Anxiety After Stroke: The Importance of Subtyping

Associations between triglyceride glucose index-related obesity indices and anxiety: Insights from the National Health and Nutrition Examination Survey 2007-2012

BACKGROUND

The triglyceride glucose index (TyG), along with its associated obesity indices, including TyG-body mass index (TyG-BMI), TyG-waist-to-height ratio (TyG-WHtR), TyG-waist circumference (TyG-WC), and TyG-weight-adjusted-waist index (TyG-WWI), have become valuable tools for evaluating insulin resistance in metabolic diseases. Few researches explored their links with anxiety.

METHODS

This observational study leveraged data from the National Health and Nutrition Examination Survey (2007-2012), analyzing 6726 participants to investigate the correlations between TyG-related indices and anxiety using multivariable logistic regression, subgroup analysis, and curve fitting.

RESULTS

After adjusting for confounders, significant positive correlations were identified between TyG, TyG-WWI, and anxious days [0.792 (0.262, 1.322); 0.033 (0.003, 0.063)]. These findings were reinforced when TyG-related indices were categorized into quartiles. Positive associations were further observed between TyG and anxiety state [1.243 (1.076, 1.437)], which was consistent across quartile groupings. Subgroup analyses revealed that racial stratification significantly influenced the relationship between TyG, TyG-BMI, TyG-WHtR, TyG-WC, TyG-WWI and anxious days. Gender stratification significantly influenced the relationship between TyG and anxiety state. Linear associations were established between TyG and anxious days, anxiety state with regression coefficients of 0.873 and 1.254 respectively. Non-linear relationships and threshold effects were detected, with inflection points at 187.731, 3.040, 725.288, and 104.011 (for TyG-BMI, TyG-WHtR, TyG-WC, TyG-WWI with anxious days) and 188.677, 3.059, 730.251, and 103.869 (for TyG-BMI, TyG-WHtR, TyG-WC, TyG-WWI with anxiety state).

CONCLUSIONS

These results enhance our understanding of relationships between TyG-related indices and anxiety, providing valuable insights for the prevention and management of obesity and anxiety.

Advancing network meta-analysis in non-invasive brain stimulation: Optimizing post-stroke mood through combined therapies

BACKGROUND

Post-stroke depression and anxiety significantly impact recovery and quality of life. Non-invasive brain stimulation (NIBS) techniques, including transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and transcranial ultrasound stimulation (TUS), have emerged as promising therapeutic options. However, the relative efficacy of single and combined NIBS therapies remains unclear. This network meta-analysis aims to identify the most effective combination therapies for optimizing post-stroke mood disorders.

NEW METHOD

A systematic search was conducted across PubMed, Embase, Cochrane Library, Web of Science, and key Chinese databases to identify randomized controlled trials (RCTs) published up to March 2023. Two independent reviewers screened the studies, extracted relevant data, and assessed the risk of bias using the Cochrane Handbook. A network meta-analysis was performed using Stata SE version 15.1 and R software version 4.2.3 to evaluate the comparative effectiveness of different NIBS interventions.

RESULTS

A total of 50 RCTs involving 3852 participants and 18 different interventions (including 11 combination therapies) were analyzed. The findings revealed: COMPARISON WITH EXISTING METHODS: Unlike previous studies focusing on single-modality interventions, this network meta-analysis systematically evaluates the comparative effectiveness of various combined NIBS strategies. Results indicate that combination therapies significantly outperform single-modality treatments, with TMS-based protocols showing the greatest overall benefit in improving both mood disorders and functional independence.

CONCLUSIONS

The findings suggest that optimized combination NIBS therapies offer superior outcomes for post-stroke depression and anxiety. HFrTMS_LFrTMS_WM was the most effective for depression and independence in activities of daily living (ADLs), while tDCS_psychotherapy and TUS_WM were particularly effective for anxiety. These results highlight the clinical potential of integrated NIBS strategies for post-stroke mood optimization and call for further research to refine treatment protocols for enhanced patient outcomes.

Clemastine Reduces post-stroke Neurodegeneration by Alleviating Endoplasmic Reticulum stress-mediated Demyelination and Cognitive Impairment Through PERK/ATF4/CHOP Signaling Pathway

The progressive brain damage following ischemic stroke is primarily due to oxidative stress and activation of inflammatory pathways. Post-stroke neurodegeneration can lead to the loss of neurons and glial cells, including oligodendrocytes, contributing to demyelination. Following ischemic stroke, reperfusion results in increased intracellular calcium, generation of free radicals, and inflammation culminating in accumulation of misfolded proteins in the endoplasmic reticulum (ER) lumen augmenting the ER stress. ER stress has been shown to aggravate post-stroke neurodegeneration by triggering neuronal apoptosis and also contributing towards demyelination of neurons. To address the limitations of current stroke therapies, repurposing of drugs as future adjunctive therapy may be promising. Clemastine, an antihistaminic drug, improves post stroke outcome as evident in the present study. Male Sprague Dawley (SD) rats were treated with clemastine following ischemic stroke. Harvested brain tissues were subjected to different biochemical assays, molecular assays, and histopathological analysis. Clemastine was able to reduce infarct size, alleviate oxidative stress, improve neuronal count, and functional outcomes. Clemastine downregulated genes and proteins responsible for ER stress, apoptosis and demyelination as shown by the western blot and qPCR results. Our study suggests that clemastine may alleviate endoplasmic reticulum stress-mediated demyelination by modulating PERK/ATF4/CHOP axis, and may be used as one of the adjunctive therapies for stroke in future.

Prevalence, Trajectory, and Factors Associated With Patient-Reported Nonmotor Outcomes After Stroke: A Systematic Review and Meta-Analysis

Importance

The evidence on nonmotor outcomes after acute ischemic stroke and intracerebral hemorrhage (ICH) is limited and domain-specific. The prevalence, natural history, and factors associated with nonmotor outcomes across multiple domains are unclear.

Objective

To synthesize the published data and to identify the prevalence, natural history, and factors associated with multidomain nonmotor outcome burden in patients with stroke.

Data Sources

A search of PubMed, MEDLINE, EMBASE, and PsycINFO databases between January 1999 to June 2023 was supplemented by search of bibliographies of the key articles.

Study Selection

The analysis included prospective cohort studies that reported nonmotor outcomes across 10 domains: anxiety, depression, fatigue, sleep disturbance, social participation, pain, bladder dysfunction, bowel dysfunction (constipation and fecal incontinence), and sexual dysfunction assessed by patient-reported scales.

Data Extraction and Synthesis

Two reviewers independently assessed studies, extracting baseline data, nonmotor prevalence, and follow-up information. Pooled prevalence of nonmotor outcomes was estimated using random-effects models. Meta-regression models were used to analyze natural history and factors associated with nonmotor outcomes. Subgroup analysis was used to assess prevalence by symptom description within each nonmotor domain. Publication bias and study quality were assessed using funnel plots and the Newcastle-Ottawa scale.

Results

A total of 279 prospective cohort studies met the inclusion criteria (117 440 participants with stroke; median [IQR] age, 65 [59-70] years; 209 of 279 studies with more male than female participants) with a nonmotor outcome follow-up period ranging from 30 days to 10 years after stroke. The most prevalent adverse nonmotor outcomes by pooled prevalence were sleep disturbance (59.9%; 95% CI, 53.9%-63.9%), sexual dysfunction (59.8%; 95% CI, 50.0%-69.5%), constipation (58.2%; 95% CI, 53.9%-62.6%), reduced social participation (56.5%; 95% CI, 52.1%-60.8%), bladder dysfunction (45.9%; 95% CI, 38.0%-53.8%), and fatigue (45.2%; 95% CI, 40.7%-49.5%). Meta-regression analysis showed no significant improvement over time for most nonmotor outcomes, except pain (coefficient = -11.0%; P = .05) and sexual dysfunction (coefficient = -24.1%; P < .001). The heterogeneity ranged between 52% and 98% across all studies. The common factors associated with adverse nonmotor outcomes were female sex, studies with mixed stroke cohort (ischemic stroke or ICH), and older age.

Conclusions and Relevance

Patient-reported nonmotor outcomes were common after stroke. Sexual dysfunction, sleep disturbance, constipation, reduced social participation, bladder dysfunction, and fatigue were most prevalent. These adverse outcomes often persisted over time, especially in women, older adults, and those in studies with mixed stroke cohorts.

The effect of transcranial direct current stimulation and inhibitory control training on depression and anxiety among post-stroke individuals

BACKGROUND

Recent research has highlighted the role of fronto-parietal brain networks and cognitive control in mood disorders. Transcranial direct current stimulation (tDCS) and computer-based cognitive training are used in post-stroke rehabilitation. This study examined the combined effects ofof computer-based inhibitory control training (ICCT) and anodal tDCS on post-stroke depression and anxiety.

METHODS

Thirty-five participants were randomly assigned to one of three groups: active tDCS treatment (A), sham tDCS treatment with ICCT (T), or active tDCS with ICCT (AT), for a duration of ten days. Primary outcome measures included the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAM-D), and Spielberger's State-Trait Anxiety Inventory (STAI-S/T). Statistical analysis was performed using a Mixed-model Analysis of Variance, with supplementary Bayesian analysis.

RESULTS

The AT group showed a significant improvement in BDI scores (p < .001), whereas no significant effects were observed on the HAM-D, STAI-T, or STAI-S scales.

CONCLUSIONS

The combination of tDCS and ICCT reduced depressive symptoms as measured by the BDI; while no significant effects were found with either treatment alone. Further research is needed to explore the mechanisms behind the synergistic effects in the treatment of post-stroke mood disorders.

