners in the region Midden-Kennemerland in the Netherlands.

RESULTS

'That's when it really begins'; at home it becomes clear what the real consequences of the stroke are on daily life. After returning home patients would have liked to (1) have had more information/support and they have a need for support for a long time after their stroke; (2) have had the possibility to get support later on (after having said 'no' in the first place). On the other hand there are (3) patients who are inclined to search for solutions by themselves.

CONCLUSION

Only after returning home stroke patients and their partners can really assess what their need for care is. Therefore the need for care of stroke patients should be assessed after a period of time after the patients return home. The care should be available for a long time after the stroke. Because patients don't realize that they can get help for the neuropsychological consequences, it is important that the initiative to organize the care lies in the hands of the caregivers.

Quality of life and loneliness in stroke survivors living in Appalachia

BACKGROUND AND PURPOSE

Negative outcomes of stroke are associated with poorer quality of life (QoL) and impact stroke recovery. The purpose of this study was to characterize QoL and loneliness in a sample of rural Appalachian stroke survivors within 1 year of stroke.

METHODS

Using mail survey methodology, survey data were collected from 121 ischemic and hemorrhagic stroke survivors living in West Virginia using 13 subscales from the Neuro-QOL survey and the three-item UCLA Loneliness Scale. Statistical Package for Social Sciences v. 20 was used to conduct descriptive, comparative, and predictive analyses. Multiple linear regression models were used to assess explanatory value of loneliness for QoL domains while controlling for comorbidities.

RESULTS

Participants who were discharged to a nursing home had poorer QoL when compared with those who were discharged to home. Stroke survivors who continued to smoke were less satisfied with social roles and reported higher mean loneliness and depression scores. History of psychological problems negatively correlated with all QoL domains and loneliness scores. Loneliness predicted poorer QoL even when controlling for age, gender, and significant comorbidities.

CONCLUSION

Nurses need to assess for loneliness, include loneliness in care planning, and implement smoking cessation and cognitive behavioral interventions. Interventions that target loneliness for stroke survivors could potentially diminish psychological sequelae after stroke and enhance QoL.

A randomised trial deploying a simulation to investigate the impact of hospital discharge letters on patient care in general practice

OBJECTIVE

To determine how the timing and length of hospital discharge letters impact on the number of ongoing patient problems identified by general practitioners (GPs).

TRIAL DESIGN

GPs were randomised into four groups. Each viewed a video monologue of an actor-patient as he might present to his GP following a hospital admission with 10 problems. GPs were provided with a medical record as well as a long or short discharge letter, which was available when the video was viewed or 1 week later. GPs indicated if they would prescribe, refer or order tests for the patient's problems.

METHODS

Setting Primary care. Participants Practising Australian GPs. Intervention A short or long hospital discharge letter enumerating patient problems. Outcome measure Number of ongoing patient problems out of 10 identified for management by the GPs. Randomisation 1:1 randomisation. Blinding (masking) Single-blind.

RESULTS

Numbers randomised 59 GPs. Recruitment GPs were recruited from a network of 102 GPs across Australia. Numbers analysed 59 GPs. Outcome GPs who received the long letter immediately were more satisfied with this information (p<0.001). Those who received the letter immediately identified significantly more health problems (p=0.001). GPs who received a short, delayed discharge letter were less satisfied than those who received a longer delayed letter (p=0.03); however, both groups who received the delayed letter identified a similar number of health problems. GPs who were older, who practised in an inner regional area or who offered more patient sessions per week identified fewer health problems (p values <0.01, <0.05 and <0.05, respectively). Harms Nil.

CONCLUSIONS

Receiving information during patient consultation, as well as GP characteristics, influences the number of patient problems addressed.

TRIAL REGISTRATION NUMBER

ACTRN12614000403639.

Associations between quality of life and socioeconomic factors, functional impairments and dissatisfaction with received information and home-care services among survivors living at home two years after stroke onset

Background

Quality of life (QoL) assessment is important when monitoring over time the recovery of stroke-survivors living at home. This study explores the associations between QoL and socioeconomic factors, functional impairments and self-reported dissatisfaction with received information and home-care services among survivors two years after stroke onset. This problem remains partially addressed though optimal information and services may improve survivors’ QoL.

