Stroke in the under-75S: Expectations, concerns and needs

Effect of outpatient cardiac rehabilitation on motor function and health-related quality of life in stroke survivors

BACKGROUND

Outpatient cardiac rehabilitation (CR) is a promising tool for improving functional outcome in stroke survivors, however, evidence for improving emotional health is limited. We aimed to clarify the effects of outpatient CR following in-hospital stroke rehabilitation on health-related quality of life (HRQOL) and motor function.

METHODS

Patients with acute ischemic stroke or transient ischemic attack discharged directly home were recruited, and 128 patients who fulfilled criteria for insurance coverage of CR were divided into the CR (+) group (n = 46) and CR (-) group (n = 82). All patients underwent in-hospital stroke rehabilitation, and within 2 months after stroke onset, patients in the CR (+) group started a 3-month outpatient CR program of supervised sessions. Changes of motor function and HRQOL assessed by the short form-36 version 2 (SF-36) from discharge to 3 months post-discharge were compared between the two groups.

RESULTS

Twenty-six patients in the CR (+) group completed the program and 66 patients in the CR (-) group were followed up at a 3-month examination. Least-square mean changes in 6-minute walk distance and isometric knee extension muscle strength were significantly higher in the CR (+) group than the CR (-) group (52.6 vs. 16.3 m; 10.1 vs. 3.50 kgf/kg). Improvement of HRQOL at 3 months was not observed in the CR (+) group.

CONCLUSIONS

Outpatient CR following in-hospital stroke rehabilitation within 2 months after stroke onset improved exercise tolerance and functional strength but not HRQOL assessed by the SF-36 after completion of CR in the present cohort.

Unmet care needs of community-dwelling stroke survivors: a systematic review of quantitative studies

OBJECTIVES

Understanding the unmet needs of community-dwelling stroke survivors is essential for further intervention. This systematic review was performed to summarise their unmet needs from a quantitative viewpoint.

DESIGN

Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

A comprehensive search of six databases was conducted from inception to February 2020: PubMed, EMBASE, CINAHL, PsycINFO, SCOPUS and CBM. The methodological quality of the studies was assessed. Unmet needs were categorised, and a pooled analysis of the main outcomes was conducted.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included quantitative studies focused on the unmet needs of stroke survivors who live at homes rather than in any other institutionalised organisation.

RESULTS

In total, 32 of 2660 studies were included, and 1980 unmet needs were identified. The prevalence of patients with unmet needs ranged from 15.08% to 97.59%, with a median of 67.20%; the median number of unmet needs per patient ranged from 2 to 8 (0-31). The prevalence of unmet needs was high at 6 months post-stroke (62.14%) and 2 years post-stroke (81.37%). After categorisation, the main concerns among these patients were revealed to be information support, physical function and mental health; a few studies reported unmet needs related to leisure exercise, return to work and so on. Additionally, differences in the measurement tools used across studies affect what unmet needs participants report.

CONCLUSIONS

Sufficient, accurate, individualised and dynamic information support is a priority among community-dwelling stroke survivors. Physical function and mental health are also the most significant concerns for re-achieving social participation. It is essential to design and disseminate standard, effective and time-saving tools to assess unmet needs.

TRIAL REGISTRATION NUMBER

CRD42018112181.

A systematic review of social service and community resource interventions following stroke

PURPOSE

Finding and accessing social services and community resources are a challenge for stroke survivors and care partners. The purpose of this systematic review was to identify and review interventions that aimed to increase access and use of such services and resources post stroke.

METHOD

A systematic review of the published literature was performed using MEDLINE, CINAHL, PsycINFO, and ProQuest Nursing and Allied Health (January 2008 to May 2020). Studies were included if they were quantitative designs and reported on outcomes of interventions addressing post-stroke access to social services or community resources. Results were synthesised narratively.

RESULTS

3566 titles and abstracts were reviewed. Ten articles met the inclusion criteria. The interventions included in this review varied in terms of target group, timing, and type of support provided (passive or active tailored information provision, referral service, navigation assistance). Outcome measures, for social service and community resource access, included discharge preparedness measures, service counts, observations, satisfaction evaluations, interviews, and open-ended questions.