Professional reintegration of stroke survivors and their mental health, quality of life and community integration

PURPOSE

To assess the association between professional reintegration and mental health, quality of life (QoL) and community reintegration of stroke survivors.

METHODS

Using a cross-sectional study design, a structured questionnaire was administered to previously working stroke survivors, 18-24 months post-stroke. Data on sociodemographic characteristics, professional reintegration (prevalence of return to work (RTW), period of RTW, job placement, function at work, reintegration support, association of stroke with work and number of working hours), mental health (Hospital Anxiety and Depression Questionnaire), QoL (Stroke Specific Quality of Life Scale) and community integration (Community Integration Questionnaire) were reported by 553 stroke survivors.

RESULTS

Twenty months after stroke, 313 (56.6%; 95%CI 52.4-60.8) stroke survivors had return to work. RTW was positively associated with both global and sub-domains scores of Community Integration Questionnaire (CIQ) (global CIQ β = 3.50; 95%CI 3.30-3.79) and with depressive symptomatology (β = 0.63; 95%CI 0.20-1.46) measured by the Hospital Anxiety and Depression Scale. No significant differences were found regarding QoL, according to RTW status. For those who RTW, no significant associations were found between any of the professional reintegration determinants assessed and mental health, QoL and community integration scores.

CONCLUSIONS

RTW seems to be associated to better community integration after stroke, but appears to be negatively associated to stroke survivor's mental health, namely considering depression symptoms. Future studies should explore the barriers to stroke survivors' RTW and the challenges and strategies used to overcome them, to allow the development of professional reintegration policies.

Navigating Neurologic Illness: Skills in Neuropalliative Care for Persons Hospitalized with Neurologic Disease

Persons hospitalized for neurologic illness face multidimensional care needs. They can benefit from a palliative care approach that focuses on quality of life for persons with serious illness. We describe neurology provider "skills" to help meet these palliative needs: assessing the patient as a whole; facilitating conversations with patients to connect prognosis to care preferences; navigating neurologic illness to prepare patients and care partners for the future; providing high-quality end-of-life care to promote peace in death; and addressing disparities in care delivery.

Nursing's Role in Psychosocial Health Management After a Stroke Event: A Scientific Statement From the American Heart Association

INTRODUCTION

Stroke can have profound psychosocial health implications. These constructs are often overlooked and undertreated yet can be as devastating as the physical, functional, and cognitive consequences after stroke.

AIM

This scientific statement aims to evaluate 5 important aspects of psychosocial health (depression, stress, anxiety, fatigue, and quality of life) after a stroke to provide a framework for related nursing care across the poststroke continuum.

METHODS

A narrative review of the literature published from 2018 to 2023 was conducted with databases such as PubMed/MEDLINE, ClinicalTrials.gov, PsychInfo/EBSCOHost, PsychArticles, CINHAL, and the Cochrane Library.

RESULTS

Findings reveal a gap in evidence-based nursing interventions for addressing poststroke psychosocial needs. Critical strategies for shaping therapeutic nursing care include enhanced screening with validated tools; educating stroke survivors, families, and staff on symptom recognition, prevention, and treatment; and ensuring appropriate pharmacological management and access to psychological and psychosocial interventions, including referrals to social services and other essential support systems. Care should be comprehensive and interdisciplinary. Nurse-led research can benefit from more inclusive inclusion, including individuals with recurrent strokes and preexisting psychosocial conditions, focusing on the impact of structural racism and care disparities and expanding evidence-based nursing interventions.

CONCLUSIONS

Although there is limited high-level evidence on the nursing care for patients with suboptimal psychosocial health after stroke, nurses have a crucial role in addressing these needs. Enhanced screening, assessment, supportive services, and education are vital to ensure that patients receive the necessary treatment and care.

Causal associations of fatigue and functional outcome after ischemic stroke: a mediation Mendelian randomization study

Background and objectives

Fatigue has been associated with adverse effects on recovery from ischemic stroke based on previous observational research. The purpose of our study was to explore the potential causal association of fatigue with poor functional outcome after ischemic stroke by employing Mendelian randomization (MR).

Methods

A set of instrumental variables, comprising 36 single-nucleotide polymorphisms (SNPs) that are only related to fatigue, were derived from a genome-wide association study (GWAS) that included 449,019 general individuals. The functional outcomes after ischemic stroke were derived from a GWAS (Genetics of Ischemic Stroke Functional Outcome Network) involving 6,021 survivors. Two-sample MR methods were used to assess the causal effect, including inverse variance weighted, MR-Egger, weighted median, simple mode, and weighted mode. In bidirectional MR analysis, the reverse causal association was analyzed using the Wald ratio method. The mediation effects of lipid metabolites were analyzed using two-step MR analysis.

Results

Genetic liability to fatigue was causally associated with the poor functional outcome (modified Rankin Scale ≥3 at 3 months) after ischemic stroke (OR = 4.20, 95%CI [1.11-15.99], p < 0.05). However, genetic predicted poor functional outcome after ischemic stroke was not associated with fatigue (OR = 1.00, 95%CI [0.99-1.02], p > 0.05). The results of the two-step MR showed that cholesteryl esters to total lipids ratio in large very low-density lipoprotein (VLDL) (ME = -0.13, p < 0.05); concentration of very large VLDL particles (ME = -0.13, p < 0.05); free cholesterol in large VLDL (ME = -0.13, p < 0.05); free cholesterol to total lipids ratio in very large VLDL (ME = -0.22, p < 0.05); phospholipids in large VLDL (ME = -0.15, p < 0.05); phospholipids in very large VLDL (ME = -0.13, p < 0.05); phospholipids to total lipids ratio in large high-density lipoprotein (HDL) (ME = -0.17, p < 0.05); total lipids in very large VLDL (ME = -0.14, p < 0.05); triglycerides in small VLDL (ME = -0.11, p < 0.05); and triglycerides to total lipids ratio in large HDL (ME = -0.10, p < 0.05) assumed a pivotal role in mediating the association between fatigue and poor functional outcome after ischemic stroke.

Conclusion

Our study provides evidence supporting the causal association between fatigue and the poor functional outcome after ischemic stroke, which emphasizes the importance of implementing interventions aimed at addressing fatigue. This could offer a therapeutic target to improve recovery after ischemic stroke and warrant exploration in a clinical context. One potential mechanism by which fatigue affects functional outcomes after ischemic stroke is through the action of lipid metabolites.

Safety-Seeking Behaviors and Anxiety Maintenance in People With Aphasia: A Viewpoint

PURPOSE

People with aphasia (PWA) often experience higher levels of anxiety and social isolation than people without aphasia. Although the presence of anxiety is appreciated in PWA, literature examining the etiology and persistent nature of anxiety in PWA is underdeveloped. Safety-seeking behaviors, or maladaptive acts used by individuals to decrease anxiety from a feared outcome, have been reported as key facilitators of long-term anxiety toward feared situations across a variety of clinical populations. The purpose of this viewpoint is to explore the concept of safety-seeking behaviors and discuss their potential relevance to the maintenance of anxiety in PWA. We further discuss the distinction between maladaptive (i.e., safety seeking) and adaptive (i.e., coping) behaviors and how this knowledge may improve the quality of clinical services for PWA.

CONCLUSIONS

The present review advocates for further exploration of the safety-seeking behaviors that are used by PWA. Until critical attention is given to this subject, clinicians may remain ill-equipped to identify and depict whether a self-management strategy is facilitative or inhibitive to PWA's communicative participation goals. Critically, a behavior that may be "maladaptive" for one individual may be "adaptive" for another. Future research should seek to identify common behavioral and cognitive strategies that PWA implement to reduce acute perceptions of anxiety. This knowledge may help facilitate holistic aphasia rehabilitation by allowing clinicians to foster conversations around behaviors that inhibit or promote successful communicative participation.

Prevalence of depression and anxiety symptoms after stroke in young adults: A systematic review and meta-analysis

BACKGROUND

Young adults with stroke have distinct professional and social roles making them vulnerable to symptoms of post-stroke depression (PSD) and post-stroke anxiety (PSA). Prior reviews have examined the prevalence of anxiety and depression in stroke populations. However, there are a lack of studies that have focused on these conditions in young adults.

OBJECTIVE

We performed a systematic review and meta-analysis of observational studies that reported on symptoms of PSD, PSA and comorbid PSD/PSA in young adults aged 18 to 55 years of age.

METHODS

MEDLINE, EMBASE, SCOPUS and PsycINFO were searched for studies reporting the prevalence of symptoms of PSD and/or PSA in young adults with stroke from inception until June 23, 2023. We included studies that evaluated depression and/or anxiety symptoms with screening tools or interviews following ischemic or hemorrhagic stroke. Validated methods were employed to evaluate risk of bias.

RESULTS

4748 patients from twenty eligible studies were included. Among them, 2420 were also evaluated for symptoms of PSA while 847 participants were evaluated for both PSD and PSA symptoms. Sixteen studies were included in the random effects meta-analysis for PSD symptoms, with a pooled prevalence of 31 % (95 % CI 24-38 %). Pooled PSA symptom prevalence was 39 % (95 % CI 30-48 %) and comorbid PSD with PSA symptom prevalence was 25 % (95 % CI 12-39 %). Varying definitions of 'young adult', combinations of stroke subtypes, and methods to assess PSD and PSA contributed to high heterogeneity amongst studies.

