Transition Experiences of Stroke Survivors Following Discharge Home

Interventions for Driving Disruption in Community Rehabilitation: A Chart Audit

PURPOSE

After injury or illness, a person's ability to drive may be impacted and they may experience a period of "driving disruption," a period during which they cannot drive although they have not permanently ceased driving. They may require additional information and supports from treating rehabilitation services; however, this process is less understood than others related to driving.

MATERIALS AND METHODS

This study aimed to document the prevalence of driving-related issues and the current practices of a community rehabilitation service, regarding driving interventions. An audit of 80 medical records was conducted in a multidisciplinary community rehabilitation service in Brisbane, Australia.

RESULTS

In total, 61% of clients were "driving-disrupted" on admission and 35% remained driving-disrupted on discharge. Majority of driving-disrupted clients had an acquired brain injury (ABI). Driving-related interventions were not routinely provided, with 29% receiving no information or supports. Clients with ABI more frequently received information; provision of psychosocial support and community access training was infrequent.

CONCLUSIONS

This study highlights that return to driving is a common issue and goal for people undergoing community rehabilitation, with the period of driving disruption extending beyond rehabilitation discharge. It also highlights gaps in community rehabilitation practice, and opportunities to better support these clients.IMPLICATIONS FOR REHABILITATIONMany clients of community rehabilitation services experience driving disruption, often beyond discharge.Driving disruption should be recognised and documented by community rehabilitation services.Current practices may not adequately address the practical and psychological needs of clients experiencing driving disruption.

Perceived service adequacy and unmet need after discharge from brain injury rehabilitation

PURPOSE

The present study aimed to quantify the perceived needs and adequacy of realised access to post-acute services in a sample of people with acquired brain injury in the first 6-months after discharge from inpatient rehabilitation. A secondary focus was the influence of access to funding and specialist transitional rehabilitation on unmet needs.

MATERIALS AND METHODS

Participants were 51 adults with a median age of 50 (IQR 35-57) recruited from an inpatient rehabilitation unit in an Australian tertiary hospital. The sample was those who had an acquired brain injury, including 23 who sustained a traumatic injury and 28 who sustained a non-traumatic injury. Measures were collected via telephone at 3- and 6-months, in a prospective observational cohort design using the Needs and Provisions Complexity Scale. A series of logistic regression models were used to determine the effects of participation in a transitional rehabilitation program and funding pathway on adequacy and unmet needs.

RESULTS

Unmet needs for rehabilitation were most commonly reported (60%), followed by unmet needs in relation to health care (40%), social care (35%), personal care (32%) and environment-related (14%). Participants who attended transitional rehabilitation were more likely to indicate unmet health care needs (OR = 6.40, 95% CI = 1.40-29.24, p = 0.02).

CONCLUSIONS

The study highlights the need to look beyond functional impairment when conceptualising appropriate access. Additionally, the present research highlighted the need for greater work into an expectation of services.IMPLICATIONS FOR REHABILITATIONThe majority of people with an acquired brain injury report unmet needs at 6 months post discharge.Present findings support the utility of patient reported measures when considering treatment evaluation with people with ABI, where assessing the personal appraisal of individuals needs may prove to be a key indicator to facilitate optimal service access.There are specific services that needed and not provided including psychological, speech pathology, family carer needs and vocational rehabilitation, and therefore are a key target for ensuring appropriate support is provided.

Rehabilitation models that support transitions from hospital to home for people with acquired brain injury (ABI): a scoping review

BACKGROUND

Research shows a lack of continuity in service provision during the transition from hospital to home for people with acquired brain injuries (ABI). There is a need to gather and synthesize knowledge about services that can support strategies for more standardized referral and services supporting this critical transition phase for patients with ABI. We aimed to identify how rehabilitation models that support the transition phase from hospital to home for these patients are described in the research literature and to discuss the content of these models.

METHODS

We based our review on the "Arksey and O`Malley framework" for scoping reviews. The review considered all study designs, including qualitative and quantitative methodologies. We extracted data of service model descriptions and presented the results in a narrative summary.

RESULTS

A total of 3975 studies were reviewed, and 73 were included. Five categories were identified: (1) multidisciplinary home-based teams, (2) key coordinators, (3) trained family caregivers or lay health workers, (4) predischarge planning, and (5) self-management programs. In general, the studies lack in-depth professional and contextual descriptions.

CONCLUSIONS

There is a wide variety of rehabilitation models that support the transition phase from hospital to home for people with ABI. The variety may indicate a lack of consensus of best practices. However, it may also reflect contextual adaptations. This study indicates that health care service research lacks robust and thorough descriptions of contextual features, which may limit the feasibility and transferability to diverse contexts.

