Knowledge of stroke in rehabilitation and community samples

Differences in Rehabilitation Needs after Stroke: A Similarity Analysis on the ICF Core Set for Stroke

Background: Successful rehabilitation is associated with physical, psychological, environmental, social, and personal factors based on the International Classification of Functioning, Disability and Health (ICF) framework. The influence of age has been suggested as crucial personal factors that may affect rehabilitation needs in post-stroke survivors. The aim of this study was to investigate the qualifiers of the ICF core set for stroke to detect differences in rehabilitation needs and goals between older (O, >65 years old) and younger (Y, ≤65 years old,) post-stroke individuals. Materials and methods: In this observational study, the comprehensive core set for stroke was filled during the rehabilitation period. Patient information was obtained using disability scales was translated into certain ICF categories using linking rules. Frequency, similarity, and linear regression analyses were performed for ICF qualifier profiles among Y and O patients. Results: Forty-eight ICF variables were significantly different between Y (n = 35, 46.17 ± 11.27 years old) and O (n = 35, 76.43 ± 6.77 years old) patients. Frequency analysis showed that activity of daily living and basic needs were more prevalent in O patients, whereas regaining of social role and social life were more prevalent in Y patients. The average Jaccard Index result (similarity analysis) was more homogeneous in O than in Y patients. Conclusions: ICF qualifiers are useful to design patient-centered care. Y patients have more heterogeneous needs and require more personalized program than O patients.

Misconceptions about Stroke: Causal Attributions for Stroke-Related Symptoms Reflect the Age of the Survivor

With visible disabilities, observers tend to overgeneralise from the disability. In contrast, with invisible disabilities such as traumatic brain injury and stroke, observers often fail to allow for challenges resulting from the disability. Persons who have suffered a stroke claim that people misunderstand their symptoms and stigmatise them as a result of these symptoms. This misunderstanding, which happens particularly with young survivors of stroke, may reflect people's causal attributions for symptoms that follow a stroke. Using a scenario design, this cross-sectional study examined whether people attribute ambiguous symptoms that may result from stroke to other causes (the stroke survivor's personality and age) and whether these attributions reflect the age of the stroke survivor. Participants (N = 120) read scenarios describing a male who was aged either 22, 72, or whose age was unstated and who showed four symptom changes: fatigue, depression, irritability and reduced friendships. For each symptom change, participants rated three causal attributions: the person's age, his personality and stroke. The age of the person in the scenario affected attributions; when the person in the scenario was 22, participants attributed his symptoms significantly more to his personality than to his age or stroke, whereas when he was 72, participants attributed his symptoms more to his age than to his personality or stroke and when his age was unstated, they attributed his symptoms equally to age, stroke and personality. Because misattributions for stroke symptoms hinder rehabilitation, therapy can target people's misattributions to enhance rehabilitation for survivors of stroke.

Patient and Family Member Factors Influencing Outcomes of Poststroke Inpatient Rehabilitation

OBJECTIVE

To investigate how family members' attitudes toward functional regain, and patients' knowledge and intention of independence influence poststroke rehabilitation.

DESIGN

Cross-sectional study.

SETTING

Three rehabilitation inpatient settings.

PARTICIPANTS

Younger (n=79) and older (n=84) poststroke patients, along with their family members (spouses, n=104; children, n=59).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Custom-designed questionnaires were used to tap into the patients' knowledge about rehabilitation (Patient's Rehabilitation Questionnaire-Knowledge About Rehabilitation) and intention of independence (Patient's Rehabilitation Questionnaire-Intention of Independence), and family members' attitudes toward patients in performing basic activities of daily living (BADL) (Family Member Attitudes Questionnaire-BADL) and instrumental activities of daily living (Family Member Attitudes Questionnaire-instrumental activities of daily living). The rehabilitation outcomes included gains in motor, cognitive, and emotional functions, and self-care independence, measured with common clinical instruments.