CONCLUSIONS

We identified high heterogeneity in studies investigating the prevalence of symptoms of PSD and PSA in young adults, emphasizing the importance of standardized approaches in future research to gain insight into the outcomes and prognosis of PSD and PSA symptoms following stroke in young adults. Larger longitudinal epidemiological studies as well as studies on tailored interventions are required to address the mental health needs of this important population.

FUNDING

None.

The association of cardiometabolic multimorbidity and fear of falling among older adults: Data from the national health and aging trends study

OBJECTIVES

Cardiometabolic diseases (CMDs) have been individually associated with fall-related outcomes, but their combined effect on fear of falling (FOF) has not been investigated. This study aims to examine the association between cardiometabolic multimorbidity and FOF in older adults.

METHODS

Data from the National Health and Aging Trends Study, 4,295 community-dwelling older adults ≥ 65 years were analyzed in this longitudinal study. CMDs were assessed at baseline, including heart disease, diabetes, stroke, and hypertension. FOF was evaluated by asking participants if they worried about falling in the past month. Data were analyzed using multi-adjusted logistic regression.

RESULTS

Cardiometabolic multimorbidity was associated with a higher risk of FOF. The combination of heart disease and diabetes showed the highest risk of FOF (OR = 3.47, 95 % CI: 1.63-7.40).

CONCLUSIONS

These findings underscore the need for targeted interventions to mitigate the combined impact of cardiometabolic multimorbidity on FOF in older adults.

Sex-Related Differences in Post-Stroke Anxiety, Depression and Quality of Life in a Cohort of Smokers

BACKGROUND

We aimed to study anxiety, depression and quality of life in smokers after stroke by sex.

METHODS

A longitudinal prospective study with a 24-month follow-up of acute stroke patients who were previously active smokers. Anxiety and depression were evaluated with the Hospital Anxiety and Depression scale, and quality of life was evaluated with the EQ-5D questionnaire.

RESULTS

One hundred and eighty patients participated (79.4% men); their mean age was 57.6 years. Anxiety was most prevalent at 3 months (18.9% in men and 40.5% in women) and depression at 12 months (17.9% in men and 27% in women). The worst perceived health occurred at 24 months (EQ-VAS 67.5 in men and 65.1 in women), which was associated with depression (p < 0.001) and Rankin Scale was worse in men (p < 0.001) and depression in women (p < 0.001). Continued tobacco use was associated with worse perceived health at 3 months in men (p = 0.034) and at 12 months in both sexes. Predictor variables of worse perceived health at 24 months remaining at 3 and 12 months were tobacco use in men and neurological damage in women.

CONCLUSION

Differences by sex are observed in the prevalence of anxiety and depression and associated factors and in the predictive factors of perceived health.

Association of blood metals with anxiety among adults: A nationally representative cross-sectional study

BACKGROUND

Previous evidence demonstrated the inconsistent associations between metals and anxiety. The purpose of this study was to evaluate the individual and joint effects of blood lead (Pb), cadmium (Cd), mercury (Hg), selenium (Se) and manganese (Mn) on anxiety in the general population.

METHODS

Data of 4000 participants (aged≥20 years) in the study were retrieved from the National Health and Nutrition Examination Survey (NHANES) 2011-2012. Multiple logistic regression, restricted cubic splines (RCS) logistic analysis, and weighted quantile sum (WQS) regression were fitted to explore the possible effects of single and mixed metal exposures on anxiety. Moreover, this association was assessed by smoking group.

RESULTS

In the study, 24.60 % of participants were in an anxiety state. In logistic regression, blood Pb, Cd, Hg, Se and Mn were not significantly associated with anxiety in all participants. After stratified by smoking group, blood Cd was positively associated with anxiety in the current smoking group [P = 0.029, OR (95 %): 1.708(1.063, 3.040)], whereas not in other groups. In RCS regression, we observed a linear dose-response effect of blood Cd on anxiety stratified by smoking group. In WQS analysis, mixed metal exposures were positively associated with anxiety [P = 0.033, OR (95 %): 1.437(1.031, 2.003)], with Cd (33.69 %) contributing the largest weight to the index.

CONCLUSIONS

Our study showed that excessive exposure to Cd is a significant risk factor for anxiety, and the co-exposures to Pb, Cd, Hg, Se and Mn were positively related with the risk of anxiety in current smokers.

Network analysis of neuropsychiatric, cognitive, and functional complications of stroke: implications for novel treatment targets

AIM

Recovery from stroke is adversely affected by neuropsychiatric complications, cognitive impairment, and functional disability. Better knowledge of their mutual relationships is required to inform effective interventions. Network theory enables the conceptualization of symptoms and impairments as dynamic and mutually interacting systems. We aimed to identify interactions of poststroke complications using network analysis in diverse stroke samples.

METHODS

Data from 2185 patients were sourced from member studies of STROKOG (Stroke and Cognition Consortium), an international collaboration of stroke studies. Networks were generated for each cohort, whereby nodes represented neuropsychiatric symptoms, cognitive deficits, and disabilities on activities of daily living. Edges characterized associations between them. Centrality measures were used to identify hub items.

RESULTS

Across cohorts, a single network of interrelated poststroke complications emerged. Networks exhibited dissociable depression, apathy, fatigue, cognitive impairment, and functional disability modules. Worry was the most central symptom across cohorts, irrespective of the depression scale used. Items relating to activities of daily living were also highly central nodes. Follow-up analysis in two studies revealed that individuals who worried had more densely connected networks than those free of worry (CASPER [Cognition and Affect after Stroke: Prospective Evaluation of Risks] study: S = 9.72, P = 0.038; SSS [Sydney Stroke Study]: S = 13.56, P = 0.069).

CONCLUSION

Neuropsychiatric symptoms are highly interconnected with cognitive deficits and functional disabilities resulting from stroke. Given their central position and high level of connectedness, worry and activities of daily living have the potential to drive multimorbidity and mutual reinforcement between domains of poststroke complications. Targeting these factors early after stroke may have benefits that extend to other complications, leading to better stroke outcomes.

Depression Negatively Impacts Dyadic Quality of Life Following Neuro-ICU Admission: A Prospective Study of Cognitively Intact Patients and Caregivers

BACKGROUND

Admission to a neurological intensive care unit (Neuro-ICU) can increase risk for depressive and anxiety symptoms for both patients and caregivers. To better understand the long-term mental health impact of a Neuro-ICU admission, we examined the dyadic interdependence between depression and anxiety at Neuro-ICU admission with 3-month quality of life (QoL) for patients and caregivers in a longitudinal, observational cohort study.

METHOD

We assessed depressive and anxiety symptoms (Hospital Anxiety and Depression Scale; HADS) reported by neurologically intact patients (n = 72) and their caregivers (n = 72) within 2 weeks of Neuro-ICU admission (baseline) and 3-months post-discharge (follow-up). We examined the longitudinal association between dyadic depression and anxiety at Neuro-ICU admission and 3-month QoL (World Health Organization; QOL-BREF) across four domains (Physical, Psychological, Social relationships, and Environmental QoL) in separate actor-partner interdependence models (APIM) for patients and caregivers.

RESULTS

In the overall models, patients' own baseline depression levels were negatively associated with their own 3-month QoL in all domains (β =  - 0.53 to - 0.64, p < 0.001), and for caregivers, only in the psychological (β =  - 0.73, p < .001) and social relationships (β =  - 0.56, p < .001) domains. No actor effects were found for one's own baseline anxiety impacting one's own 3-month QoL. Partner effects for one's own depression were significant for caregivers on patients' 3-month psychological (β =  - 0.26, p < .02) and environmental (β =  - 0.29, p < .03) QoL, as well as for patients on caregiver's 3-month psychological QoL (β = 0.25, p < .02). No partner effects were significant in association with baseline anxiety and 3-month QoL in both patients and caregivers.

CONCLUSION

Neuro-ICU patients' and caregivers' baseline depression has significant negative impacts on their own long-term QoL. Caregivers demonstrate significant negative impacts on patient long-term QoL in domains related to emotional distress and caregiver burden. Early identification of mental health symptoms, especially depression, during Neuro-ICU admission may provide an intervention opportunity to improve QoL post-discharge for both dyad members.

Cognitive behavioural therapy for neurologists

In neurological practice, we take pride in accurate diagnosis and using neuroscience to develop novel disease-modifying therapies, but we sometimes neglect symptom management and the treatment of distress. Most patients with neurological disorders report that their mental health needs are not being met. Of the many forms of psychological therapy, cognitive behavioural therapy (CBT) is the most likely to be available to our patients. This article sets out to answer the following questions: (1) What is CBT? (2) What will patients experience if they have CBT? (3) Is CBT effective for people with neurological disorders? (4) Who is most suitable for CBT? (5) How and where can a neurologist refer their patients for CBT? (6) Can we as neurologists use aspects of the CBT model in our own consultations?

Evaluating the feasibility and acceptability of the Mood Assessment Post-Stroke (MAPS) mood screening training

Mood problems are common after stroke, and screening is recommended. Training may support staff knowledge and implementation of screening, but the feasibility of training programmes in the Australian healthcare system has not been formally established. This study aimed to assess the feasibility of a mood screening training for a multidisciplinary team (MDT) of stroke clinicians working in a post-acute inpatient rehabilitation service.Twelve staff from a rehabilitation service at a major hospital in Sydney, Australia participated in a 3-h interactive training session. The feasibility of running the course, assessment of knowledge gained via a consolidation exercise and quiz and acceptability of the training were assessed via focus groups.The in-person modality of the training hindered recruitment and assessment of participants' knowledge, though the actual measures themselves appeared appropriate. Nine participants provided feedback in two focus groups. Thematic analysis identified positive reactions to the training. However, low self-efficacy persisted and organisational/socio-cultural barriers to implementation emerged. Following training, the medical officers of the MDT had successfully implemented routine screening.Overall, the training appeared acceptable and to foster knowledge in staff. However, limitations to recruitment and administering evaluations were identified. The development of flexible online training may improve future evaluations of screening training programmes/pathways.

