Implementation of evidence-based assessment of upper extremity in stroke rehabilitation: From evidence to clinical practice

Objective

There is an evidence–practice gap in assessment of the upper extremities during acute and subacute stroke rehabilitation. The aim of this study was to target this gap by describing and evaluating the implementation of, and adherence to, an evidence-based clinical practice guideline for occupational therapists and physiotherapists.

Methods

The upper extremity assessment implementation process at Sahlgrenska University Hospital comprised 5 stages: mapping clinical practice, identifying evidence-based outcome measures, development of a guideline, implementation, and evaluation. A systematic theoretical framework was used to guide and facilitate the implementation process. A survey, answered by 44 clinicians (23 physiotherapists and 21 occupational therapists), was used for evaluation.

Results

The guideline includes 6 primary standardized assessments (Shoulder Abduction, Finger Extension (SAFE), 2 items of the Actions Research Arm Test (ARAT-2), Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Box and Block Test (BBT), 9-Hole Peg Test (9HPT), and grip strength (Jamar hand dynamometer)) performed at specified time-points post-stroke. More than 80% (35 to 42) clinicians reported reported being content with the guideline and the implementation process. Approximately 60–90% of the clinicians reported good adherence to specific assessments, and approximately 50% reported good adherence to the agreed time-points. Comprehensive scales were more difficult to implement compared with the shorter screening scales. High levels of work rotation among staff, and the need to prioritize other assessments during the first week after stroke, hindered to implementation.

Conclusion

The robustness of evidence, adequate support and receptive context facilitated the implementation process. The guideline enables a more structured, knowledge-based and consistent assessment, and thereby supports clinical decision-making and patient involvement.

Stroke survivors' long-term QALY-weights in relation to their spouses' QALY-weights and informal support: a cross-sectional study

Background

Healthcare interventions that have positive effects on the stroke survivors’ health-related quality of life (HRQoL) and quality-adjusted life-years (QALYs) might also have positive effects for their spouses in terms of improved HRQoL and/or reduced spousal informal support. However, knowledge about stroke survivors’ HRQoL and QALY and the consequences for their spouses’ HRQoL and QALY is limited. Therefore, the aim of this study was to describe the HRQoL and QALY-weights in dyads of stroke survivors in comparison with dyads of healthy controls, and to study the relationship between the stroke survivors’ QALY-weights and consequences for spouses in terms of QALY-weight and annual cost of informal support, using a long-term perspective.

Methods

Data on stroke survivors, controls, and spouses were collected from the seven-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). HRQoL was assessed by the SF-36, and the preference-based health state values were assessed with the SF-6D. The magnitude of the support was assessed with a study specific time-diary. An ordinary least squares (OLS) regression was used to estimate the association between stroke survivors’ and spouses’ QALY-weights. A two-part econometric model was used to estimate the association between stroke survivors’ QALY-weights and the time spent and cost of spouses’ informal support.

Results

Cohabitant dyads of 248 stroke survivors’ aged <70 at stroke onset and 245 controls were included in the study. Stroke survivors had lower HRQoL in the SF-36 domains physical functioning, physical role, general health, vitality (P < 0.001), and social functioning (P = 0.005) in comparison with their cohabitant spouses. There was no significant difference in HRQoL for the dyads of controls. The results from the regression analyses showed that lower QALY-weights of the stroke survivors were associated with lower QALY-weights of their spouses and increased annual cost of spousal informal support.

Conclusion

Our results show that the QALY-weights for stroke survivors had consequences for their spouses in terms of annual cost of spousal informal support and QALY-weights. Hence, economic evaluation of interventions that improve the HRQoL of the stroke survivors but ignore the consequences for their spouses may underestimate the value of the intervention.

Long-term QALY-weights among spouses of dependent and independent midlife stroke survivors

Purpose

The aim of this study was to investigate whether the dependency of midlife stroke survivors had any long-term impact on their spouses’ QALY-weights.