Methods

Stroke-survivors admitted to all hospitals in Luxembourg 18 months or more previously were identified using the only care-expenditure-reimbursement national system database. The clinical diagnosis was confirmed. Ninety four patients aged 65 years and living at home were interviewed to gather socioeconomic characteristics, functional impairments, dissatisfaction with information and home-care services, and QoL (using the Newcastle Stroke-Specific QoL, newsqol) assessing 11 domains. Data were analyzed using multiple linear regression models.

Results

About 50% of survivors had low education and lower income. Functional impairments were common: sensory (45%), motor (35%), memory (32%), language (31%), and vision (20%). Survivors with education (<12th grade) or lower income had low values for most newsqol domains (sex-age-adjusted regression coefficient saRC, i.e. mean difference, between -23 and -8). Patients who were working had better values for pain, mental feelings and sleep domains than did retired people (saRC between -3.9 and 4.2). Various functional impairments were associated with markedly low values of nearly all domains (saRC between -33.5 and -7.5) and motor, language, memory and sensory impairments had the highest impact. The survivors’ perceived QoL was markedly low, especially for the domains of interpersonal relationship, sleep, cognition, mental feelings, and pain. Various QoL domains were strongly related to dissatisfaction with information about stroke and its consequences/changes over time, accuracy of information obtained, help received, coordination between services, and the possibility of receiving help when necessary (saRC reaching -30).

Conclusions

Stroke-survivors had major alterations in QoL that reflected depressive symptoms, which should be appropriately treated. These findings may help with the development of public policies aiming at improving QoL among stroke survivors. The newsqol could be used routinely to measure the recovery of survivors over time and their needs in terms of information, help and care services.

Survival of stroke patients after introduction of the 'Dutch Transmural Protocol TIA/CVA'

Background

Earlier research showed that healthcare in stroke could be better organized, aiming for improved survival and less comorbidity. Therefore, in 2004 the Dutch College of General Practitioners (NHG) and the Dutch Association of Neurology (NVN) introduced the ‘Dutch Transmural Protocol TIA/CVA’ (the LTA) to improve survival, minimize the risk of stroke recurrence, and increase quality of life after stroke. This study examines whether survival improved after implementation of the new protocol, and whether there was an increase in contacts with the general practitioner (GP)/nurse practitioner, registration of comorbidity and prescription of medication.

Methods

From the primary care database of the Registration Network Groningen (RNG) two cohorts were composed: one cohort compiled before and one after introduction of the LTA. Cohort 1 (n = 131, first stroke 2001–2002) was compared with cohort 2 (n = 132, first stroke 2005–2006) with regard to survival and the secondary outcomes.

Results

Comparison of the two cohorts showed no significant improvement in survival. In cohort 2, the number of contacts with the GP was significantly lower and with the nurse practitioner significantly higher, compared with cohort 1. All risk factors for stroke were more prevalent in cohort 2, but were only significant for hypercholesterolemia. In both cohorts more medication was prescribed after stroke, whereas ACE inhibitors were prescribed more frequently only in cohort 2.

Conclusion

No major changes in survival and secondary outcomes were apparent after introduction of the LTA. Although, there was a small improvement in secondary prevention, this study shows that optimal treatment after introduction of the LTA has not yet been achieved.

[Importance of secondary conditions in rehabilitation medicine]

The author interprets disability on the basis of the "International Classification of Functioning, Disability and Health (ICF)". In this review the applied method is a purpose oriented, restricted survey of continuously increasing articles published during the last two decades. Definition and interpretation of secondary conditions are based on the cited international classification. It is noted that secondary conditions frequently develop during acute care and usually require rehabilitation. Significance of secondary conditions in rehabilitation is highlighted by selected examples of traumatic spinal cord injury, stroke, lower limb amputation and intellectual disabilities. The author states that there is an insufficiency of presently available knowledge and raises the need for the use of the International Classification of Functioning, Disability and Health as foundation of future research.

Time course of depression and one-year prognosis of patients with stroke in mainland China

AIMS

To investigate the incidence of depression at different time points within the first year after stroke in mainland China and to identify risk factors related to a poor 1-year prognosis in stroke patients.