Post-Stroke Neuropsychiatric Complications: Types, Pathogenesis, and Therapeutic Intervention

Almost all stroke survivors suffer physical disabilities and neuropsychiatric disturbances, which can be briefly divided into post-stroke neurological diseases and post-stroke psychiatric disorders. The former type mainly includes post-stroke pain, post-stroke epilepsy, and post-stroke dementia while the latter one includes post-stroke depression, post-stroke anxiety, post-stroke apathy and post-stroke fatigue. Multiple risk factors are related to these post-stroke neuropsychiatric complications, such as age, gender, lifestyle, stroke type, medication, lesion location, and comorbidities. Recent studies have revealed several critical mechanisms underlying these complications, namely inflammatory response, dysregulation of the hypothalamic pituitary adrenal axis, cholinergic dysfunction, reduced level of 5-hydroxytryptamine, glutamate-mediated excitotoxicity and mitochondrial dysfunction. Moreover, clinical efforts have successfully given birth to many practical pharmaceutic strategies, such as anti-inflammatory medications, acetylcholinesterase inhibitors, and selective serotonin reuptake inhibitors, as well as diverse rehabilitative modalities to help patients physically and mentally. However, the efficacy of these interventions is still under debate. Further investigations into these post-stroke neuropsychiatric complications, from both basic and clinical perspectives, are urgent for the development of effective treatment strategies.

Associations between urinary heavy metals and anxiety among adults in the National Health and Nutrition Examination Survey (NHANES), 2007-2012

BACKGROUND

Few studies have investigated the associations between heavy metals and anxiety. The purpose of this study was to examine the associations between single and combined exposure to heavy metals and anxiety.

METHODS

This study employed data from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2012. Anxiety was assessed by patients self-reporting the number of anxious days per month. First, we evaluated the associations between 10 heavy metals single exposure and anxiety by multivariable logistic regression. We then selected 5 heavy metals (cadmium, antimony, cobalt, tungsten, and uranium) for further analysis by elastic net regression. Subsequently, principal component analysis (PCA), weighted quantile regression (WQS), and Bayesian kernel machine regression (BKMR) were utilized to evaluate the associations between 5 heavy metals co-exposure and anxiety.

RESULTS

This study included 4512 participants, among whom 1206 participants were in an anxiety state. Urinary cadmium and antimony were separately related to an increased risk of anxiety (p for trend <0.01 and < 0.01, respectively). In PCA analysis, PC1 was associated with an increased risk of anxiety (p for trend <0.001). In WQS analysis, the positive WQS index was substantially linked with the risk of anxiety (OR (95%CI): 1.23 (1.04,1.39)). In BKMR analysis, the overall effects of co-exposure to heavy metals were positively connected with anxiety.

CONCLUSION

Our study identified a positive correlation between individual exposure to cadmium and antimony and the risk of anxiety. Additionally, the co-exposure to cadmium, antimony, cobalt, tungsten, and uranium was associated with an increased risk of anxiety.

Predicting the relationship between anxiety and health-related quality of life in post-stroke patients: The role of sleep duration

OBJECTIVES

Sleep and psychological disorders are common complaints in stroke survivors. The effectiveness of sleep duration in post-stroke on mental well-being and health outcomes has been reported recently. This study aimed to investigate the mediating effect of sleep duration on the relationship between anxiety and health-related quality of life in Chinese post-stroke; MATERIALS AND METHODS: We conducted a quantitative, cross-sectional study with participants recruited through a multistage, stratified, probability proportional to size sampling method. Anxiety, health-related quality of life, and sleep duration were measured by Zung Self-rating Anxiety Scale, World Health Organization Quality of Life Questionnaire, and a self-administered, structured questionnaire. A multiple linear regression analysis was conducted to identify the association between anxiety, sleep duration, and quality of life. The direct and indirect effects of sleep duration on health-related quality of life was assessed using the bootstrap method via Model 4 (parallel mediation) of SPSS PROCESS macro; RESULTS: A total of 856 post-stroke patients participated in the study, and incidence of anxiety symptom amongst post-stroke was 33.53%. Sleep duration mainly plays partial mediating roles in the relationship between mild-to-moderate anxiety and quality of life in physical, psychological, and environment domains, with sleep duration of 7-8h playing a major role; CONCLUSIONS: A significant relationship among anxiety, sleep duration, and quality of life in post-stroke was found in this study. The sleep duration partially mediated the association between anxiety and quality of life. Suitable prevention methods and early interventions for sleep duration may improve the quality of life for post-stroke anxiety.

A cohort study on anxiety and perceived recovery 3 and 12 months after mild to moderate stroke

Background

Anxiety is a common complication of stroke, affecting one in every three stroke survivors. Stroke recovery is a dynamic process, with most recovery occurring within the first 3 months. However, how anxiety affects this dynamic remains unknown. Therefore, this study aimed to investigate how anxiety affects perceived recovery at 3 and 12 months after stroke. Additionally we also examined the change in perceived stroke recovery from 3 to 12 months and its relationship with anxiety.

Methods

In this longitudinal study patients with stroke were enrolled at Sahlgrenska University Hospital, Gothenburg, Sweden. The Hospital Anxiety and Depression Scale was used to assess anxiety, and the Stroke Impact Scale was used to assess perceived recovery 3 and 12 months after the stroke. The difference in perceived stroke recovery between the anxiety and no-anxiety groups at 3 and 12 months was analyzed. Changes in perceived stroke recovery were calculated and trichotomized from 3 to 12 months based on clinically significant positive changes (+10 points or more), clinically important negative changes (-10 points or less), or no changes (±9). At 3 and 12 months after the stroke, negative and positive recovery was compared to no change in recovery regarding anxiety scores.

Results

This study included 99 patients (44.4% female, median age, 77 years). At 3 and 12 months after the stroke, the median recovery score was 80 out of 100. At 3- and 12-months 17.6 and 15.7% of the patients experienced anxiety, respectively. At both time points, there was a significant association between anxiety and lower perceived stroke recovery (at 3 months: p < 0.001; and 12 months p = 0.002). Among participants with anxiety at 3 or 12 months after stroke, a positive change in recovery from 3 to 12 months was identified (3 months, p = 0.004 and 12 months, p = 0.0014).

Conclusion

Anxiety symptoms following a stroke are associated with lower levels of perceived stroke recovery for at least 1 year after the stroke. Identifying patients with anxiety early after stroke may be beneficial for identifying those at risk of lower recovery.Clinical trial registration:ClinicalTrials.gov, identifier [NCT01622205]. Registered on June 19, 2012 (retrospectively registered).

Acute stress symptoms 1-2 weeks after stroke predict the subsequent development of post-traumatic stress symptoms: A prospective cohort study

OBJECTIVE

To date no research has examined the potential influence of acute stress symptoms (ASD) on subsequent development of post-traumatic stress disorder (PTSD) symptoms in stroke survivors. Our objective was to examine whether acute stress symptoms measured 1-2 weeks post-stroke predicted the presence of post-traumatic stress symptoms measured 6-12 weeks later.

DESIGN

Prospective within-groups study.

METHODS

Fifty four participants who completed a measure of acute stress disorder at 1-2 weeks following stroke (time 1) and 31 of these participants completed a measure of posttraumatic stress disorder 6-12 weeks later (time 2). Participants also completed measures of stroke severity, functional impairment, cognitive impairment, depression, anxiety, pre-morbid intelligence and pain across both time points.

RESULTS

Some 22% met the criteria for ASD at baseline and of those, 62.5% went on to meet the criteria for PTSD at follow-up. Meanwhile two of the seven participants (28.6%) who met the criteria for PTSD at Time 2, did not meet the ASD criteria at Time 1 (so that PTSD developed subsequently). A hierarchical multiple regression analysis indicated that the presence of acute stress symptoms at baseline was predictive of post-traumatic stress symptoms at follow-up (R2 = .26, p < .01). Less severe stroke was correlated with higher levels of post-traumatic stress symptoms at Time 2 (rho = .42, p < .01).

CONCLUSIONS

The results highlight the importance of early assessment and identification of acute stress symptoms in stroke survivors as a risk factor for subsequent PTSD. Both ASD and PTSD were prevalent and the presence of both disorders should be assessed.

Factors Associated With Anxiety After Hemorrhagic Stroke

OBJECTIVE

A significant number of patients develop anxiety after stroke. The objective of this study was to identify risk factors for anxiety after hemorrhagic stroke that may facilitate diagnosis and treatment.

METHODS

Patients admitted between January 2015 and February 2021 with nontraumatic hemorrhagic stroke (intracerebral [ICH] or subarachnoid [SAH] hemorrhage) were assessed telephonically 3 and 12 months after stroke with the Quality of Life in Neurological Disorders Anxiety Short Form to evaluate the relationships between poststroke anxiety (T score >50) and preclinical social and neuropsychiatric history, systemic and neurological illness severity, and in-hospital complications.