RESULTS

The Family Member Attitudes Questionnaire-BADL predicted cognitive outcome and the Patient's Rehabilitation Questionnaire-Intention of Independence predicted motor outcome for both groups. Differential age-related effects were revealed for the Patient's Rehabilitation Questionnaire-Intention of Independence in predicting emotional outcome only for the younger group, and self-care independence only for the older group.

CONCLUSIONS

Patients' intention of independence positively affected motor recovery, while family members' positive attitudes promoted cognitive regain. The findings suggested plausible age-related differences in how patients' intentions affect emotion versus self-care independence outcomes. Future studies should explore strategies for promoting positive attitudes toward independence among patients and family members during poststroke rehabilitation.

Validation of the Scale for the Assessment of Illness Behavior (SAIB) in a community sample of elderly people

The aim of this study was to evaluate the construct validity of the SAIB in a community sample of elderly people. The SAIB was administered to a large community sample representative of the German population aged 60-85 years (n=1593). The original model was assessed and then refined through confirmatory and exploratory factor analyses. Criterion validity was evaluated by comparing SAIB scores with external criteria in 3 categories: subjective health, chronic illness and health care utilization. The originally suggested five factor structure of the SAIB yielded a comparative fit index (CFI) of 0.70 and the weighted root mean square residual (WRMR) was 3.68. A shortened questionnaire with 13 items and four factors resulted in better model fit (CFI 0.97 and WRMR 1.3). Correlations between subjective health and the new scales ranged from 0.06 to 0.33. Effect sizes (Cohens d) of mean differences in factor scores between those with and without healthcare system contact varied by healthcare type, ranging from 0.05 to 0.94; effect sizes were largest in relation to contact with psychotherapy and alternative medicine practitioners. We propose a shortened version of the SAIB with a different scale structure, which resulted in better model fit with our data. Neither the original nor revised SAIB appeared to discriminate well in terms of health care use, suggesting that the illness behavior as currently conceptualized may not fully explain the increased use of healthcare in the elderly.

Patients' experiences with self-referral to in-patient rehabilitation: A qualitative interview study

PURPOSE

To describe objectives, experiences and satisfaction among subjects referring themselves to in-patient rehabilitation.

METHOD

Persons suffering from stroke or multiple sclerosis were invited to refer themselves to a specialised rehabilitation department. Ten patients referred themselves within the study period, of whom two were excluded. The remaining eight underwent qualitative semi-structured in-depth interviews, focusing on the decision of self-referral, the personal goals for the rehabilitation, and the satisfaction with the stay. The interviews were tape-recorded and subjected to content analysis. As an underlying theoretical framework, we applied Antonovsky's Sense of Coherence model.

RESULTS

Half of the patients had not written the application themselves and did not know which grounds had been put forward in the application. Nevertheless, all the patients were able to formulate their personal goals for the rehabilitation stay. These were distributed in three main categories: those who recently had got a progressive disability wanted education and improved knowledge on their disease; those who had had an acute, traumatic change of health status wanted training in order to improve muscular strength or everyday skills; and those who had been disabled for several years wanted inspiration for further life.

CONCLUSIONS

Patients may put forward other reasons to apply for rehabilitation than health personnel. Does the Sense of Coherence Model seems applicable to describe these reasons.

Knowledge of stroke risk factors among primary care patients with previous stroke or TIA: a questionnaire study

Background

Survivers of stroke or transient ischaemic attacks (TIA) are at risk of new vascular events. Our objective was to study primary health care patients with stroke/TIA regarding their knowledge about risk factors for having a new event of stroke/TIA, possible associations between patient characteristics and patients' knowledge about risk factors, and patients' knowledge about their preventive treatment for stroke/TIA.

Methods

A questionnaire was distributed to 240 patients with stroke/TIA diagnoses, and 182 patients (76%) responded. We asked 13 questions about diseases/conditions and lifestyle factors known to be risk factors and four questions regarding other diseases/conditions ("distractors"). The patients were also asked whether they considered each disease/condition to be one of their own. Additional questions concerned the patients' social and functional status and their drug use. The t-test was used for continuous variables, chi-square test for categorical variables, and a regression model with variables influencing patient knowledge was created.

