Mapping patients’ experiences after stroke onto a patient-focused intervention framework

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

OBJECTIVE

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adaptation to poststroke fatigue in stroke survivors and their care partners: a scoping review

PURPOSE

Fatigue is a long-term symptom for stroke survivors. This scoping review synthesized how survivors achieve fatigue adaptation.

METHODS

Four databases were searched for studies between 2012 and 2021. Qualitative studies or qualitative findings from mixed-methods studies were included if they described survivors' experiences with fatigue and/or care partners' experiences in helping survivors adapt to fatigue. Studies were excluded if they were poster abstracts, reviews, or editorials.

RESULTS

Thirty-six articles were analyzed. Survivors with fatigue described different adaptive challenges - fatigue made them less productive, brought emotional distress, and was indiscernible to others. To respond to these challenges, stroke survivors did adaptive work including conserving energy, changing mindset, and restructuring normality. Care partners, employers, and colleagues showed adaptive leadership by adjusting daily routines or role responsibilities. Most survivors described that the current clinical practice did not meet their needs to address fatigue.

CONCLUSIONS

Stroke survivors had many types of challenges and strategies for fatigue adaptation. Survivors received family, employer, and colleague support but how care partners help survivors develop new skills is unknown. Stroke survivors expressed that healthcare professionals need to teach survivors and care partners basic knowledge of fatigue that meet their personal needs and provide adaptive interventions for survivors. Implications for rehabilitationThe challenges of poststroke fatigue are multifaceted because fatigue influences stroke survivors' physical, cognitive, mental, and social aspects of recovery.Stroke survivors need support from their care partners such as helping them adapt to the fatigue, adapt to new life routine, and adjust role responsibilities.Healthcare professionals, stroke survivors, and care partners need to work together to develop strategies about poststroke fatigue that meet stroke survivors' personal needs.

Co-creating Digital Stories With UK-Based Stroke Survivors With the Aim of Synthesizing Collective Lessons From Individual Experiences of Interacting With Healthcare Professionals

Background

Stroke survivor narratives can provide valuable insight into experiences of healthcare and beyond. There is need to further understand collective lessons from stroke survivor narratives, yet prior studies utilizing digital storytelling tend to not synthesize lessons from individual experiences. This study aims to develop a novel method to co-create digital stories with stroke survivors that will aim to synthesize and portray important collective lessons from individual stroke survivors' experiences of interacting with healthcare professionals.

Methods

This study follows-up a qualitative study conducted with 30 stroke survivors exploring factors that help or hinder survivors to positively reconfigure their identity post-stroke. Five co-creation workshops were conducted with a subset of UK-based stroke survivors from this previous study. Participants were invited to join through: online workshops, an online bulletin board, and as an advisor. A four-stage workshop framework was developed through the integration of UK Design Council's Double Diamond method, digital storytelling strategies and the Behavior Change Wheel (BCW) framework for developing behavioral change interventions.

Findings

Six online workshop participants (three male, three female; aged 33–63; time since stroke 2–16 years) co-created digital stories that share six collective lessons aimed at increasing empathy and encouraging behavior change in healthcare professionals (HCPs) working with stroke survivors. Online bulletin board participants (n = 1) and advisors (n = 5) supported the co-creation process. Collective lessons identified were: (1) Stroke has a variety of symptoms that must all be considered; (2) Stroke can affect anyone of any age and not just the elderly; (3) Assumptions should not be made about a survivor's lifestyle or habits; (4) It is important to acknowledge the person behind the stroke and ensure that they are communicated with and listened to; (5) Stroke survivors can often feel unprepared for the reality of life after stroke; (6) Adapting to life after stroke is a long-term process requiring long-term support.

Conclusion

Stroke survivor stories highlighted preconceptions, attitudes and behaviors embedded within healthcare that negatively impacted their experiences and recovery. The novel methodology employed in this study enabled these stories to be synthesized into collective lessons to bring about improvements in these behaviors in future.