RESULTS

Of 71 patients who completed the 3-month assessment, 28 (39%) had anxiety. There was a difference in Glasgow Coma Scale (GCS) scores on admission between patients with anxiety (median=14, interquartile range [IQR]=12-15) and those without anxiety (median=15, IQR=14-15) (p=0.034), and the incidence of anxiety was higher among patients with ICH (50%) than among those with SAH (20%) (p=0.021). Among patients with ICH, anxiety was associated with larger median ICH volume (25 cc [IQR=8-46] versus 8 cc [IQR=3-13], p=0.021) and higher median ICH score (2 [IQR=1-3] versus 1 [IQR=0-1], p=0.037). On multivariable analysis with GCS score, hemorrhage type, and neuropsychiatric history, only hemorrhage type remained significant (odds ratio=3.77, 95% CI=1.19-12.05, p=0.024). Of the 39 patients who completed the 12-month assessment, 12 (31%) had anxiety, and there was a difference in mean National Institutes of Health Stroke Scale scores between patients with (5 [IQR=3-12]) and without (2 [IQR=0-4]) anxiety (p=0.045). There was fair agreement (κ=0.38) between the presence of anxiety at 3 and 12 months.

CONCLUSIONS

Hemorrhage characteristics and factors assessed with neurological examination on admission are associated with the development of poststroke anxiety.

Evaluation & Treatment of Psychological Effects of Stroke

Strokes are a common medical condition in the United States, including in Delaware. An under-recognized effect of stroke is the impact on mood that often occurs. Many individuals develop depression, anxiety, PTSD, and other psychological sequelae. These disorders can significantly affect their lives and their relationships. The emotional effects of stroke pose a public health problem for our residents, leading to devastating decreases in the quality of life for the patient and the family. These challenges negatively impact the community due to the associated healthcare and economic burdens. The population of the State of Delaware is growing, and the proportion of senior residents, who are also at greater risk for strokes, is also increasing. Strokes will remain an ongoing important clinical concern for our healthcare providers. Emotional changes after a stroke will occur in many Delaware residents who suffer a stroke. The emotional sequelae of stroke are under-treated. It is critical for healthcare professionals to be trained to recognize, assess, and treat the psychological disorders that can result from having a stroke. This article provides an overview of the major psychological effects of stroke, recommended assessment tools, promising treatment trends, and directions for further research. Improving our ability to detect and treat these difficult emotional challenges can facilitate effective treatment and prevention strategies and increase quality of life for stroke survivors, their loved ones, and their communities.

Acceptance and commitment therapy for individuals with depressive and anxiety symptoms following acquired brain injury: A non-concurrent multiple baseline design across four cases

Patients with acquired brain injury (ABI) often experience symptoms of anxiety and depression. Until now, evidence-based treatment is scarce. This study aimed to investigate the effectiveness of Acceptance and Commitment Therapy (ACT) for patients with ABI. To evaluate the effect of ACT for people with ABI, a non-concurrent multiple baseline design across four cases was used. Participants were randomly assigned to a baseline period, followed by treatment and then follow-up phases. Anxiety and depressive symptoms were repeatedly measured. During six measurement moments over a year, participants filled in questionnaires measuring anxiety, depression, stress, participation, quality of life, and ACT-related processes. Randomization tests and NAP scores were used to calculate the level of change across phases. Clinically significant change was defined with the Reliable Change Index. Three out of four participants showed medium to large decreases in anxiety and depressive symptoms (NAP = 0.85 till 0.99). Furthermore, participants showed improvements regarding stress, cognitive fusion, and quality of life. There were no improvements regarding psychological flexibility, value-driven behaviour, or social participation. This study shows that ACT is possibly an effective treatment option for people experiencing ABI-related anxiety and depression symptoms. Replication with single case or large scale group studies is needed to confirm these findings.

Physical Therapists Use Different Motivational Strategies for Stroke Rehabilitation Tailored to an Individual's Condition: A Qualitative Study

OBJECTIVE

Various strategies are used to motivate individuals with stroke during rehabilitation. However, how physical therapists select the motivational strategies that they use for each individual is yet to be established. Therefore, this study aimed to explore how physical therapists use different motivational strategies for individuals in stroke rehabilitation programs.

METHODS

A criterion sample of 15 physical therapists who have worked in rehabilitation for over 10 years and were interested in an individual's motivation participated in one-on-one semi-structured online interviews. The interviews explored their perspectives and experiences regarding the motivational strategies used depending on each individual's condition. The collected data were analyzed with thematic analysis.

RESULTS

A total of 9 themes emerged from the data upon thematic analysis and inductive coding. Participants used different strategies to encourage individuals' active participation in physical therapy depending on (1) their mental health, (2) their physical difficulties, (3) their level of cognitive function, (4) their personality, (5) their activities and participation, (6) their age, (7) their human environment, and (8) the type of rehabilitation service where the individual underwent treatment. For example, in cases where an individual lost self-confidence, participants offered practice tasks that the individual could achieve with little effort to make them experience success. The interviews also revealed (9) motivational strategies used regardless of the individual's condition. For instance, patient-centered communication was used to build rapport with individuals, irrespective of their condition.

CONCLUSION

This qualitative study suggests that physical therapists use different strategies depending on the individual's mental health conditions, physical problems, level of cognitive function, personality, activities and participation, age, human environment, and the type of rehabilitation service where the individual undergoes treatment to motivate individuals with stroke during physical therapy.

IMPACT

The findings of this study can provide experience-based recommendations regarding the selection of motivational strategies for stroke rehabilitation.

Predictive model, miRNA-TF network, related subgroup identification and drug prediction of ischemic stroke complicated with mental disorders based on genes related to gut microbiome

Background

Patients with comorbid schizophrenia, depression, drug use, and multiple psychiatric diagnoses have a greater risk of carotid revascularization following stroke. The gut microbiome (GM) plays a crucial role in the attack of mental illness and IS, which may become an index for the diagnosis of IS. A genomic study of the genetic commonalities between SC and IS, as well as its mediated pathways and immune infiltration, will be conducted to determine how schizophrenia contributes to the high prevalence of IS. According to our study, this could be an indicator of ischemic stroke development.

Methods

We selected two datasets of IS from the Gene Expression Omnibus (GEO), one for training and the other for the verification group. Five genes related to mental disorders and GM were extracted from Gene cards and other databases. Linear models for microarray data (Limma) analysis was utilized to identify differentially expressed genes (DEGs) and perform functional enrichment analysis. It was also used to conduct machine learning exercises such as random forest and regression to identify the best candidate for immune-related central genes. Protein-protein interaction (PPI) network and artificial neural network (ANN) were established for verification. The receiver operating characteristic (ROC) curve was drawn for the diagnosis of IS, and the diagnostic model was verified by qRT-PCR. Further immune cell infiltration analysis was performed to study the IS immune cell imbalance. We also performed consensus clustering (CC) to analyze the expression of candidate models under different subtypes. Finally, miRNA, transcription factors (TFs), and drugs related to candidate genes were collected through the Network analyst online platform.

Results

Through comprehensive analysis, a diagnostic prediction model with good effect was obtained. Both the training group (AUC 0.82, CI 0.93-0.71) and the verification group (AUC 0.81, CI 0.90-0.72) had a good phenotype in the qRT-PCR test. And in verification group 2 we validated between the two groups with and without carotid-related ischemic cerebrovascular events (AUC 0.87, CI 1-0.64). Furthermore, we investigated cytokines in both GSEA and immune infiltration and verified cytokine-related responses by flow cytometry, particularly IL-6, which played an important role in IS occurrence and progression. Therefore, we speculate that mental illness may affect the development of IS in B cells and IL-6 in T cells. MiRNA (hsa-mir-129-2-3p, has-mir-335-5p, and has-mir-16-5p) and TFs (CREB1, FOXL1), which may be related to IS, were obtained.

Conclusion

Through comprehensive analysis, a diagnostic prediction model with good effect was obtained. Both the training group (AUC 0.82, CI 0.93-0.71) and the verification group (AUC 0.81, CI 0.90-0.72) had a good phenotype in the qRT-PCR test. And in verification group 2 we validated between the two groups with and without carotid-related ischemic cerebrovascular events (AUC 0.87, CI 1-0.64). MiRNA (hsa-mir-129-2-3p, has-mir-335-5p, and has-mir-16-5p) and TFs (CREB1, FOXL1), which may be related to IS, were obtained.

Education Level Modulates the Presence of Poststroke Depression and Anxiety, But It Depends on Age

ABSTRACT

Depression and anxiety are common complications after stroke and little is known about the modulatory roles of education and age. Our study aimed to evaluate the modulatory effects of education level on anxiety and depression after stroke and their effect on each age group. Adults with first stroke took part in this cross-sectional observational clinical study. We used the following instruments: Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Scale, Pittsburgh Sleep Quality Index, Barthel index, and Functional Independence Measure. There were 89 patients. The mean (SD) age was 58.01 (13) years, mean (SD) years of education was 9.91 (5.22), 55.1% presented depression symptoms and 47.2% anxiety symptoms, 56.2% were young adults and 43.8% were older adults. We identified a negative association between education and anxiety score (r = -0. 269, p = 0.011) and depression score (r = -0.252, p = 0.017). In the linear regression analysis, we found that education is negatively associated with HADS, but this influence was more consistent in young adults. In conclusion, a higher education level reduces the risk of depression and anxiety, but their effect is less consistent in older adults.

Association between obstructive sleep apnea and risk for post-stroke anxiety: A Chinese hospital-based study in noncardiogenic ischemic stroke patients

OBJECTIVE

This study explored the role of obstructive sleep apnea (OSA) in post stroke anxiety (PSA) in noncardiogenic ischemic stroke patients.

