The role of rehabilitation psychology in stroke care described through case examples

What are the effects of pharmacological, non-invasive brain stimulation and psychological interventions, and their combination, in the treatment of post-stroke depression? A Cochrane Review summary with commentary

BACKGROUND

Post-stroke depression (PSD) is a prevalent condition that can significantly influence the recovery process.

OBJECTIVE

To assess the effects of pharmacological, non-invasive brain stimulation and psychological interventions, and their combination on PSD.

METHODS

A summary of the Cochrane Review by Allida et al. (2023), with comments from a rehabilitation perspective.

RESULTS

Sixty-one studies with 5831 participants were included in the Cochrane Review. Very low-certainty evidence indicated favorable treatment effects of pharmacological interventions, psychological therapies, and the combination of pharmacological intervention and non-invasive brain stimulation on PSD. Pharmacological intervention has resulted in increased side effects associated with the central nervous system and gastrointestinal system, with very low-certainty evidence.

CONCLUSION

Evidence for the effectiveness of pharmacological, psychological, and combination therapies for the management of PSD is uncertain, as the quality of the evidence has been assessed as very low. Therefore, further studies with improved methods should investigate pharmacological and non-pharmacological interventions for the treatment of depression in stroke survivors.

Examining the impact of spatial accessibility to rehabilitation facilities on the degree of disability: A heterogeneity perspective

The positive effect of healthcare facilities on residents' health has been extensively studied. However, few studies have focused on the role of rehabilitation services as unique healthcare services for persons with disabilities. This study aimed to examine the relationship between the spatial accessibility of rehabilitation facilities and the degree of disability. To this end, an approach of measuring the spatial accessibility of rehabilitation facilities to persons with disabilities was proposed. This approach integrates multiple key elements including the characteristics of facilities (i.e., the capacity, frequency of use and service radius), characteristics of the mobility of persons with disabilities (i.e., the mode of travel, escort support, transportation fee and barrier-free environment requirements) and travel time obtained from a routing application programme interface. The accessibility of rehabilitation facilities was calculated at the neighbourhood level within the Central Urban Area of Tianjin Municipality. The ordinal logistic regression analysis revealed that higher accessibility to rehabilitation facilities generally corresponded to lower severity of disability. However, the impact varied depending on the type of disability. Increased accessibility was associated with greater severity of intellectual disability, whereas it was linked to reduced severity of visual, hearing, limb, mental and speech disabilities. It is suggested to incorporate disability diversity and the accessibility of rehabilitation facilities into spatial planning and governance.

Mediating effect of post-stroke depression between activities of daily living and health-related quality of life: meta-analytic structural equation modeling

BACKGROUND

Stroke survivors face various problems that affect their health-related quality of life (HRQoL). Reduced activities of daily living (ADL) may contribute to post-stroke depression (PSD) and low HRQoL, and depression might be associated with low HRQoL. However, these relationships are not well known. This study aimed to analyze correlations among ADL, PSD, and HRQoL in stroke survivors and further explore the mediating role of PSD between ADL and HRQoL.

METHODS

This study utilized meta-analytic structural equation modeling (MASEM) on systematically searched articles from six electronic databases, namely PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure (China), Wanfang database (China), and SinoMed (China), from inception up to July 31, 2021. Two researchers independently assessed study eligibility, and data from the eligible studies were encoded and assessed for quality. MASEM was utilized to examine correlations among ADL, PSD, and HRQoL, with an estimation of a pooled correlation matrix under a random-effects model. The matrix was directly fitted to a structural equation model using webMASEM.

RESULTS

In total, 8580 articles were screened, and data from 27 studies involving 33 effect sizes were used in the MASEM analysis. Correlations among the three variables were significant (both P < 0.01). Furthermore, PSD partially mediated the correlation between ADL and HRQoL (β = 0.24, 95% confidence interval 0.15-0.30).

CONCLUSIONS

The findings suggest that both decreased ADL and PSD may reduce HRQoL, while a decrease in ADL tends to cause depression after stroke. Therefore, ADL and PSD reductions should be improved to achieve better HRQoL of stroke survivors. Future studies should continue to discuss other factors affecting HRQoL to achieve optimal recovery in stroke survivors.

A Qualitative Study on the Humanistic Care Needs of Patients with Stroke and Their Families

Background

International stroke care guidelines recommend the routine assessment and management of psychological and emotional problems in patients and their families after a stroke. This study aimed to explore the humanistic nursing needs of patients with stroke and their families and provide a basis for the construction of humanistic nursing practice guidelines for advanced stroke.