Patient Perspectives to Inform a Health Literacy Educational Program: A Systematic Review and Thematic Synthesis of Qualitative Studies

Patient-centred care is tailored to the needs of patients and is necessary for better health outcomes, especially for individuals with limited health literacy (LHL). However, its implementation remains challenging. The key to effectively address patient-centred care is to include perspectives of patients with LHL within the curricula of (future) healthcare providers (HCP). This systematic review aimed to explore and synthesize evidence on the needs, experiences and preferences of patients with LHL and to inform an existing educational framework. We searched three databases: PsychInfo, Medline and Cinahl, and extracted 798 articles. One-hundred and three articles met the inclusion criteria. After data extraction and thematic synthesis, key themes were identified. Patients with LHL and chronic diseases encounter multiple problems in the care process, which are often related to a lack of person-centeredness. Patient perspectives were categorized into four key themes: (1) Support system; (2) Patient self-management; (3) Capacities of HCPs; (4) Barriers in healthcare systems. "Cultural sensitivity" and "eHealth" were identified as recurring themes. A set of learning outcomes for (future) HCPs was developed based on our findings. The perspectives of patients with LHL provided valuable input for a comprehensive and person-centred educational framework that can enhance the relevance and quality of education for (future) HCPs, and contribute to better person-centred care for patients with LHL.

Exploring challenges at 6 months after stroke: what is important to patients for self-management?

Background/Aims:

Self-management models have recently been applied to stroke, but the most effective components are yet to be determined. To inform the ongoing refinement of stroke self-management programmes, this study explored challenges at 6 months after stroke.

Methods:

A total of 53 stroke survivors and 26 significant others were interviewed 6 months after stroke. Results were analysed qualitatively using thematic analysis.

Findings:

Stroke was experienced as a shocking and frightening event regardless of severity, and participants struggled to manage the consequences of their stroke. The stroke experience occurred within the context of more than one chronic condition and with competing demands of everyday life. Participants struggled to formulate a model of causation for their stroke, yet this appeared a necessary basis for action.

Conclusions:

The findings suggest that health care targeted at enhancing self-management, including self-management programmes, may benefit from encompassing a specific focus on participants' beliefs as an important foundation for recovery after stroke.

Mismatch between observed and perceived upper limb function: an eye-catching phenomenon after stroke

PURPOSE

To investigate the relation between observed and perceived upper limb motor function in patients with chronic stroke.

MATERIAL AND METHODS

We investigated 32 patients at six months after stroke with the Fugl-Meyer Assessment (observed function) and hand subscale of the Stroke Impact Scale (perceived function). Spearman correlation was calculated to relate observed and perceived function. Through cut-off scores, we divided our sample in low (Fugl-Meyer Assessment <31/66) and good observed function, and low (hand subscale of Stroke Impact Scale <61/100) and good perceived function. Scatterplot and hierarchical clustering analysis was conducted to detect distinct groups.

RESULTS

A strong positive relation was found between observed and perceived function (r = 0.84). Three groups could be identified; a "low match group" of patients with low observed and low perceived function (n = 11, 34%), a "good match group" containing patients with good observed and good perceived function (n = 15, 47%), and a "mismatch group" comprising patients with good observed but low perceived function (n = 6, 19%).

CONCLUSIONS

In our chronic sample, one in five patients showed good upper limb observed but low perceived function. Measuring both observed and perceived arm and hand function seems warranted together with considering a differential therapy approach for the distinct groups. Implications for rehabilitation A considerable group of patients in the chronic phase post-stroke have good motor function in their affected upper limb, but nevertheless perceive a restricted ability. In order to identify a mismatch in people with chronic stroke, both observed and perceived upper limb motor function should be assessed. Besides common measurement tools for observed function like the Fugl-Meyer Assessment, perceived function can be evaluated by means of the hand function section of the Stroke Impact Scale. For patients with good observed but low perceived function, an additional rehabilitation strategy should be considered, potentially including awareness of ability and a self-efficacy approach.

Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services - A systematic review and meta-ethnography

Objective

To describe and explain stroke survivors and informal caregivers’ experiences of primary care and community healthcare services. To offer potential solutions for how negative experiences could be addressed by healthcare services.

Design

Systematic review and meta-ethnography.

Data sources

Medline, CINAHL, Embase and PsycINFO databases (literature searched until May 2015, published studies ranged from 1996 to 2015).

Eligibility criteria

Primary qualitative studies focused on adult community-dwelling stroke survivors’ and/or informal caregivers’ experiences of primary care and/or community healthcare services.