METHODS

Subjects with acute cerebrovascular diseases were recruited and enrolled from 56 hospitals in mainland China between April 2008 and April 2010. Demographic data, previous disease history, and clinical data were collected. Four follow-up visits were occurred within the first year after stroke. The modified Rankin Scale ≥ 2 represents an unfavorable prognosis. Depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition and was divided into persistent, recurrent and transient types.

RESULTS

The 1-year cumulative incidence of depression in stroke patients was 41.8%. Logistic regression analysis showed that the 1-year prognosis level was associated with age, disability before onset, neurological functional deficit level at admission, and a range of depression types. The odds ratio for persistent depression is the highest (OR = 7.615, P < 0.0001, 95% confidence interval 5.011-11.572).

CONCLUSIONS

In our study, depression occurred in >40% of patients within the first year after stroke. Persistent depression is the first independent determinant of prognosis during the first year after stroke.

Life satisfaction two-years after stroke onset: the effects of gender, sex occupational status, memory function and quality of life among stroke patients (Newsqol) and their family caregivers (Whoqol-bref) in Luxembourg

Background

Life satisfaction (LS) of cerebrovascular disease survivors and their family caregivers may relate to socioeconomic factors, impaired functions, health-related quality of life (QoL), but their respective influences remain unclear. This study assessed, two years post-stroke onset, the effects of these factors on patients’ LS and family caregivers’ LS in Luxembourg.

Methods

All stroke patients admitted to all hospitals in Luxembourg were identified by the ‘Inspection Général de la Sécurité Sociale’ using the only national system database for care expenditure reimbursement. Their diagnosis was confirmed by medical investigator. The sample included ninety four patients living at home having given consent (mean age 65.5 years) and sixty two main caregivers (mean age 59.3 years). Questionnaires were completed during face-to-face interviews. LS was assessed via European single question (range 1–10), survivors’ QoL via Newsqol (11 dimensions), and caregivers’ QoL via Whoqol-bref (4 domains) (range 0–100). Data were analysed using multiple regression models.

Results

Two years after stroke onset, 44.7% of patients suffered from impaired sensory function, 35.1% from impaired motor function, and 31.9% from impaired memory function. Mean patient’ LS was 7.1/10 (SD 1.9). It was higher in women (+12.4) and lower among unemployed socioeconomically active patients (−13.1, vs. retired people). Adjusted for sex, occupation, impaired motor and memory functions, LS positively correlated with scores of Newsqol feelings, sleep, emotion, cognition and pain dimensions (slopes 0.20 to 0.31), but did not correlate with those of caregivers’ Whoqol-bref domains. Family caregiver’ LS was 7.2 (SD 1.7). It was lower in those with patients suffering from impaired memory function (−12.8) as well as from feelings and emotion issues (slopes 0.22). It was associated with all caregivers’ Whoqol-bref domains (physical health, psychological health, environment, and social relationships) (slopes 0.53 to 0.68).

Conclusions

Two-year post-cerebrovascular disease patient’ LS was associated with gender, occupation, and impaired memory function. It correlated with feelings, sleep, emotion, cognition, and pain issues. Family caregivers of patients with impaired memory function had lower LS. Family caregiver’ LS correlated with dimensions of patients’ feelings (less independent, yourself, life changed, depressed, useless, less control because of stroke) and emotion (get more emotional, fear of another stroke or to become dependent on others), and with their own QoL. LS, Newsqol, and Whoqol appeared to be appropriate tools. Our findings may be useful for policy makers in relation to family and medical-social issues of stroke home-based rehabilitation.

Quality of life of elderly ischaemic stroke patients one year after thrombolytic therapy. A comparison between patients with and without thrombolytic therapy

Background

An observational study to examine whether thrombolytic therapy in stroke patients realizes better quality of life outcomes compared to patients without thrombolytic therapy one year after stroke. We also examined whether daily functioning, mental functioning and activities improved after thrombolytic treatment.

Methods

A total of 88 stroke patients were interviewed at home one year post-stroke. Health-related quality of life (HRQOL) was assessed using the RAND-36, disability with the Barthel Index, depression and anxiety with the Hospital Anxiety and Depression Scale, and a questionnaire about patient way of life was completed. People aged under 60, moving to a nursing home or with a haemorrhage were excluded.