Methods

From September to October 2019, using the descriptive phenomenological research method, a semi-structured interview outline was formed based on a literature review and subject group discussions. A targeted sampling method was used to investigate 21 patients with stroke and 21 family members, respectively, and their care needs were investigated in depth. Colaizzi's thematic cluster analysis was used to analyse the data, and a total of 6 themes and 14 sub-themes were summarised.

Results

The 6 themes and 14 sub-themes were as follows: ① psychological care, ② security concerns (professional personal integrity, timely response), ③ emotional care (service consciousness, positive incentives, empathy, effective communication, provision of a communication platform, personalised care), ④ respect for rights, ⑤ rehabilitation care (rehabilitation programme, professional guidance, rehabilitation configuration, continuation of services) and ⑥ family care (physical and psychological support, care guidance).

Conclusion

Among the humanistic care needs of patients with stroke and their families, the most basic physiological care accounts for the largest proportion of emotional and rehabilitation care, followed by safety care, respect for rights and family care. Based on the actual humanistic care needs of patients with stroke and their families, the practical effect of humanistic care in stroke wards can be improved. This study provides a reference for the construction of humanistic nursing practice guidelines for late stroke.

Development of humanistic nursing practice guidelines for stroke patients

Purpose

To construct humanistic nursing practice guidelines suitable for stroke patients.

Design

This study was a development and validation study of guidelines using multiple methods, including literature review, qualitative research, questionnaire survey, thematic discussion, and Delphi expert consultation.

Methods

Twenty-five experts from seven provinces and municipalities in China were interviewed over two rounds from December 2020 to February 2021. The first-level index was scored for importance and rationality, while the second-level index was scored for importance and feasibility using a five-point Likert scale. Delphi data was collected via a paper version of the questionnaire. The coefficients of variation and coordination were used to represent the degree of dispersion of expert opinions.

Findings

In the two rounds of letter consultation, the questionnaire's recovery and effective rates were both 100%, while the opinion submission rates of the two rounds were 84 and 52%, respectively. Moreover, the expert authority coefficient was 0.91, and the coordination coefficients of expert opinions in the first round were as follows: importance of 0.03 and rationality of 0.07 for the first-level index; importance of 0.09 and feasibility of 0.11 for the secondary index. In round two, the coordination coefficients of expert opinions were as follows: importance of 0.04 and rationality of 0.05 for the first-level indicators; importance of 0.12 and feasibility of 0.10 for the secondary index. The results for the secondary index were P < 0.001 for the two rounds. The humanistic nursing practice guidelines for stroke patients that were ultimately formed included five first-level indicators (physiological care, safety care, emotional care, dignity care, and rehabilitation needs) and 46 s-level indicators.

Conclusion

Our results show that the "Practice Guidelines for Humanistic Nursing for Stroke" established by experts adopts Maslow's hierarchy of needs as its structural framework. It meets people's basic needs and can provide a reference for the construction of a humanistic nursing specialty practice for stroke patients.

Clinical relevance

Humanistic nursing guidelines for stroke could provide a reference for the construction of humanistic nursing practice in the stroke specialty.

Clinical resources

Copeptin and long-term risk of recurrent vascular events after transient ischemic attack and ischemic stroke: population-based study https://pubmed.ncbi.nlm.nih.gov/26451023/. Effectiveness and usage of a decision support system to improve stroke prevention in general practice: a cluster randomized controlled trial https://pubmed.ncbi.nlm.nih.gov/28245247/. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association https://pubmed.ncbi.nlm.nih.gov/27145936/.

Reminiscence therapy is a feasible care program for improving cognitive function, anxiety, and depression in recurrent acute ischemic stroke patients: a randomized, controlled study

OBJECTIVE

Reminiscence therapy provides benefits among first-episode acute ischemic stroke (AIS) patients and their caregivers. This study intended to further compare the effect of reminiscence therapy plus usual care (RTUC) and usual care (UC) on cognitive function, anxiety, and depression among recurrent AIS patients.

METHODS

Totally, 160 recurrent AIS patients were enrolled and randomized in a 1:1 ratio into the RTUC group (N = 81) and UC group (N = 79), then a 12-month corresponding intervention was conducted in each group. Mini-Mental State Examination (MMSE) score and Hospital Anxiety and Depression Scale (HADS) were evaluated on discharge (M0), at month (M) 3, M6, M9, and M12 after discharge.