Data synthesis

A set of common second order constructs (original authors’ interpretations of participants’ experiences) were identified across the studies and used to develop a novel integrative account of the data (third order constructs). Study quality was assessed using the Critical Appraisal Skills Programme checklist. Relevance was assessed using Dixon-Woods’ criteria.

Results

51 studies (including 168 stroke survivors and 328 caregivers) were synthesised. We developed three inter-dependent third order constructs: (1) marginalisation of stroke survivors and caregivers by healthcare services, (2) passivity versus proactivity in the relationship between health services and the patient/caregiver dyad, and (3) fluidity of stroke related needs for both patient and caregiver. Issues of continuity of care, limitations in access to services and inadequate information provision drove perceptions of marginalisation and passivity of services for both patients and caregivers. Fluidity was apparent through changing information needs and psychological adaptation to living with long-term consequences of stroke.

Limitations

Potential limitations of qualitative research such as limited generalisability and inability to provide firm answers are offset by the consistency of the findings across a range of countries and healthcare systems.

Conclusions

Stroke survivors and caregivers feel abandoned because they have become marginalised by services and they do not have the knowledge or skills to re-engage. This can be addressed by: (1) increasing stroke specific health literacy by targeted and timely information provision, and (2) improving continuity of care between specialist and generalist services.

Systematic review registration number

PROSPERO 2015:CRD42015026602

Predictors of Vascular Cognitive Impairment Poststroke in a Middle Eastern (Bahrain) Cohort: A Proposed Case-Control Comparison

BACKGROUND

Poststroke dementia and cognitive impairment are associated with poor long-term outcomes after stroke. The contribution of genetic factors such as the presence of apolipoprotein (ApoE) ɛ4 allele and its association with cognitive impairment poststroke remains inconclusive, particularly in Middle Eastern regions.

OBJECTIVE

The aim of this study is to examine all correlates and potential predictors of cognitive impairment including self-awareness and regulation deficits in stroke patients and compare these functions with healthy older adults from a Middle Eastern population.

METHODS

A prospective stroke sample of 200 patients (case group) and 100 healthy aging individuals (control group) will be recruited from the largest medical complex in Bahrain. A neuropsychological battery of cognitive assessments (global, executive, and metacognition) will be conducted on all participants. Participants will be categorized into 4 subgroups (nonvascular cognitive impairment, vascular cognitive impairment with no dementia, vascular dementia, and mixed dementia) using standardized cognitive assessment scores and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, dementia criteria. Biomarkers will include ApoE genotype, soluble form of receptor for advanced glycation end products, neprilysin, beta-secretase 1, biochemistry, and hematology measurements.

RESULTS

The primary study outcome is to determine early risk factors for cognitive impairment after stroke in a Bahraini cohort. The study has received full ethical approval from the Bahrain Ministry of Health and from the affiliated university.

CONCLUSIONS

With increasing stroke incidence rates in the Middle East, this research study will provide useful biological and epidemiological data for future development and planning of health policies and guidelines for stroke care within the Gulf region.

Examining the relationship between fatigue and cognition after stroke: A systematic review

Many stroke survivors experience fatigue, which is associated with a variety of factors including cognitive impairment. A few studies have examined the relationship between fatigue and cognition and have obtained conflicting results. The aim of the current study was to review the literature on the relationship between fatigue and cognition post-stroke. The following databases were searched: EMBASE (1980-February, 2014), PsycInfo (1806-February, 2014), CINAHL (1937-February, 2014), MEDLINE (1946-February, 2014), Ethos (1600-February, 2014) and DART (1999-February, 2014). Reference lists of relevant papers were screened and the citation indices of the included papers were searched using Web of Science. Studies were considered if they were on adult stroke patients and assessed the following: fatigue with quantitative measurements (≥ 3 response categories), cognition using objective measurements, and the relationship between fatigue and cognition. Overall, 413 papers were identified, of which 11 were included. Four studies found significant correlations between fatigue and memory, attention, speed of information processing and reading speed (r = -.36 to .46) whereas seven studies did not. Most studies had limitations; quality scores ranged from 9 to 14 on the Critical Appraisal Skills Programme Checklists. There was insufficient evidence to support or refute a relationship between fatigue and cognition post-stroke. More robust studies are needed.