CONCLUSION

Overall, interventions demonstrated some improvements in information received and access to social services and community resources following stroke. Future research should focus on carrying out high quality studies that examine the effectiveness of various social service and community resource interventions, and on setting valid and reliable outcome measures.IMPLICATIONS FOR REHABILITATIONStroke survivors and care partners have unmet social service and community resource needs.Stroke survivors and care partners can benefit from interventions that provide information, referrals, and ongoing support to access services and resources.Clearly identifying social service and community resource needs is important for tailoring interventions to individual situations.Interventions should ideally be provided throughout the hospital stay, in acute care and rehabilitation, and continue on in the community.

Unmet care needs of community-dwelling stroke survivors: a protocol for systematic review and theme analysis of quantitative and qualitative studies

INTRODUCTION

Stroke is a leading cause of disability worldwide. The average hospital length of stay ranges from 3 to 28 days, and after discharge home the stroke survivors will live with physical, cognitive, even psychological disorders for the rest of their lives. It is essential to review the unmet needs of stroke survivors.

METHODS AND ANALYSIS

A systematic review of previous quantitative and qualitative studies reporting the unmet needs of stroke survivors in their homes will be conducted. The following six databases will be searched from inception to December 2018 for relevant articles: PubMed, EMBASE, CINAHL, PsycINFO, SCOPUS and China Biology Medicine. We will include studies limited to human and published in English or Chinese, and the patients with stroke should discharge home rather than any other professional organisations including nursing homes or community rehabilitation units and so on. Data of quantitative research will be standardised for comparison, thematic analysis will be used for qualitative data and a narrative synthesis and pooled analysis of the main outcomes will be reported.

ETHICS AND DISSEMINATION

This review will be submitted to an international professional journal, and the detailed search strategies and analysis flowchart will be openly included as supplements. This study does not require ethical approval as no patient's identifiable data will be used. Our findings will give a new look at the aspect of stroke survivors' unmet needs in their long-term recovery stage, especially the trajectories of unmet needs at different timepoints. What is more, this review will demonstrate the long-term unmet needs of stroke survivors from different countries, will compare any variations between high-income and low-income regions, and the geographical differences of needs will be mapped if necessary. We will endeavour to provide as much information as possible to healthcare professionals and public health policy makers in order to promote further medical reform.

TRIAL REGISTRATION NUMBER

CRD42018112181.

Impact of Co-occurring Dysarthria and Aphasia on Functional Recovery in Post-stroke Patients

Objective

To elucidate the impact of co-occurring dysarthria and aphasia on functional recovery in post-stroke patients.

Methods

The medical records, including results of primary screening tests and secondary definite examinations for language problems, of 130 patients admitted to our institute's Department of Rehabilitation Medicine were retrospectively reviewed. Functional outcomes were assessed longitudinally using the Functional Ambulation Category (FAC), Mini-Mental State Examination-Korean version (MMSE-K), European Quality of Life-5 Dimensions 3-Level version (EQ-5D-3L), the Korean version of the Modified Barthel index (K-MBI), and Motricity Index (MI) of the hemiplegic side.

Results

Patients were classified into four groups regarding language function: aphasia only (group A, n=9), dysarthria only (group D, n=12), aphasia and dysarthria (group AD, n=46), and none (group N, n=55). The initial functional outcome scores in the group AD were significantly poor compared to those of the groups N and A. Within groups, there were significant improvements in all outcome measurements in the groups AD and N. A between-group analysis revealed significant improvements in K-MBI for the group AD after adjusting for the initial severity and patient's age compared to other groups.

Conclusion

Post-stroke patients suffering from aphasia with dysarthria showed significantly lower initial functional level and relatively wide range of recovery potential in activities of daily living compared to patients without language problems.

Evaluation of brief interventions for managing depression and anxiety symptoms during early discharge period after stroke: a pilot randomized controlled trial

BACKGROUND

Prevalence estimates for depression and anxiety in individuals post-stroke are approximately 33 and 29%, yet there are few effective preventive interventions. Interventions which commence pre-discharge and continue during the early post-discharge period may support individuals during the critical transition to home adjustment period. This study aimed to evaluate the efficacy of a self-management intervention and a coping skills intervention, compared to usual care, on anxiety and depression post-stroke.