RESULTS

MMSE scores at M6 (27.0 ± 1.6 vs. 26.3 ± 2.3, P = 0.031) and M12 (27.0 ± 1.7 vs. 26.1 ± 2.4, P = 0.009) were elevated, while cognitive impairment rate at M12 (29.2% vs. 45.7%, P = 0.042) and cognitive impairment severity at M12 (P = 0.029) were declined in RTUC group compared to UC group. Meanwhile, the HADS-anxiety scores at M9 (5.7 ± 3.1 vs. 6.9 ± 4.0, P = 0.046) and M12 (5.6 ± 2.7 vs. 7.0 ± 4.3, P = 0.024), anxiety rate at M12 (22.2% vs. 38.2%, P = 0.039) and anxiety severity at M12 (P = 0.018) were declined in RTUC group compared to UC group. Besides, the HADS-depression score at M12 (5.7 ± 3.1 vs. 6.8 ± 3.3, P = 0.043) was decreased in RTUC group compared to UC group, but depression rate and severity were not different between the two groups at each visit point (all P > 0.05).

CONCLUSION

RTUC program elevates cognitive functions and alleviates mental problems in recurrent AIS patients.

Memory rehabilitation: restorative, specific knowledge acquisition, compensatory, and holistic approaches

Memory impairment following an acquired brain injury can negatively impact daily living and quality of life—but can be reduced by memory rehabilitation. Here, we review the literature on four approaches for memory rehabilitation and their associated strategies: (1) the restorative approach, aimed at a return to pre-morbid functioning, (2) the knowledge acquisition approach, involving training on specific information relevant to daily life, (3) the compensatory approach, targeted at improving daily functioning, and (4) the holistic approach, in which social, emotional, and behavioral deficits are addressed alongside cognitive consequences of acquired brain injury. Each memory rehabilitation approach includes specific strategies such as drill and practice (restorative), spaced retrieval (knowledge acquisition), memory aids (compensatory), or a combination of psychotherapy and cognitive strategies (holistic). Past research has demonstrated mixed support for the use of restorative strategies to improve memory function, whereas knowledge acquisition strategies show promising results on trained tasks but little generalization to untrained tasks and activities of daily living. Compensatory strategies remain widely used but require intensive training to be effectively employed. Finally, the holistic approach is becoming more widespread due to improvements in psychosocial wellbeing, yet there are considerable resource and cost requirements. Several factors can influence rehabilitation outcomes including metacognition and emotional disturbances. Considerations for future research to improve the applicability of strategies for memory rehabilitation include assessing memory impairment severity, examining memory needs in daily life, and exploring the long-term effects of memory rehabilitation.

Third wave cognitive behavioural therapies for people with multiple sclerosis: a scoping review

PURPOSE

Multiple sclerosis (MS) is a chronic condition linked to a wide range of psychological difficulties. While traditional cognitive behavioural therapy has been studied extensively with people with MS, much less is known about more recent "third wave" approaches.

METHODS

A scoping review was carried out by performing a systematic search across MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library up to January 2022.

RESULTS

From an initial return of 8306 citations, 35 studies were included, 20 of which were randomised controlled trials (RCTs). These showed that four third wave approaches have been investigated with people with MS to date: acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT). MBSR and MBCT may be helpful to address a range of psychological difficulties up to three months post-intervention. However, MS-specific adaptations may be required, and more evidence is needed on longer-term effectiveness. Limited evidence is also available for DBT and ACT, but additional research is warranted before any recommendation can be made.

CONCLUSIONS

As third wave approaches keep being refined, further more rigorous investigations are needed to implement them to the benefit of people with MS. Implications for RehabilitationMultiple sclerosis is linked to a wide range of psychological difficulties in adults.Little is currently known on third wave psychotherapies for people with MS.Mindfulness-based stress reduction and mindfulness-based cognitive therapy may be helpful to address a wide range of difficulties in MS.Specific adaptations may be needed to deliver suitable therapies to people with MS.Additional research is warranted to build on preliminary findings for DBT and ACT.

Personalized Neurophysiological and Neuropsychological Assessment of Patients with Left and Right Hemispheric Damage in Acute Ischemic Stroke