Results

The thrombolysis group (TG) had more severe stroke (higher NIHSS) scores and were younger than the group without thrombolytic therapy (WTG). The primary outcome was HRQOL, which was high and nearly identical in both groups, however the TG had significantly better HRQOL for the ‘mental health’ and ‘vitality’ scales. Patients who stopped or reduced their hobbies because of stroke had a significantly worse HRQOL.

One year after stroke, more patients in the TG were totally or severely ADL dependent (12% TG and 0% WTG, p = 0.022). The level of dependence decreased in the TG (p = 0.042) and worsened in the WTG (p < 0.001) after one year. Being more dependent is related to diminishing daily occupations in both groups. In the TG the level of dependence had less impact on visiting family and friends and going on holiday. The prevalence of anxiety disorder and depression was low compared to other studies and there is no significant difference between the two groups.

Conclusion

No major differences in the primary outcome (HRQOL) could be found between the two groups. In addition, no essential difference could be found in mental functioning and participation. We expected that patients undergoing thrombolytic therapy would have worse quality of life because of the greater initial severity of their stroke. Therefore, thrombolytic therapy seems to be of great importance in achieving better quality of life in ischemic stroke patients who respond to this therapy.

Towards a better integrated stroke care: the development of integrated stroke care in the southern part of the Netherlands during the last 15 years (Special 10th Anniversary Edition paper)

Introduction

Stroke care is complex and often provided by various healthcare organisations. Integrated care solutions are needed to optimise stroke care. In this paper, we describe the development of integrated stroke care in the region of Maastricht during the last 15 years.

Description of integrated care case

Located in the south of the Netherlands, the region of Maastricht developed integrated stroke care to serve a population of about 180,000 people. Integration was needed to improve the continuity, coordination and quality of stroke care. The development of integrated care in Maastricht was a phased process. The last phase emphasized early discharge from hospital and assessing the best individual rehabilitation track in a specialized nursing home setting.

Discussion and lessons learned

The development and implementation of integrated stroke care in the region of Maastricht led to fewer days in hospital, more patients being directly admitted to the stroke unit and an earlier start of rehabilitation. The implementation of early discharge from the hospital and rehabilitation assessment in a nursing home led to some unforeseen problems and lessons learned.

The economic impact of stroke in The Netherlands: the €-Restore4Stroke study

BACKGROUND

Stroke has a considerable socio-economic impact worldwide and is the leading cause of disabilities in the Western world. Economic studies of stroke focus merely on physical aspects and clinical interventions. To our current knowledge there is no comprehensive economic study investigating the economic impact of stroke including psychological and social aspects. The €-Restore4Stroke project, part of a large comprehensive research programme Restore4Stroke, aims to investigate the total economic impact of stroke in the Netherlands.

METHODS

Two trial-based economic evaluation studies will be conducted within the €-Restore4Stroke project: one focussing on a self-management intervention and one on an augmented cognitive behavioural therapy intervention. Both include cost-effectiveness analyses and cost-utility analyses as primary research methods. Furthermore, a cost-of-illness study investigating costs after stroke attached to a cohort study and a record linkage study in which four databases are linked to investigate patterns of health care consumption before and after stroke, are embedded in €-Restore4Stroke. All studies will be performed from a societal perspective. The primary outcome measure for the cost-effectiveness analysis is the increase in health status on the primary outcome scales. Within the cost-utility analysis, the primary outcome measure is quality-adjusted life years (QALYs) for which an indirect preference-based technique will be used. In the self-management study we will also look at the estimation of health effects on informal caregivers. Cost outcomes in the cost-of-illness study will be computed with a cost questionnaire and linkage of several databases will be used to derive outcomes in the record linkage study.

DISCUSSION

€-Restore4Stroke will provide new insights and evidence for the economic impact of psychosocial consequences after stroke. Besides being innovative in various ways (i.e. focussing on the chronic phase after stroke and including personal factors as possible determinants of long-term re-integration including quality of life in a prospective longitudinal design), a major strength of €-Restore4Stroke is that we include impact on informal caregivers. The outcomes of this study will provide health care decision makers with valuable and necessary information regarding stroke care related decisions.

TRIAL REGISTRATION

NTR3051 (RCT Self-management), NTR2999 (RCT Augmented Cognitive Behavioural Therapy).