METHODS

A pilot, three-arm randomized trial involving 33 stroke patients (coping skills: n = 11, self-management: n = 12, usual care: n = 10) recruited from an Australian stroke unit. Both interventions were eight 1-hour weekly sessions, with the first two pre-discharge and the remainder at home; targeted both anxiety and depression; and tailored content to individuals. Primary outcome was severity of depressive and anxiety symptoms (measured using Montgomery andÅsberg Depression Rating Scale and Hospital Anxiety and Depression Scale). Secondary measures were: self-efficacy, stroke knowledge, basic and extended activities of daily living, and quality of life. Outcome measures were administered at baseline, one week post-intervention, and at a three month follow-up by a blinded assessor.

RESULTS

Thirty (91%) participants completed the trial. Immediately post-intervention there was a small improvement in stroke knowledge and a small increase in depression symptoms (on one of the two measures of depression symptoms) in the coping skills group compared to usual care. These differences did not remain significant at the 3-month follow-up, nor were there any other significant differences.

CONCLUSION

Neither a coping skills nor self-management intervention reduced anxiety nor depression symptoms early post-stroke more than usual care. Lack of statistical power may have contributed to the non-significant findings in this pilot study.

Aphasia and Dysarthria in Acute Stroke: Recovery and Functional Outcome

Background Aphasia and dysarthria have major implications for activities of daily living and social participation following stroke. Few studies describe recovery in the acute stroke setting. We described the evolution of aphasia and dysarthria by three-months poststroke. Methods We conducted a retrospective analysis of pooled clinical trial data from the Virtual International Stroke Trials Archive. We defined aphasia and dysarthria at baseline as a score of ≥1 on the Best Language (Item 9) and Dysarthria (Item 10) domains of the National Institutes of Health Stroke Scale, respectively. We described recovery from these impairments by three-months. Covariate adjusted analyses described the associations between aphasia, dysarthria, and functional outcome using the modified Rankin Scale at three-months following stroke. Results At baseline, 4039/8904 (45·4%) people presented with aphasia and 6192 (69·5%) with dysarthria; 2639 (29·6%) had both impairments. By three-months, aphasia and dysarthria had resolved in 1292/7219 (17·9%) and 2892/7219 (40·1%) survivors, respectively, but persisted in 1713/7219 (23·7%) and 1940/7219 (27%), respectively. Age and severity of initial stroke were associated with poor recovery, whereas thrombolysis was associated with improved recovery. Aphasia at baseline [ P = 0·049, odds ratio = 0·89, 95% confidence interval (0·79,1·00)] and persistent aphasia at three-months [ P < 0·0001, odds ratio = 0·31, 95% confidence interval (0·27, 0·35)] were each associated with poorer modified Rankin Scale scores at three-months. Conclusion Aphasia or dysarthria persisted in at least a quarter of people in our dataset at three-months following stroke. The association between persistent aphasia at three-months and poor modified Rankin Scale renders this impairment a major therapeutic target for recovery and restitution.

Individuals with stroke reporting unmet need for occupational therapy following discharge from hospital

ABSTRACT The purpose of this study was to identify the characteristics and needs of individuals with stroke who report an unmet need for occupational therapy following discharge from hospital. Needs were assessed using a semi-structured interview and a survey in a sample of 209 adults hospitalized with a stroke. Participants were divided into three groups-those needing occupational therapy; those receiving occupational therapy, and those neither needing nor receiving occupational therapy. Thirteen percent (n = 28) reported an unmet need for occupational therapy and were more dependent in activities of daily living (ADL) before and after their stroke and had lower acute functional independence measure (FIM) scores than the comparison groups (p < .05). Participants with unmet needs for occupational therapy were more likely to report unmet needs related to upper extremity function, basic and instrumental ADL, leisure, assistive devices, and the resumption of social roles.

Representation of People with Aphasia in Randomized Controlled Trials of Acute Stroke Interventions

Background

Aphasia affects up to a third of the stroke population and is associated with poor social participation and quality of life. Yet people with aphasia may be excluded from some types of stroke research due to challenges in informing, consenting, and conducting follow-up in this population.