Method

Data on stroke survivors, controls, and spouses were collected from the 7-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke. Health-related quality of life was assessed by the SF-36, and the preference-based health state values were assessed with the SF-6D. Spouses of dependent and independent stroke survivors were categorized according to their scores on the modified Rankin Scale. An ordinary least squares regression analysis was used to evaluate whether the dependency of the stroke survivors had any impact on the spouses’ QALY-weights.

Result

Cohabitant dyads of 247 stroke survivors aged <70 at stroke onset and 245 dyads of controls were included in the study. Spouses of dependent stroke survivors (n = 50) reported a significant lower mean QALY-weight of 0.69 in comparison to spouses of independent stroke survivors (n = 197) and spouses of controls, (n = 245) who both reported a mean QALY-weight of 0.77. The results from the regression analysis showed that higher age of the spouse and dependency of the stroke survivor had a negative association with the spouses’ QALY-weights.

Conclusion

The QALY-weights for spouses of dependent midlife stroke survivors were significantly reduced compared to spouses of independent midlife stroke survivors. This indicates that the inclusion of spouses’ QALYs in evaluations of early treatment and rehabilitation efforts to reduce stroke patients’ dependency would capture more of the total effect in dyads of stroke survivors.

Long-term cost of spouses' informal support for dependent midlife stroke survivors

OBJECTIVES

Stroke is a major global disease that requires extensive care and support from society and relatives. The aim of this study was to identify and quantify the long-term informal support and to estimate the annual cost of informal support provided by spouses to their stroke surviving partner.

METHOD

Data were based on the 7-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke. One-third of the spouses stated that they provided support to their stroke surviving partner. The magnitude of the support was assessed with a study-specific time-diary and was estimated for independent and dependent stroke survivors based on the scores of the modified Rankin Scale. To deal with skewed data, a two-part econometric model was used to estimate the annual cost of informal support.

RESULT

Cohabitant dyads of 221 stroke survivors aged <70 at stroke onset were included in the study. Spouses of independent stroke survivors (n = 188) provided on average 0.15 hr/day of practical support and 0.48 hr/day of being available. Corresponding figures for spouses of dependent stroke survivors (n = 33) were 5.00 regarding practical support and 9.51 regarding being available. The mean annual cost of informal support provided for independent stroke survivors was estimated at €991 and €25,127 for dependent stroke survivor.

CONCLUSION

The opportunity cost of informal support provided to dependent midlife stroke survivors is of a major magnitude many years after stroke onset and should be considered in economic evaluations of health care.

Psychological well-being of spouses of stroke patients during the first year after stroke

Objective: To investigate whether spouses' psychological well-being changed between the first weeks after their partner's stroke and four months and one year later, and to study the relationship between spouses’ psychological well-being and objective characteristics of the stroke patients.

Design: Prospective, longitudinal study.

Setting: Hospital care and follow-ups.

Subjects: Sixty-seven consecutively enrolled spouses to first-ever stroke patients B/ 75 years.

Main measures: The Psychological General Well-Being (PGWB) Index. Clinical examination of the stroke patients. The Barthel Index.

Results: The spouses' psychological well-being was significantly lower in the first weeks after their partner's stroke as compared with norms. At four months, it had increased significantly. Between four months and one year, individual changes were observed in both positive and negative directions; thus, the mean level of the group remained constant. The spouses’ psychological well-being in the first weeks was significantly related to the patients’ sensorimotor impairments, while it was related at four months to cognitive impairment and the patients’ abilities in self-care. At one year, psychological well-being was related to remaining sensorimotor and cognitive impairments. A significant relationship was also seen between the spouses’ and the stroke patients’ emotional health.

Conclusions: The spouses' psychological well-being increased after the first chaotic weeks. The presence of visible impairments initially seemed to affect spouses’ emotional health, while cognitive and emotional impairments became more evident in everyday life. In the long term, however, the spouses’ individual life situations and coping abilities seem to be of relatively increasing importance for their continued well-being.

Spouses of Stroke Survivors Report Reduced Health-Related Quality of Life Even in Long-Term Follow-Up

Background and Purpose—

The consequences for the family of stroke survivor are generally studied in a short-term perspective. The aim of this study was to assess long-term aspects of health-related quality of life among spouses of stroke survivors.