METHODS

180 patients with noncardiogenic ischemic stroke were consecutively enrolled from January 2019 to December 2019. All patients underwent polysomnography (PSG) to assess for OSA. OSA severity was identified based on the apnea hypopnea index (AHI), i.e., no OSA (AHI <5), mild OSA (5 = AHI <15), and moderate to severe OSA (AHI ≥15). Neuropsychological assessments were performed at acute phase and 6 months later to evaluate anxiety (Chinese version of the Zung self-rating anxiety scale [SAS], and Beck Anxiety Inventory [BAI]), depression (Patient Health Questionnaire-9, [PHQ-9]), and cognition (Mini-mental state examination, [MMSE], and Montreal Cognitive Assessment, [MOCA]). Clinical diagnoses of PSA were made based on interviews and the anxiety scales. The correlations between PSA and OSA were investigated in Logistic regression analysis.

RESULTS

The prevalence of acute-phase and 6-month PSA were 27 (15%) and 52 (28.9%) respectively. Moderate to severe OSA and post-stroke depression (PSD) were the influencing factors of acute-phase PSA. 6-Month PSA was not associated with OSA but was associated with acute-phase anxiety, education status and MOCA. Logistic regression analysis including respiratory and sleeping parameters showed that AHI and micro-arousal index contributed to acute-phase PSA.

CONCLUSIONS

Acute-phase PSA was associated with OSA severity, potentially through OSA-caused sleep discontinuity. While 6-month PSA was associated with acute-phase anxiety, highlighting the need for integration of screening for and management of OSA and PSA at acute phase.

Biological, Psychiatric, Psychosocial, and Cognitive Factors of Poststroke Depression

BACKGROUND

Depression is the most common psychiatric condition that occurs after cerebrovascular accident, especially within the first year after stroke. Poststroke depression (PSD) may occur due to environmental factors such as functional limitations in daily activities, lower quality of life, or biological factors such as damage to areas in the brain involved in emotion regulation. Although many factors are hypothesized to increase the risk of PSD, the relative contribution of these factors is not well understood.

PURPOSE

We evaluated which cross-sectional variables were associated with increased odds of PSD in our adult outpatient stroke neuropsychology clinic population.

METHODS

The sample included 325 patients (49.2% female; mean age of 59-years old) evaluated at an average of 8.1 months after an ischemic or hemorrhagic stroke. Variables included in logistic regression were stroke characteristics, demographics, psychosocial factors, comorbid medical problems, comorbid psychiatric conditions, and cognitive status. The Mini International Neuropsychiatric Inventory was used to determine DSM-defined PSD and anxiety disorders. A standard neuropsychological test battery was administered.

RESULTS

PSD occurred in 30.8% of the sample. Logistic regression indicated that increased odds of PSD were associated with a comorbid anxiety disorder (5.9 times more likely to suffer from PSD, p < 0.001). Further, increased odds of PSD were associated with a history of depression treatment before stroke (3.0 times more likely to suffer from PSD), fatigue (2.8 times more likely), memory impairment (2.4 times more likely), and younger age at stroke (all p values < 0.006).

DISCUSSION

Results suggest that PSD is likely multifactorial and extends the literature by demonstrating that a comorbid anxiety disorder correlated strongest with PSD. Poststroke screening and treatment plans should address not only depression but comorbid anxiety.

Associations of systemic inflammation and social support with suicidal ideation in patients with acute coronary syndrome and stroke

BACKGROUND

This study aimed to investigate associations of serum high-sensitivity C-reactive protein (hsCRP) and social support (SS) levels with suicidal ideation (SI), and to evaluate potential modifying effects of SS on the associations between serum hsCRP levels and SI in two longitudinal cohorts with cardio-/cerebrovascular diseases.

METHODS

1152 acute coronary syndrome (ACS) and 423 stroke patients were recruited at baseline within 2 weeks of disease onset, and evaluated for: i) serum hsCRP levels; ii) SS by the Social Support Scale and Social Undermining Scale; iii) SI by the "suicidal thoughts" item of the Montgomery-Åsberg Depression Rating Scale; and iv) covariates including socio-demographics, depression, vascular risk factors, and index disease severity. At 12-month follow-up, SI was re-evaluated. Logistic regression models were used to adjust for potential covariates.

RESULTS

In the ACS cohort, higher serum hsCRP and lower SS levels were significantly associated with SI at baseline; and only lower SS levels were significantly associated with SI at follow-up. In the stroke cohort, lower SS levels were significantly associated with SI at baseline; but no other association was found. Associations of serum hsCRP levels with SI at both baseline and follow-up were only significant at higher SS levels with significant interaction terms in both cohorts.

LIMITATIONS

This study evaluated SI, but not suicide attempts or death; it also used a single-center design.

CONCLUSIONS

By considering SS evaluations with routine serum hsCRP levels in cardio-/cerebrovascular disease, clinical prediction of SI both at acute and chronic phases of the diseases might be improved.

Co-prevalence and incidence of myocardial infarction and/or stroke in patients with depression and/or anxiety: A systematic review and meta-analysis

OBJECTIVE

Co-prevalence and incidence of depression and/or anxiety with stroke and myocardial infarction are currently unclear. This paper explores the relationships, as these are important comorbidities affecting patient outcomes.

METHODS

A systematic search across five databases (PubMed, Scopus, PsycINFO, Embase, Cochrane) was conducted for observational studies reporting co-prevalence of depression or anxiety with stroke or myocardial infarction. We used random-effects models in all meta-analyses and evaluated heterogeneity using I².

RESULTS

This analysis included 48 studies with a total of 57,342 patients. In patients with depression, the pooled prevalence of stroke was 5.9% (95% CI = 5.53-6.37). In patients with myocardial infarction, the pooled prevalence of anxiety and depression was 9.1% (95% CI = 7.07-11.40, I² = 85.6%) and 25.9% (95% CI = 18.46-34.12, I² = 99.1%), respectively, and the pooled cumulative incidence of depression at one year was 20.5% (95% CI = 18.36-22.79). The pooled prevalence of anxiety and depression in patients with stroke was 13.5% (95% CI = 7.67-22.66, I² = 96.9%) and 23.0% (95% CI = 17.93-28.99, I² = 96.7%), respectively. The pooled cumulative incidences of depression at two weeks, three months, six months, and one year, were 29.1% (95% CI = 26.60-31.81), 17.0% (95% CI = 10.74-25.92, I² = 98.0%), 7.4% (95% CI = 6.52-8.49), and 9.1% (95% CI = 3.71-20.79, I² = 99.8%), respectively.

CONCLUSIONS

This meta-analysis outlines the co-morbid burden between depression/anxiety and stroke/myocardial infarction. Future research should be done to evaluate the effectiveness of screening anxiety/depression in myocardial infarction/stroke.

New Insights into Stroke from Continuous Passively Collected Temperature and Sleep Data Using Wrist-Worn Wearables

Actigraphy may provide new insights into clinical outcomes and symptom management of patients through passive, continuous data collection. We used the GENEActiv smartwatch to passively collect actigraphy, wrist temperature, and ambient light data from 27 participants after stroke or probable brain transient ischemic attack (TIA) over 42 periods of device wear. We computed 323 features using established algorithms and proposed 25 novel features to characterize sleep and temperature. We investigated statistical associations between the extracted features and clinical outcomes evaluated using clinically validated questionnaires to gain insight into post-stroke recovery. We subsequently fitted logistic regression models to replicate clinical diagnosis (stroke or TIA) and disability due to stroke. The model generalization performance was assessed using a leave-one-subject-out cross validation method with the selected feature subsets, reporting the area under the curve (AUC). We found that several novel features were strongly correlated (|r|>0.3) with stroke symptoms and mental health measures. Using selected novel features, we obtained an AUC of 0.766 to estimate diagnosis and an AUC of 0.749 to estimate whether disability due to stroke was present. Collectively, these findings suggest that features extracted from the temperature smartwatch sensor may reveal additional clinically useful information over and above existing actigraphy-based features.

Health anxiety in stroke survivors: a cross-sectional study on the prevalence of health anxiety in stroke survivors and its impact on quality of life

PURPOSE

To explore the prevalence of health anxiety in stroke survivors and its relative impact on quality of life.

MATERIALS AND METHODS

A cross-sectional design was used including between group comparisons of high and low health anxious stroke survivors. Stroke survivors (n = 105) were recruited via online stroke community forums. Participants completed measures of health anxiety (Short Health Anxiety Inventory), general anxiety and depression (Hospital and Anxiety and Depression Scale), disability (WHO Disability Assessment Schedule), and quality of life (Quality of Life Index). Demographics and medical histories were also assessed.

RESULTS

Thirty percent of the sample scored above the clinical cut off for health anxiety. Stroke survivors with high health anxiety (HiHA) were found to have significantly lower quality of life (p < 0.001) and higher rates of depression (p < 0.001). Regression analysis found health anxiety to be a significant predictor of quality of life (β = -0.12; p < 0.05) in addition to levels of depression (β = -0.33; p < 0.001) and disability (β = -0.53; p < 0.001).