Aims and/or hypothesis

We described the representation of those with aphasia in acute stroke clinical research, the level of inclusion across international trial sites, and whether there have been improvements in the inclusion of this population in recent clinical trials.

Methods

We conducted a retrospective analysis of clinical trial data from the Virtual International Stroke Trials Archive (VISTA), defining aphasia using the Best Language (item 9) domain of the National Institutes of Health Stroke Scale. We used proportional odds modeling, adjusting for age, gender, ethnicity, stroke severity, medical history, hemisphere affected by stroke, and trial eligibility criteria, to examine the associations between year, location of enrollment, inclusion, and attrition of those with aphasia.

Results

Data were available for 8904 patients from 10 trials; no trials listed aphasia as an exclusion criterion. At baseline, aphasia was present in 4039 (45·4%); severe/global aphasia was present in 2688 (30·2%). We observed no geographic or longitudinal disparity in the attrition of these patients at three-months. Centers in the Philippines recruited fewer people [ P = 0·05, odds ratio = 0·5, 95% confidence interval (0·2, 1·0)], while centers in Central and South America included more people with severe/global aphasia [ P = 0·0004, odds ratio = 2·4, 95% confidence interval (1·3, 4·3)], when compared with centers in the USA and Canada.

Conclusion

Acute stroke trials have demonstrated the feasibility of including people with aphasia in stroke research; we observed geographic variations that were not entirely explained by case mix or trial eligibility criteria. Similar levels of inclusion should be sought in nonemergency stroke trials to improve the applicability of research findings to this population.

Determinants of utilization and expenditures for episodes of ambulatory physical therapy among adults

BACKGROUND

Comprehensive information on determinants and patterns of use and spending for ambulatory physical therapy services is needed to inform health planning and policy decisions. Most research in the literature on this topic is limited to specific payers, age groups, and conditions.

OBJECTIVE

The purpose of this study was to examine factors associated with the resource intensity of physical therapy episodes for adults in the United States as measured by number of visits and expenses per visit.

DESIGN

This study was a secondary analysis of longitudinal survey data from the Medical Expenditure Panel Survey (MEPS) panels 9, 10, and 11.

METHODS

An analytic file was created based on data from the longitudinal data files for 3 MEPS panels and the annual office-based and hospital outpatient event files. A total of 1,377 episodes of physical therapy care were identified. Variation in both the total number of visits per episode and expenses per visit was examined by fitting regression models to evaluate the effects of selected independent variables classified into 4 categories: episode-level variables, demographic characteristics, geographic variables, and health status indicators.

RESULTS

Average total expenses per episode (in 2007 dollars) were $1,184 (median=$651), with an average number of visits per episode of 9.6 (median=6.0) and average expenses per visit of $130 (median=$95). Significant variation by geographic characteristics, sex, and one comorbid condition (high blood pressure) was found in the number of visits model. In the expenditures model, expenses per visit were associated with age/insurance coverage, setting (hospital outpatient versus office based), primary condition category, and mental health status. Limitations Limitations include limited sample sizes of physical therapy users and lack of detailed clinical information.

CONCLUSIONS

Variability in the resource intensity of physical therapy episodes is influenced to some degree by nonclinical variables.

Communication impairment and activity limitation in stroke patients with severe aphasia

PURPOSE

This study investigated how patients with severe aphasia communicated in daily living, which verbal and non-verbal communication skills were spared and which were impaired, and whether activity limitations in communication are related to verbal impairments.

METHODS

Twenty-seven patients with severe aphasia and 9 with moderate aphasia originating from a sample of 102 aphasic persons followed up in a French regional survey were assessed with a communication test and a communication activity limitation questionnaire 12-18 months after a first stroke.

RESULTS

Patients with severe aphasia suffered severe activity limitations in communication, with performance 3-fold lower than that of patients with moderate aphasia, and 4-fold lower than scores attained by normals. Both aphasia severity and communication disability at follow-up were related to the initial severity of aphasia. Using a phone, credit card and a chequebook, reading and filling in administrative documents, and communication behaviours involved in social life were the most severely impaired. Non-verbal communication performance was not related to aphasia severity.

CONCLUSIONS

We conclude that there is a great need for speech therapy research to develop new compensatory or alternative strategies for patients with severe aphasia.