The leading factors of post-stroke disability are motor disorders and cognitive dysfunctions. The aim of the study was to identify and provide a rationale for the variable early cognitive dysfunction in right and left hemispheric damage in patients with acute stroke. The study included 80 patients diagnosed with ischemic stroke. All patients were assessed for cognitive status, depression, fatigue and anxiety. For objectification, the method of evoked potentials (P300) and neuroimaging were used. Our findings revealed distinguishing features of cognitive dysfunction and identified a combination of the most informative markers characteristic of right and left hemispheric damage in patients with acute ischemic stroke. In patients with damage to the left hemisphere, a predominance of dysregulation syndrome (decrease in executive function and attention) was revealed, accompanied by various disorders such as severe anxiety and fatigue. The causes of this cognitive dysfunction may be directly related to stroke (damage to subcortical structures), as well as to a preexisting reduction in higher mental functions associated with age and vascular conditions. Cognitive impairments in patients with lesions of the right hemisphere were characterized by polymorphism and observed in the mental praxis, speech (with predominant semantic component) and abstract thinking domains. They are closely linked to each other and are more related to the lateralization of the lesion and preexisting neurodegeneration than to the localization of the ischemic lesion. The study of P300-evoked potentials is a good tool for confirming cognitive dysfunction. The latent period of the P300 wave is more sensitive to neurodegeneration, while the amplitude factor characterizes vascular pathology to a greater extent. The results of the study provide a rationale for a comprehensive assessment of lateralization, stroke localization, underlying diseases, neurophysiological parameters and identified cognitive impairments when developing a plan of rehabilitation and neuropsychological measures aimed at cognitive and emotional recovery of patients both in the acute phase of ischemic stroke and when selecting further personalized rehabilitation programs.

Behavioral Activation Therapy for Subthreshold Depression in Stroke Patients: An Exploratory Randomized Controlled Trial

BACKGROUND

Subthreshold depression (SD) is known to be a major risk factor for the development of post-stroke depression (PSD). Appropriate intervention to prevent the transition from SD to PSD is thus imperative. As a form of short-term psychotherapy adapted for individuals with cognitive and communication impairments, behavioral activation therapy (BAT) may be a suitable choice. However, the effects of BAT on psychological outcomes in stroke patients with SD has not been established. This study investigated the feasibility and effectiveness of BAT in reducing the development of depressive symptoms in this patient population.

METHODS

A double-blind, randomized controlled trial was performed. Seventy participants were randomized to either a BAT group (n=35) or a control group (n=35). Participants in the BAT group received a six-week BAT intervention. The feasibility of BAT was assessed by the number of sessions attended by participants, and the acceptability of BAT to participants and the incidence of adverse events were recorded. The primary clinical outcome measure was the Center for Epidemiological Studies Depression Scale (CES-D) and the 17-item Hamilton Depression Scale (HAMD-17) at baseline, six weeks, and three months after the group allocation. Secondary outcomes included behavioral activation and the incidence of depression.

RESULTS

The intervention was feasible and acceptable, with 94.3% of participants in the BAT group (33 of 35) attending at least five sessions. No adverse events were reported in either group. Compared with the control group, the BAT group showed significant improvements in the CES-D (F=67.689, P<0.05), HAMD-17 (F=4.170, P<0.05), and behavioral activation (F=25.355, P<0.05) scores after intervention, and these differences were maintained at the three-month assessment.

CONCLUSION

BAT appears to be feasible and efficacious for reducing depressive symptoms and increasing behavioral activation among stroke patients with SD. The findings of this study may contribute to the primary prevention of PSD.

Psychological Experience of Humanistic Care Among Medical Staff in Stroke Wards: A Qualitative Research Study Conducted in China

BACKGROUND

As a special patient group, stroke patients have a significant attachment to humanistic care. However, multiple problems remain in clinical practice. Medical staff in stroke wards are the primary providers of humanistic care. Finding out the opinions of the staff that provide these medical services is vitally important for stroke patients that need access to curative and humanistic care.

OBJECTIVE

The aim of the study is to explore the psychological experiences of doctors, nurses, and physiotherapists during the implementation of humanistic care in stroke wards.

METHOD

This is a qualitative phenomenological study. Medical staff (i.e., doctors, nurses, and physiotherapists) were selected from stroke wards in general hospitals (minimum level two) from 13 cities within six provinces in China. A purposive sampling method was used until saturation (n = 18). Face-to-face or video call semi-structured interviews were conducted by using a phenomenological research method. The average interview length was 60 min (range 30-90 min). The Colaizzi seven-step method was used for analysis.

RESULTS

Four themes and 12 sub-themes were extracted from the qualitative interviews of the medicine, nursing and technology staff, as follows. ➀ The ward staff reported that the behaviors of the stroke patients gradually improved when they assisted with stroke treatment idea changes, when they paid attention to solving the patients' existing problems, and when they took the initiative to create a caring atmosphere; ➁ when humanistic care in the stroke wards was carried out with consciousness and ability improvement (including proactive caring behaviors in which vocational value was not strong and in which the whole-person rehabilitation was given attention, not just implementation), the patients' behaviors improved; ➂ the stroke wards themselves were improved (the gap between the current management and the needs of medical institutions and the gap between the rehabilitation conditions and the patients' needs were addressed); and ➃ the urgent needs of the staff in the implementation of humanistic care in stroke wards were considered (the addition of full-time posts, the effective training of humanistic care, and the construction of a more harmonious doctor-patient relationship).