CONCLUSIONS

Almost a third of stroke survivors were experiencing clinical levels of health anxiety, with HiHA significantly associated with lower quality of life. Future research should explore the use of existing evidence based psychological interventions for health anxiety in this population.Implications for rehabilitationOur findings suggest almost one in three stroke survivors residing in the community have clinical levels of health anxiety.High health anxiety in stroke survivors was significantly related to lower levels of quality of life.Given this finding, evidence-based treatments for health anxiety may improve quality of life and reduce distress for a significant proportion of stroke survivors.Rehabilitation approaches aimed at improving overall quality of life for stroke survivors should consider both physical and psychological interventions, with levels of physical disability, depression and anxiety all significantly associated with quality of life.

The efficacy of therapist-supported acceptance and commitment therapy-based bibliotherapy for psychological distress after stroke: a single-case multiple-baseline study

BACKGROUND

Psychological distress is common after stroke, and affects recovery. However, there are few evidence-based psychological treatments. This study evaluates a bibliotherapy-based approach to its amelioration.

AIMS

To investigate a stroke-specific self-management book, based on acceptance and commitment therapy (ACT), as a therapist-supported intervention for psychological distress after stroke.

METHOD

The design was a single case, randomised non-concurrent multiple-baseline design (MBD). Sixteen stroke survivors, eight males and eight females (mean age 60.6 years), participated in an MBD with three phases: A (randomised-duration baseline); B (intervention); and follow-up (at 3 weeks). During the baseline, participants received therapist contact only. In the bibliotherapy intervention, participants received bi-weekly therapist support. The primary measures of psychological distress (General Health Questionaire-12; GHQ-12) and quality of life (Satisfaction with Life Scale; SWLS) were completed weekly. Secondary measures of mood, wellbeing and illness impact were completed pre- and post-intervention.

RESULTS

Omnibus whole-group TAU-U analysis was statistically significant for each primary measure with a moderate effect size on both (0.6 and 0.3 for GHQ-12 and SWLS, respectively). Individual TAU-U analyses demonstrated that the majority of individuals exhibited positive change. All the secondary measures showed significant pre-post improvements. Eighty-one per cent of participants reported the book was helpful and 81% also found the ACT-based sections helpful. Relative risk calculations showed finding the book helpful was associated with improvement in GHQ-12 and SWLS scores.

CONCLUSIONS

ACT-based bibliotherapy, with therapist support, is a promising intervention for psychological difficulties after stroke.

Palliative care approaches to acute stroke in the hospital setting

Stroke is a prevalent neurologic condition that portends a high risk of morbidity and mortality such that patients impacted by stroke and their caregivers can benefit from palliative care at the time of diagnosis and throughout the disease trajectory. Clinicians who care for stroke patients should be adept at establishing rapport with patients and caregivers, delivering serious news, responding to emotions, discussing prognosis, and establishing goals of care efficiently in an acute stroke setting. Aggressive stroke care can be integrated with a palliative approach to care that involves aligning the available treatment options with a patient's values and goals of care. Reassessing the goals throughout the hospitalization provides an opportunity for continued shared decision-making about the intensity of poststroke interventions. The palliative needs for stroke patients may increase over time depending on the severity of disease, poststroke complications, stroke-related symptoms, and treatment intensity preferences. If the decision is made to transition the focus of care to comfort, the support of an interdisciplinary palliative care or hospice team can be beneficial to the patient, family members, and surrogate decision makers.

Dental anxiety and oral health following stroke: a pilot study

BACKGROUND

Oral health is often poorer in people living with acquired brain injury relative to non-clinical controls. However, although anxiety disorders become more common following stroke, no study to date has tested whether dental anxiety might contribute to stroke survivors' increased vulnerability to poorer oral health. This pilot study reports the first test of whether the anxiety disturbances that commonly present following stroke extend to dental anxiety, and if dental anxiety in this group is linked to poorer oral health.

MATERIALS AND METHODS

First-time stroke survivors (N = 35) and demographically matched controls (N = 35) completed validated measures of dental anxiety, oral health, negative affect, and life satisfaction.

RESULTS

Stroke survivors did not differ from controls in their overall levels of dental anxiety or oral health, but uniquely for the stroke group, dental anxiety was strongly associated with poorer oral health, and this effect remained significant even after controlling for negative affect and life satisfaction.

CONCLUSION

Stroke survivors who have higher levels of dental-related anxiety may be at increased risk of poorer oral health.

The longitudinal changes of serum JKAP and IL-17A, and their linkage with anxiety, depression, and cognitive impairment in acute ischemic stroke patients

BACKGROUND

Our previous study discovers that Jun N-terminal kinase pathway-associated phosphatase (JKAP) is dysregulated and negatively links with the disease severity in acute ischemic stroke (AIS) patients. This study intended to further evaluate the linkage of JKAP and interleukin (IL)-17A with anxiety, depression, and cognitive impairment in AIS patients.

METHODS

Serum JKAP and IL-17A levels in 120 AIS patients at admission, 1st (D1), 3rd (D3), 7th (D7) day after admission, and from 20 controls, were detected by ELISA. Hospital Anxiety and Depression Scale (HADS) and Mini-Mental State Examination (MMSE) were assessed in AIS patients at discharge.

RESULTS

JKAP (p < 0.001) was reduced, but IL-17A (p < 0.001) was increased in AIS patients versus controls, and negatively correlated with each other in AIS patients (p = 0.014). In AIS patients, JKAP was reduced from baseline to D1 and then increased to D7 (p < 0.001), while IL-17A exhibited an opposite trend (p < 0.001). Notably, JKAP at D3 was negatively linked with HADS-anxiety score (p = 0.044), then decreased JKAP at D3 (p = 0.017) and D7 (p = 0.037) related to increased anxiety occurrence. However, JKAP was not linked to HADS-depression score or depression occurrence. Besides, JKAP at multiple time points were positively associated with MMSE score (all p < 0.05); decreased JKAP at D3 (p = 0.017) and D7 (p = 0.026) related to raised cognitive impairment occurrence.

CONCLUSION

JKAP initially decreases then shows an increasing trend after disease onset, and its decrement relates to elevated IL-17A, anxiety and cognitive impairment in AIS patients.

Patients' experience of and participation in a stroke self-management programme, My Life After Stroke (MLAS): a multimethod study

OBJECTIVE

A self-management programme, My Life After Stroke (MLAS), was developed to support stroke survivors. This evaluation reports patients' experience.

DESIGN

Multimethod, involving interviews and questionnaires.

SETTING

23 general practices in the intervention arm of a cluster randomised controlled trial in East of England and East Midlands, UK.

PARTICIPANTS

People on the stroke registers of participating general practices were invited to attend an MLAS programme.

INTERVENTIONS

MLAS comprises one-to-one and group-based sessions to promote independence, confidence and hope.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was uptake of the programme. Participants who declined MLAS were sent a questionnaire to ascertain why. Attendees of four programmes completed evaluation forms. Attendees and non-attendees of MLAS were interviewed. Ad-hoc email conversations with the lead author were reviewed. Thematic analysis was used for qualitative data.

RESULTS

141/420 (34%) participants (mean age 71) attended an MLAS programme and 103 (73%) completed 1. 64/228 (28%) participants who declined MLAS gave reasons as: good recovery, ongoing health issues, logistical issues and inappropriate. Nearly all attendees who completed questionnaires felt that process criteria such as talking about their stroke and outcomes such as developing a strong understanding of stroke had been achieved.

CONCLUSIONS

MLAS was a positive experience for participants but many stroke survivors did not feel it was appropriate for them. Participation in self-management programmes after stroke might be improved by offering them sooner after the stroke and providing a range of delivery options beyond group-based, face-to-face learning.

TRIAL REGISTRATION NUMBER

NCT03353519, NIH.

The longitudinal course of anxiety, depression and apathy through two years after stroke

OBJECTIVE

Estimate the prevalence of anxiety disorders, depressive disorders and apathy two years after stroke, examine their longitudinal course, describe the course of psychological distress through two years after stroke, and evaluate Hospital Anxiety and Depression Scale HADS-A and HADS-D cut-off scores of ≥4 and ≥ 8 for detection of anxiety and depressive disorders two years after stroke.

METHODS

In a longitudinal cohort study of 150 consecutive stroke patients in a stroke unit, 103 were assessed four months and 75 two years after stroke. Anxiety and depression disorders and symptoms were assessed by the Structured Clinical Interview for DSM-IV and HADS, apathy by the Apathy Evaluation Scale.

RESULTS

Prevalence of at least one anxiety disorder or one depressive disorder decreased from four months to two years (23% vs 9%, P = 0.026, 19% vs 10%, P = 0.17). Apathy remained stable at 48% vs 50%. After two years, 80%, 79% and 19% of those with anxiety, depression or apathy at four months had recovered. Recovery-rates among patients with anxiety were 83% for panic disorder, 60% for generalized anxiety disorder (GAD), and 50% for social phobia.

CONCLUSIONS

In contrast to apathy, recovery from anxiety and depression was high. About half of the patients with GAD, social phobia or agoraphobia did not recover. Co-morbid depression and apathy at four months implied a high risk for not recovering at two years. HADS-A and HADS-D cut-off scores of ≥8 were feasible for detection of anxiety and depression disorders two years after stroke.

Stroke and TIA Survivors' Perceptions of the COVID-19 Vaccine and Influences on Its Uptake: Cross Sectional Survey

BACKGROUND

People who have experienced a stroke or transient ischaemic attack (TIA) have greater risks of complications from COVID-19. Therefore, vaccine uptake in this vulnerable population is important. To prevent vaccine hesitancy and maximise compliance, we need to better understand individuals' views on the vaccine.

OBJECTIVES

We aimed to explore perspectives of the COVID-19 vaccine and influences on its uptake from people who have experienced a stroke or TIA.