Motivational Interviewing Post-Stroke: An Analysis of Stroke Survivors' Concerns and Adjustment

Our earlier research demonstrated that participation in four sessions of motivational interviewing (MI) early post-stroke has a positive impact on stroke survivors' mood. However, the theoretical underpinnings of MI in supporting adjustment (rather than its traditional use in supporting behavior change) require clarification. This article describes a content analysis of MI transcripts for 10 participants in our previous study, to identify the focus of discussions (patient "concerns") and potential effective components of our MI approach. Patients' post-stroke concerns were shown in 16 categories, including frustration, family impact, and getting well. There was a pattern of change discourse across sessions: "Sustain talk" (reasons for not changing) reduced from Session 1 onward, "change talk" (intent to change) increased then reduced, and "change expressed" (changes achieved) increased from Sessions 1 to 4. MI facilitates healthy adjustment post-stroke in some patients, in turn affecting mood, but clarification of how this effect is achieved requires further exploration.

A cross sectional study of upper extremity strength ten days after a stroke; relationship between patient-reported and objective measures

Background

Reduced upper extremity function early after a stroke is common, and a combination of strength capacity and patient-reported measures contribute to setting realistic goals. The validity of the patient’s perception of upper extremity strength in relation to objective strength assessments early after a stroke needs to be clarified. The objective was to investigate the relationship between perceived upper extremity strength and measured hand strength at ten days post-stroke.

Methods

This study of 99 patients with reduced upper extremity function at 3 days post stroke, were consecutively included from a stroke unit to the Stroke Arm Longitudinal Study at the University of Gothenburg, (the SALGOT-study). The correlations between two questions from the Stroke Impact Scale (SIS 1a and 1b), and a dynamometer measure of hand strength values (percentage of normative values) were investigated. In order to explain differences between the two types of measurements, the accordance between perceived strength in a dichotomized SIS and objective measures was explored. In SIS 1a and 1b, 1–3 points correspond to reduced strength (<80 % or normative strength values). In SIS 1a and 1b, 4–5 points correspond to normal strength (≥80 % of normative strength values).

Results

The correlation between the measured strength values and perceived arm strength was rho 0.82 (p = <0.001) and with perceived grip strength rho 0.87 (p = <0.001). Using the dichotomized SIS and the 80 % cut-off correctly classified arm strength in 81 % and grip strength in 84 % of the patients, with a sensitivity of 0.86-0.87, a specificity of 0.62-0.77, positive predicted values of 0.87-0.91 and negative predicated values of 0.64-0.67.

Discussion

The discrepancy between assessed strength capacity and self-perceived strength highlights the importanceof including self-perceived assessments early after stroke, in order to increase knowledge of a patient'sawareness of functioning or lack thereof.

Conclusions

Ten days after stroke in patients without severe cognitive disabilities, this study suggests that despite high correlations between measures, an objective assessment of arm and hand strength does not always reflect the patient’s perspective. A combination of self-reported and objective strength assessment is requested to enhance in setting of realistic goals early after stroke.

Trial registration

ClinicalTrials.gov: NCT01115348, May 3, 2010

A thematic framework of illness narratives produced by stroke patients

PURPOSE

The present study aims at elucidating the impact of stroke on psychosocial functioning of stroke survivors.

METHODS

Data were investigated using interpretative thematic analysis of illness stories produced by 29 patients.

RESULTS

Eight themes emerged from the data: Medical Information; Interpersonal Changes; Cognitive, Physical and Emotional Functioning; Strategies of Coping; Social Support; and Information Irrelevant to the Question. The most frequent organization of the themes followed the course of medical intervention and rehabilitation. Narrations of individual patients varied in terms of the presence of particular themes, the amount of information on each topic and organization.

CONCLUSIONS

The results suggest that the analysis of non-guided illness narratives can be effectively used to identify the thematic areas important to individual stroke patients. The thematic content analysis of stroke stories can allow health professionals to better understand the patient's state of knowledge related to illness as well as his or her socio-psychological functioning which may be useful in the course of planning further assessment and rehabilitation of patients with stroke. Implications for Rehabilitation Experience of illness and life changes following stroke should be recognized as central to the provision of targeted rehabilitation. To understand the subjective perspective a content analysis of the content narrative is recommended. Our study highlights seven general thematic categories that may be regarded as key. The categories may be useful for clinicians to help individuals to clarify their main concerns following a stroke.