CONCLUSION

In implementing humanistic care in stroke wards, the consciousness and ability of the medical staff need to be improved. In addition, the practical problems and contradictions affecting the development of humanistic care must be addressed. To improve the level of humanistic care in stroke wards, attention should be paid to the overall improvement of the personal qualities of the medical staff and the integration of a humanistic management mode.

Arm-Hand Boost Therapy During Inpatient Stroke Rehabilitation: A Pilot Randomized Controlled Trial

Objective: It was the aim to assess feasibility, safety, and potential efficacy of a new intensive, focused arm-hand BOOST program and to investigate whether there is a difference between early vs. late delivery of the program in the sub-acute phase post stroke. Methods: In this pilot RCT, patients with stroke were randomized to the immediate group (IG): 4 weeks (4 w) BOOST +4 w CONTROL or the delayed group (DG): 4 w CONTROL +4 w BOOST, on top of their usual inpatient care program. The focused arm-hand BOOST program (1 h/day, 5x/week, 4 weeks) consisted of group exercises with focus on scapula-setting, core-stability, manipulation and complex ADL tasks. Additionally, 1 h per week the Armeo®Power (Hocoma AG, Switzerland) was used. The CONTROL intervention comprised a dose-matched program (24 one-hour sessions in 4 w) of lower limb strengthening exercises and general reconditioning. At baseline, after 4 and 8 weeks of training, the Fugl-Meyer assessment upper extremity (FMA-UE), action research arm test (ARAT), and stroke upper limb capacity scale (SULCS) were administered. Results: Eighteen participants (IG: n = 10, DG: n = 8) were included, with a median (IQR) time post stroke of 8.6 weeks (5-12). No adverse events were experienced. After 4 weeks of training, significant between-group differences were found for FMA-UE (p = 0.003) and SULCS (p = 0.033) and a trend for ARAT (p = 0.075) with median (IQR) change scores for the IG of 9 (7-16), 2 (1-3), and 12.5 (1-18), respectively, and for the DG of 0.5 (-3 to 3), 1 (0-1), and 1.5 (-1 to 9), respectively. In the IG, 80% of patients improved beyond the minimal clinical important difference of FMA-UE after 4 weeks, compared to none of the DG patients. Between 4 and 8 weeks of training, patients in the DG tend to show larger improvements when compared to the IG, however, between-group comparisons did not reach significance. Conclusions: Results of this pilot RCT showed that an intensive, specific arm-hand BOOST program, on top of usual care, is feasible and safe in the sub-acute phase post stroke and suggests positive, clinical meaningful effects on upper limb function, especially when delivered in the early sub-acute phase post stroke. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04584177.

Reminiscence therapy-based care program relieves post-stroke cognitive impairment, anxiety, and depression in acute ischemic stroke patients: a randomized, controlled study

BACKGROUND

Cognitive and mental impairments are common health problems in acute ischemic stroke (AIS) patients. In this study, we aimed to assess the benefit of a reminiscence therapy-based care (RTBC) program on cognitive impairment restoration, anxiety, and depression reduction in AIS patients.

METHODS

Totally 130 AIS patients were recruited in this randomized, controlled study and randomly assigned to the RTBC group or control group in 1:1 ratio for 12-month intervention. Mini-Mental State Examination (MMSE), Montreal cognitive assessment (MoCA), Hospital Anxiety and Depression Scale for anxiety/depression (HADS-A/HADS-D), and Zung self-rating anxiety/depression scale (SAS/SDS) were assessed at month 0 (M0), M3, M6, M9, and M12. Meanwhile, patients' satisfaction was also evaluated at M3, M6, M9, and M12.

RESULTS

RTBC increased MMSE score and MoCA score and reduced cognitive impairment patients' percentage assessed by MoCA score at M12 compared with control. RTBC reduced HADS-A score at M12, but not anxiety patients' percentage or severity by HADS-A at M12; besides, RTBC significantly lowered the SAS score at M9 and M12, and anxiety patients' percentage and severity by SAS at M12 compared with control. RTBC reduced HADS-D score at M9 and M12 (while statistically non-significant), but not depression patients' percentage or severity by HADS-D at M12; it decreased SDS score at M9 and M12, but not depression patients' percentage or severity by SDS at M12 compared with control. Additionally, RTBC obsessed higher patients' satisfaction at M3, M6, and M12 compared with control.

CONCLUSION

RTBC could help reduce cognitive impairment, anxiety, and depression in post-stroke management for AIS patients.