Results

Hypertension, hyperlipidemia and smoking were identified as risk factors by nearly 90% of patients, and atrial fibrillation and diabetes by less than 50%. Few patients considered the distractors as stroke/TIA risk factors (3-6%). Patients with a family history of cardiovascular disease, and patients diagnosed with carotid stenosis, atrial fibrillation or diabetes, knew these were stroke/TIA risk factors to a greater extent than patients without these conditions. Atrial fibrillation or a family history of cardiovascular disease was associated with better knowledge about risk factors, and higher age, cerebral haemorrhage and living alone with poorer knowledge. Only 56% of those taking anticoagulant drugs considered this as intended for prevention, while 48% of those taking platelet aggregation inhibitors thought this was for prevention.

Conclusions

Knowledge about hypertension, hyperlipidemia and smoking as risk factors was good, and patients who suffered from atrial fibrillation or carotid stenosis seemed to be well informed about these conditions as risk factors. However, the knowledge level was low regarding diabetes as a risk factor and regarding the use of anticoagulants and platelet aggregation inhibitors for stroke/TIA prevention. Better teaching strategies for stroke/TIA patients should be developed, with special attention focused on diabetic patients.

Desarrumou tudo!O impacto do acidente vascular encefálico na família

O acidente vascular encefálico (AVE) resulta em déficits neurológicos temporários ou permanentes, de variadas intensidades, que podem comprometer a independência do indivíduo acometido na realização de atividades de vida diária. Este estudo de caso investigou famílias de pacientes com diagnóstico de AVE, buscando compreender as dificuldades de ordem estrutural, socioeconômica e emocional pelas quais elas passam; a relação entre o grau de severidade de agravo, tempo de ocorrência da doença e o desenvolvimento de estratégias de proteção e cuidado ao familiar doente. Foram utilizados como instrumentos de coleta de dados: questionário; roteiro de entrevista; observações registradas em diário de pesquisa; aplicação do Índice de Barthel, escala de avaliação funcional internacionalmente validada. A análise dos dados foi realizada pelo Discurso do Sujeito Coletivo, produzindo representações sociais e idéias centrais. Constatou-se que a família passa por um processo de transformação que implica em reorganização e adoção de estratégias de enfrentamento favorecidas pela existência de uma rede de suporte. Esses resultados apontam para a necessidade de se habilitar a família para o cuidado ao paciente com incapacidade decorrente de acidente vascular encefálico e para o autocuidado.

Family carers of stroke survivors: needs, knowledge, satisfaction and competence in caring

PURPOSE

To examine the support required by family carers for stroke survivors.

METHODS

Forty-two family carers were recruited for surveys of needs, knowledge, satisfaction, and competence in caring before and 4 - 6 weeks after discharge from an Acute Stroke Unit (ASU).

RESULTS

Information deficits about dealing with psychological, emotional, and behavioural problems and local service information were priorities before and after discharge. Younger female carers (under 56 years) were least satisfied with communication with ASU staff. Face to face contact was valued. After discharge younger female carers, particularly of non-White ethnic groups, reported lower levels of competence in caring and higher burden. Knowledge of stroke risk factors was low in all groups. High satisfaction with treatment and therapy in the ASU, was not transferred to the community. Carers reported feeling alone and described uncoordinated services.

CONCLUSIONS

Carers are able to anticipate and prioritise their needs, value communication with staff and involvement with discharge-planning, but particular difficulties were experienced by younger female carers and those from non-White ethnic groups. This requires particular attention when developing targeted interventions for family carers from a mixed ethnic community. In-depth and longitudinal studies are needed to detail psychosocial needs and guide practice particularly amongst non-White family carers.

O papel do enfermeiro como educador junto a cuidadores familiares de pessoas com AVC

Trata-se de uma pesquisa do tipo bibliográfico com a finalidade de fazer uma análise temática da produção do conhecimento em periódicos, sobre o papel do enfermeiro como educador junto a cuidadores familiares de pessoas com AVC (Acidente Vascular Cerebral). O corpus de análise reuniu artigos localizados nas décadas de 80 e 90, a partir das bases de dados Medline, Lilacs e Cinahl. A análise de conteúdo foi o referencial metodológico que permitiu organizar o conhecimento em duas categorias: a intervenção educacional na fase aguda e o suporte após a alta hospitalar.