Methods—

Data on stroke survivors, controls, and spouses were collected from the 7-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). The health-related quality of life of spouses was assessed by the Short Form-36, and the characteristics of stroke survivors were assessed using the National Institutes of Health Stroke Scale, the Mini-Mental State Examination, the Hospital Anxiety and Depression Scale, the Barthel Index, and the modified Rankin Scale.

Results—

Dyads of 248 stroke survivors aged <70 at stroke onset and 245 dyads of matched controls were included. Spouses of stroke survivors and spouses of controls had a median age of 64 and 65, respectively; proportion of men was 35% and 34%, respectively. The spouses of stroke survivors reported lower scores in all the mental domains ( P =0.045; P <0.001), as well as in the domains of general health ( P =0.013) and physical role ( P =0.006), compared with the spouses of controls. Predictors of poor physical health of the spouses were their own age and the level of global disability of the stroke survivor. Predictors of poor mental health of the spouses were depressive symptoms, cognitive impairment, and global disability among the stroke survivors.

Conclusions—

The health-related quality of life of spouses of stroke survivors is reduced not only during the first years but also in the long-term perspective.

Comparison of life satisfaction within couples one year after a partner's stroke

OBJECTIVE

To compare life satisfaction within couples one year after a partner's stroke and with norm values and social factors.

SUBJECTS AND METHODS

A total of 56 couples were consecutively included. The respondents estimated life satisfaction using the Life Satisfaction Checklist 9-item version. Patients' impairments, self-care ability and handicap were assessed. Social characteristics were registered. Non-parametrical statistical methods were used for analyses.

RESULTS

Patients were physically mildly disabled by their stroke. The most common symptom was mental fatigability. Patients were, in general, less satisfied than spouses. The couples were less satisfied than norms. Satisfaction with life as a whole, leisure and sex life were most affected for both patients and spouses. Relationship with partner was the only domain in which patients were more satisfied than their spouses and almost equally satisfied compared with norms. The proportion of couples in which both partners agreed they were satisfied, for the following domains was: leisure time 20%, sex life 25%, vocation/occupation 29%, life as a whole 30%, finances 47%, social contacts 48%, relationship with partner 60%, family life 66% and ability in self-care 66%.

CONCLUSION

Life satisfaction was negatively affected in both partners, although in different life domains. Support should address the different needs of patients and spouses as well as their mutual needs.

Life satisfaction in spouses of patients with stroke during the first year after stroke

OBJECTIVE

The aims of this study were to investigate whether spouses' life satisfaction changed between their life prior to their partner's stroke, and at 4 months and 1 year after stroke, and to study the association between spouses' life satisfaction and objective characteristics of the stroke patients.

SUBJECTS AND METHODS

Sixty-seven consecutively enrolled spouses to first-ever stroke patients < 75 years of age participated. Life satisfaction was measured with the Life Satisfaction Checklist (LiSat-9).

RESULTS

Compared with their life before stroke, the spouses' satisfaction with life as a whole, their leisure situation, daily occupation, sexual life, partner relationship and social contacts was lower 4 months after stroke. No significant change in life satisfaction was observed between 4 months and 1 year. Spouses of patients with sensorimotor impairment and low ability in self-care were less satisfied with their leisure situation, daily occupations, own ability in self-care, sexual life and partner relationship. Spouses of patients with cognitive or astheno-emotional impairments were less satisfied with their partner relationship, family life and sexual life. The associations were stronger at 1 year than at 4 months.

CONCLUSION

There is a need for support over a long time period that focuses on the social, occupational and leisure situation of spouses as well as that of patients.

Spouses of first-ever stroke patients: their view of the future during the first phase after stroke

BACKGROUND

A partner's stroke can be perceived as a critical event by a spouse. Previous studies have focused primarily on the impact of stroke on spouses' psychosocial well-being over the long term. However, the experience of spouses in the first phase after stroke is not well known.

AIM

To investigate spouses' perception of their future daily life after stroke and the association between this perception and the objective characteristics of the stroke.