Life changed existentially: a qualitative study of experiences at 6-8 months after mild stroke

PURPOSE

To explore experiences of mild-stroke survivors in the context of early supported discharge. The meanings patients attributed to activities and participation in the home recovery process were our main interest.

METHODS

Eight participants (45-80 years) from a randomised controlled study were selected for this sub-study. This purposive sample had received rehabilitation in their homes in the post-stroke acute phase of recovery as part of the larger study. Extensive interview data were analysed using an interpretive strategy and systematic text condensation. Coping theory was included in later stages of analysis.

FINDINGS

The mild-stroke survivors' stories revealed that life had changed profoundly. Differences and similarities in experienced changes were related to: self-perceived health, the body, practical activities, taking part in society, and self-perception. The findings showed the ways in which life changed for mild-stroke survivors, experienced challenges, and survivors' thoughts about the future.

CONCLUSIONS

Mild-stroke rehabilitation should focus more strongly on basic concerns related to self-perceived health, self-perception, and body, since these dimensions seem to complicate daily activities and close relationships. Professionals should also be aware of patients who experience an uncertain situation and unresolved rehabilitation needs, which still can be present 6-8 months after the stroke.

IMPLICATIONS FOR REHABILITATION

When living with mild stroke, entrance to practical and social activities seemed founded on the patients' perception of the body and self as comprehensible or not. Comprehending their own changed body and sense of self seem to be a long-term process when living with mild stroke. It is suggested that long-term follow-up be incorporated in home rehabilitation service, also in the context of early supported discharge. This may contribute to help patient cope more optimally with activities and participation of importance to them.

The experience of stroke survivors three months after being discharged home: A phenomenological investigation

BACKGROUND

Stroke is the leading cause of disability in adults, and has a significant impact on individuals, families, and society. Returning home after a stroke represents a challenging experience for patients who struggle to adapt to their new life conditions. Although many studies have been conducted on stroke survivors, few studies have focused on the lived experience of patients at three months after they came home after rehabilitation.

AIMS

The aim of this study was to describe the experience of stroke survivors three months after being discharged home from rehabilitation hospitals.

METHOD

A phenomenological methodology was used to conduct the study. Participants were enrolled from rehabilitation hospitals in the cities of Rome and Naples. Interviews were conducted at the patients' house and data were analysed with a phenomenological approach

FINDINGS

Fifteen stroke survivors were interviewed (mean age 70 years; 12 males). Five themes emerged from the phenomenological analysis of the interviews and the field notes: deeply changed life, vivid memory of the acute phase of the stroke, slowed lives, relief after recovering from stroke, being a burden for family members.

CONCLUSIONS

The results of this study give an overview of the experience of stroke survivors three months after being discharged home. From a clinical perspective, health care providers need to provide more interventions to help survivors to cope better with life changes and encourage them to adapt to daily life limitations caused by stroke. Also, health care providers should improve support provided to family members of stroke patients.

Baltes' SOC model of successful ageing as a potential framework for stroke rehabilitation

AIM

The aim of this paper is to explore approaches used to address some stroke rehabilitation interventions and to examine the potential use of one of the life-span theories called the Baltes' model of selective optimisation with compensation (SOC) as a potential framework.

KEY FINDINGS AND IMPLICATIONS

Some of the key considerations for a stroke rehabilitation intervention framework are highlighted including accommodating for the life management changes post stroke, alterations in self-regulation, acknowledge losses and focusing on a person-centred approach for transition from acute rehabilitation to the home or community setting. The Baltes' SOC model is then described in terms of these considerations for a stroke rehabilitation intervention framework.

CONCLUSIONS AND RECOMMENDATIONS

The Baltes' SOC model may offer further insights, including ageing considerations, for stroke rehabilitation approaches and interventions. It has potential to facilitate some of the necessary complexities of adjustment required in stroke rehabilitation. However, further development in terms of empirical support is required for using the model as a framework to structure stroke rehabilitation intervention. Implications for Rehabilitation There is a scarcity of theoretical frameworks that can facilitate and be inclusive for all the necessary complexities of adjustment, required in stroke rehabilitation. In addition to motor recovery post stroke, rehabilitation intervention frameworks should be goal orientated; address self-regulatory processes; be person-centred and use a common language for goal planning, setting and attainment. The Baltes' SOC model is one such framework that may address some of the considerations for stroke rehabilitation, including motor recovery and other life management aspects.