A randomized controlled trial of an education and counselling intervention for families after stroke

OBJECTIVES

To determine whether education and counselling after stroke leads to improved family functioning and psychosocial outcomes for stroke patients and their spouses, and better functional and social outcomes for patients.

DESIGN

Two-group randomized controlled trial. Data were collected on admission to and discharge from rehabilitation, and again six months later.

SETTING

Rehabilitation units at Repatriation General Hospital and Griffith Hospital, in Adelaide, South Australia.

PARTICIPANTS

Sixty-two stroke patients and their spouses, 32 in the intervention group and 30 in the control group.

INTERVENTION

Stroke information package and three visits from a social worker trained in family counselling.

OUTCOME MEASURES

Family functioning: McMaster Family Assessment Device (FAD); functional status: Barthel Index (BI); social recovery: Adelaide Activities Profile (AAP); depression: Geriatric Depression Scale (GDS); anxiety: Hospital Anxiety and Depression Scale (HADS); mastery: Mastery Scale (MS); health status: SF-36.

RESULTS

At six months the intervention group had better family functioning for both patients (mean FAD difference 0.19) and spouses (mean difference 0.09). A modest benefit in functional status for intervention patients (mean BI difference 1.3) was related to improved family functioning. Intervention patients reported better social recovery (mean AAP differences: domestic chores 5.7, household maintenance 4.6, social activities 11.5), but there were no significant effects on depression, anxiety, mastery or health status.

CONCLUSIONS

An education and counselling intervention maintained family functioning, and in turn led to improved functional and social patient outcomes. This approach helps patients and their spouses to make the optimal adjustment to living with stroke.

Psychological correlates of outcome following rehabilitation from stroke

OBJECTIVES

To confirm, in a new sample, the value of our previously described procedure for identifying abnormal illness behaviour (AIB) in stroke rehabilitation patients, and to examine the relative effects of AIB, depression, family functioning, knowledge of stroke, and expectations of rehabilitation on long-term rehabilitation outcome.

DESIGN

A longitudinal design, with assessments on admission to and discharge from rehabilitation, and six and twelve months after discharge.

SETTING

The study was undertaken in the rehabilitation unit at Repatriation General Hospital, in Adelaide, South Australia.

SUBJECTS

Sixty twelve-month stroke survivors, residing in a family environment, who had undergone an inpatient rehabilitation programme.

MAIN OUTCOME MEASURES

AIB was assessed using the Illness Behaviour Questionnaire, depression with the Zung Self-Rating Depression Scale, family functioning with the McMaster Family Assessment Device, stroke knowledge with the Stroke Care Information Test, and expectations of rehabilitation with an open-ended question. Functional outcome was assessed with the competence and performance assessments of the Australian ADL Index, and lifestyle activities with the Frenchay Activities Index.

RESULTS

Using our previously derived AIB classification rule, AIB cases scored poorly on functional, social and psychological indicators. Further, cluster analysis of discharge data replicated the rule for identifying patients with AIB. AIB was a strong predictor of functional competence and performance at rehabilitation discharge and both six and twelve months later, while depression was associated with an inactive lifestyle at both six and twelve months. Greater stroke knowledge and clearer expectations of rehabilitation were associated with better functional outcome at discharge. Family functioning was strongly associated with lifestyle activities and ADL performance at both six and twelve months.

CONCLUSIONS

The procedure for identifying AIB in this rehabilitation environment appears to be robust. AIB was a key determinant of long-term functional disability, while depression was associated with poorer social functioning. Family functioning was an important determinant of social activities, and of the activities the patient actually does, rather than those the patient is capable of carrying out. Good stroke knowledge and clear expectations of rehabilitation were important determinants of rehabilitation success, and should be fostered to ensure a good rehabilitation outcome. Psychological factors are crucial in determining long-term outcomes after rehabilitation from stroke.