METHOD

Eighty-three consecutively enrolled spouses of first-ever stroke patients < 75 years admitted to Sahlgrenska University Hospital in Göteborg, Sweden participated. The mean age of the spouses was 57 years. Sixty-two of the spouses were women and 21 men. Interviews about their experiences 10 days after onset were generally made at the hospital. The interviews were analysed, categorized and combined with statistical analyses of variables such as ages and sex of the spouses, type of lesion and presence of neurological impairments in the stroke patient.

RESULTS

Four different categories of the concept 'view of the future' were developed on the basis of the interviews. Of the different characteristics of the stroke, the severity of the sensorimotor impairment seemed to have the greatest impact on the spouses' view of the future. The spouses of stroke patients with pure sensorimotor impairment were more likely to have an optimistic view of the future than when the sensorimotor impairment was combined with cognitive deficits. There was a broad distribution of the different characteristics of stroke between the four categories.

CONCLUSIONS

Although the perception of future daily life varied, it was possible to categorize the spouses' cognitive image of future life according to degree of optimism. While the severity of stroke was of importance, the individual perception of the disease, impact on future activities and the spouses' own coping capacity was of great significance for the perception of future daily life.

Spouses of first-ever stroke victims: sense of coherence in the first phase after stroke

According to Antonovsky, the individual's sense of coherence is assumed to be crucial in coping with stressful life events. The purpose of this study was to investigate the associations between the sense of coherence of the spouses of stroke victims, the objective severity of the stroke and the spouses' perception of life satisfaction, psychological well-being and cognitive image of life in the future in the first phase after stroke. Eighty-three consecutively enrolled spouses to first-ever stroke victims < 75 years participated. Multiple correlations were done to study the association between Antonovsky's 29-item Sense of Coherence scale and the objective impairments of the stroke victim, the Life Satisfaction Checklist, the "view of the future" and the Psychological General Well-being Index. The sense of coherence was significantly associated with satisfaction with life as a whole before stroke (p < 0.001), partnership (p = 0.002), sexual life (p = 0.005), family life (p < 0.001) and financial situation (p = 0.001). The severity of the impairments of the stroke victims was not significantly associated with the spouses' sense of coherence. However, the sense of coherence was significantly associated with the perception of the future life situation (p = 0.006). The sense of coherence was also significantly associated with the perception of positive well-being (p = 0.007), self-control (p = 0.009), general health (p = 0.009) and vitality (p = 0.002) at the present, whereas the association with anxiety and depressed mood were not statistical significant. In the experience of a stressful life event such as stroke, satisfaction with general life, close relationships and the socio-economic situation were significantly associated with the spouse's sense of coherence. Spouses with a low sense of coherence were more likely to have low psychological well-being and a more pessimistic view of their life in the future.

Spouses of first-ever stroke patients: psychological well-being in the first phase after stroke

BACKGROUND AND PURPOSE

A stroke affects not only the patient but also the spouse. To better support the spouse during the acute phase of stroke, knowledge is needed about his or her experience with the situation. The aim of the present study was to study the well-being of the spouses of stroke patients during the acute state of stroke and to identify factors that may influence their well-being.

METHODS

Eighty-three consecutively enrolled spouses of first-ever stroke patients <75 years old participated. Their psychological well-being, measured by the Psychological General Well-Being Index 10 days after the stroke, was compared with norm values. Multiple analyses of correlation were performed to investigate the effects on psychological well-being of (1) age and sex, (2) level of impairment of the stroke patient, and (3) intrapersonal variables such as previous life satisfaction and view of the future.

RESULTS

The study group showed significantly lower psychological well-being compared with norm values except for the dimension of general health. The variables that correlated significantly with the Psychological General Well-Being total score were the sensorimotor impairment of the stroke patient and the "view of the future." This view of the future also correlated significantly with the level of functional ability of the stroke patients.

CONCLUSIONS

During the acute phase of stroke, the severity of the stroke has an impact on the spouse's image of his or her future life, whereas the individual appraisal of personal consequences and of his or her own coping capacity seems to have a greater impact on the psychological well-being of the spouses than does the objective state of disability.