METHOD

A cross-sectional, electronic survey comprising multiple choice and free text questions. Convenience sampling was used to recruit people who have experienced a stroke/TIA in the UK/Ireland.

RESULTS

The survey was completed by 377 stroke/TIA survivors. 87% (328/377) had either received the first vaccine dose or were booked to have it. The vaccine was declined by 2% (7/377) and 3% (11/377) had been offered the vaccine but not yet taken it up. 8% (30/377) had not been offered the vaccine despite being eligible. Some people expressed concerns around the safety of the vaccine (particularly risk of blood clots and stroke) and some were hesitant to have the second vaccine. Societal and personal benefits were motivations for vaccine uptake. There was uncertainty and lack of information about risk of COVID-19 related complications specifically for people who have experienced a stroke or TIA.

CONCLUSION

Despite high uptake of the first vaccine, some people with stroke and TIA have legitimate concerns and information needs that should be addressed. Our findings can be used to identify targets for behaviour change to improve vaccine uptake specific to stroke/TIA patients.

Determinants of functioning and health-related quality of life after vestibular stroke

Background

Stroke accounts for 5–10% of all presentations with acute vertigo and dizziness. The objective of the current study was to examine determinants of long-term functioning and health-related quality of life (HRQoL) in a patient cohort with vestibular stroke.

Methods

Thirty-six patients (mean age: 66.1 years, 39% female) with an MRI-proven vestibular stroke were followed prospectively (mean time: 30.2 months) in the context of the EMVERT (EMergency VERTigo) cohort study at the Ludwig-Maximilians Universität, Munich. The following scores were obtained once in the acute stage (<24 h of symptom onset) and once during long-term follow-up (preferably >1 year after stroke): European Quality of Life Scale-five dimensions-five levels questionnaire (EQ-5D-5L) and Visual Analog Scale (EQ-VAS) for HRQoL, Dizziness Handicap Inventory (DHI) for symptom severity, and modified Rankin Scale (mRS) for general functioning and disability. Anxiety state and trait were evaluated by STAI-S/STAI-T, and depression was evaluated by the Patient Health Questionnaire-9 (PHQ-9). Voxel-based lesion mapping was applied in normalized MRIs to analyze stroke volume and localization. Multiple linear regression models were calculated to determine predictors of functional outcome (DHI, EQ-VAS at follow-up).

Results

Mean DHI scores improved significantly from 45.0 in the acute stage to 18.1 at follow-up (p < 0.001), and mean mRS improved from 2.1 to 1.1 (p < 0.001). Mean HRQoL (EQ-5D-5L index/EQ-VAS) changed from 0.69/58.8 to 0.83/65.2 (p = 0.01/p = 0.11). Multiple linear regression models identified higher scores of STAI-T and DHI at the time of acute vestibular stroke and larger stroke volume as significant predictors for higher DHI at follow-up assessment. The effect of STAI-T was additionally enhanced in women. There was a significant effect of patient age on EQ-VAS, but not DHI during follow-up.

Conclusion

The average functional outcome of strokes with the chief complaint of vertigo and dizziness is favorable. The most relevant predictors for individual outcomes are the personal anxiety trait (especially in combination with the female sex), the initial symptom intensity, and lesion volume. These factors should be considered for therapeutic decisions both in the acute stage of stroke and during subsequent rehabilitation.

The efficacy and safety of Jin's three-needle therapy vs. placebo acupuncture on anxiety symptoms in patients with post-stroke anxiety: A study protocol for a randomized controlled trial

Background

A large number of clinical RCTs have verified that Jin's three-needle therapy (JTNT) has a great contribution to promoting the function of paralyzed limbs and relieving anxiety disorders for patients with post-stroke anxiety (PSA). However, there is still a lack of sham needle control, and its placebo effect cannot be ruled out. This study firstly verifies the real effectiveness of JTNT. Besides, the changes in serum indexes on the hypothalamic-pituitary-adrenal axis (HPA axis) are observed dynamically by the Enzyme-Linked ImmunoSorbent Assay (ELISA). The activation of different brain regions by JTNT is recorded using resting functional magnetic resonance imaging (rs-fMRI). Therefore, we can provide more practical and powerful evidence-based medical evidence for clinical decisions.

Method

This is a 16 week parallel, single-blind, random, controlled trial, including baseline, 4 weeks of treatment, and 12 weeks of follow-up. A total of 114 participants will be randomly divided into three groups in the proportion of 1:1:1. Participants will receive Jin's three-needle therapy in the active acupuncture group and accept sham needle treatment in the sham acupuncture group. In the waitlist control group, patients will not receive any acupuncture treatment. Outcomes cover three types of indicators, including scale indicators, serum indicators, and imaging indicators. The primary outcome is the change in the performance of anxiety symptoms, which is estimated by the 14-item Hamilton Anxiety Rating Scale (HAMA-14) and the 7-item Generalized Anxiety Disorder scale (GAD-7). Secondary outcomes are physical recovery and daily quality of life, which are evaluated by the National Institute of Health stroke scale (NIHSS) and the Modified Barthel Index Score (MBI Scale). Therefore, the assessment of the scale is carried out at baseline, 2nd, 4th, 8, 12, and 16 weeks. Adrenocorticotropin and cortisol will be quantitatively detected by ELISA at baseline and 4 weeks after treatment. In addition, regional homogeneity analysis (ReHo) will be used to record the activity of brain regions at baseline and 4 weeks after intervention.

Discussion

The study aims to provide high-quality clinical evidence on the effectiveness and safety of JTNT for patients with PSA. In addition, this trial explores a possible mechanism of JTNT for patients with PSA.

Clinical trial registration

Chinese Clinical Trial Registry, identifier [ChiCTR2200058992].

Optimising rehabilitation and recovery after a stroke

Stroke can cause significant disability and impact quality of life. Multidisciplinary neurorehabilitation that meets individual needs can help to optimise recovery. Rehabilitation is essential for best quality care but should start early, be ongoing and involve effective teamwork. We describe current stroke rehabilitation processes, from the hyperacute setting through to inpatient and community rehabilitation, to long-term care and report on which UK quality care standards are (or are not) being met. We also examine the gap between what stroke rehabilitation is recommended and what is being delivered, and suggest areas for further improvement.

Predictors of Post-Stroke Depression: A Retrospective Cohort Study

Despite reports of a high incidence and various predictors of post-stroke depression (PSD), the underdiagnosis and undertreatment rates of PSD are still high. This study aimed to examine the incidence of depression in stroke patients and identify factors associated with PSD. This was a retrospective cohort study on ischemic stroke patients from the Geisinger Neuroscience Ischemic Stroke (GNSIS) registry. The following statistical analyses were performed to predict PSD in the studied population: a Kaplan−Meier estimator and a Cox proportional hazards model. A total of 5882 patients were included in the study. The median age at the time of an ischemic stroke was 72 years and 56% were males. A total of 294 patients were diagnosed with PSD within one year of a stroke. The cumulative incidence of depression was found to be 6.4% (95% CI 5.7−7.1%) at one year for the entire cohort. Women were found to have a higher risk of PSD than men (HR for women = 1.47, 95% CI 1.18−1.85, p = 0.001). A history of prior stroke (HR = 1.58, 95% CI 1.18−2.11, p = 0.002) and myocardial infarction (HR = 1.47, 95% CI 1.05−2.06, p = 0.025) were associated with PSD. Medicaid patients had a higher risk for PSD (HR = 2.16, 95% CI 1.5−3.12, p < 0.001) than those with commercial insurance or health maintenance organization plans. Our findings showed that women, patients with a history of prior stroke or myocardial infarction, and with Medicaid insurance were more likely to develop PSD. Through an observational study on the EHR data, we confirmed that chronic stress, including financial and health-related stress, irrespective of age, significantly increased the risk for PSD.

Theory-Based Self-Management Interventions for Community-Dwelling Stroke Survivors: A Systematic Review and Meta-Analysis

IMPORTANCE

Self-management is a critical component of stroke rehabilitation. A better understanding of the use of theory and behavior change techniques (BCTs) informs the development of more effective stroke self-management interventions.

OBJECTIVE

To examine what theories and BCTs have been applied in stroke self-management interventions; investigate the extent to which these interventions encourage implementation of behavior changes; and appraise their effectiveness to enhance self-efficacy, quality of life, and functional independence.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, CINAHL, Cochrane Library, and ClinicalTrials.gov were searched from inception to May 26, 2020.

STUDY SELECTION AND DATA COLLECTION

Randomized controlled trials (RCTs) in six databases were reviewed for inclusion and analysis. We included trials that involved community-dwelling adult stroke survivors, assessed the effectiveness of self-management interventions, and explicitly mentioned the use of theory in the development of the intervention. We assessed use of theory and BCTs using the Theory Coding Scheme and BCT taxonomy v1, respectively.

FINDINGS

A total of 3,049 studies were screened, and 13 RCTs were included. The predominant theory and BCT categories were Social Cognitive Theory (7 studies) and goals and planning (12 studies), respectively. Significant and small effect sizes were found for self-efficacy (0.27) and functional independence (0.19).

CONCLUSIONS AND RELEVANCE

Theory-based self-management interventions have the potential to enhance stroke outcomes. Systematic reporting on the use of theory and BCTs is recommended to enhance clarity and facilitate evaluations of future interventions. What This Article Adds: This review supports and guides occupational therapy practitioners to use theory-based self-management intervention as a routine part of stroke rehabilitation to improve stroke survivors' experience in the community.