Care Transition Interventions to Improve Stroke Outcomes: Evidence Gaps in Underserved and Minority Populations

In many countries hospital length of stay after an acute stroke admission is typically just a few days, therefore, most of a person's recovery from stroke occurs in the community. Care transitions, which occur when there is a change in, or handoff between 2 different care settings or providers, represent an especially vulnerable period for patients and caregivers. For some patients with stroke the return home is associated with substantial practical, psychosocial, and health-related challenges leading to substantial burden for the individual and caregiver. Underserved and minority populations, because of their exposure to poor environmental, social, and economic conditions, as well as structural racism and discrimination, are especially vulnerable to the problems of complicated care transitions which in turn, can negatively impact stroke recovery. Overall, there remain significant unanswered questions about how to promote optimal recovery in the post-acute care period, particularly for those from underserved communities. Evidence is limited on how best to support patients after they have returned home where they are required to navigate the chronic stages of stroke with little direct support from health professionals.

The experience of close personal relationships after stroke: scoping review and thematic analysis of qualitative literature

Background and Purpose:

Psychosocial difficulties, including changed relationships are among the most pervasive and concerning issues following stroke. This study aimed to collate and thematically analyse qualitative literature describing the experience of close personal relationships from the perspective of stroke survivors.

Method:

Using a scoping review methodology, four databases (CINAHL/EBSCO, MEDLINE/Pubmed, Embase, Psychinfo) were systematically searched, yielding 3100 citations. Following exclusion of duplicates and screening against inclusion criteria at title/abstract and full text levels, 53 articles were included in the review. Data were charted and thematically analysed.

Results:

While research has increased since 2000, longitudinal designs are few. Four overarching themes and 12 subthemes were identified. ‘Social disruption’ described changing social worlds, lost social opportunities and shrinking networks. ‘Changed relationships’ included changed family and spousal relationships and changed parenting relationships. The third theme ‘relationships help’ highlighted positive aspects including belonging, support and a life worth living. The final theme was ‘coping with an altered social world’ and described adjustment and emotional responses.

Conclusions:

Relationships are an important aspect of life post stroke but are subject to changes and challenges. This article brings together a breadth of qualitative data to describe lived experiences. Further research, in particular, longitudinal research is required.

Sexuality after stroke: Exploring knowledge, attitudes, comfort and behaviours of rehabilitation professionals

BACKGROUND

Sexual dysfunction after stroke is common and is associated with poor health and quality of life outcomes. Clinical guidelines for stroke typically recommend that all stroke survivors have access to support relating to sexuality during rehabilitation. However, the extent to which rehabilitation professionals are prepared to address sexuality after stroke is unclear.

OBJECTIVE

To investigate the knowledge, comfort, approach, attitudes, and practices of rehabilitation professionals toward supporting stroke survivors with their sexuality concerns.

METHODS

Cross-sectional analytic survey design. Data were collected by using an electronic questionnaire that contained the Knowledge, Comfort, Approaches, and Attitudes towards Sexuality Scale (KCAASS) and sexuality-related practice questions. Participants were recruited from Australia, New Zealand, the United States, Canada, United Kingdom, Ireland, Singapore, and South Africa. Multiple regression was used to explore KCAASS scores and sexuality-related practices.

RESULTS

A total of 958 multi-disciplinary, stroke rehabilitation professionals participated in the study. Only 23% (n = 216) of health professionals' reported directly initiating sexuality discussions with stroke survivors. On regression analysis, professionals' practices, perception of their role in sexuality rehabilitation, sexuality training, education, age and sex predicted their knowledge of sexuality after stroke (r² = 0.44; p<0.001). Sexuality training, religious affiliation and provision of sexuality-rehabilitation services predicted comfort (r² = 0.21; p<0.001). Professionals' age and provision of sexuality-rehabilitation services predicted approach-related comfort (r² = 0.2; p<0.001). Professionals' perception of health professionals' role in sexuality rehabilitation, religious affiliation and geographical location predicted professionals' attitudes toward sexuality (r² = 0.11; p<0.001). Open-ended responses indicated that participants perceived a need to improve their competency in providing sexuality rehabilitation. The timing of training predicted knowledge (t = 3.99; p<0.001), comfort (t = 3.47; p<0.001) and the provision of sexuality-rehabilitation services (t = 3.68; p<0.001).

CONCLUSION

Findings confirm that sexuality is neglected in stroke rehabilitation and point to the need for a considered approach to the timing and nature of education.

Enablers and barriers in hospital-to-home transitional care for stroke survivors and caregivers: A systematic review

AIMS AND OBJECTIVES

To synthesise qualitative research evidence on the experience of stroke survivors and informal caregivers in hospital-to-home transitional care.

BACKGROUND

Due to a shortened hospital stay, stroke survivors/caregivers must take over complex care on discharge from hospital to home. Gaps in the literature warrant a meta-synthesis of qualitative studies on perceived enablers and barriers during this crucial period.

DESIGN

A systematic review and meta-synthesis.

METHODS

A review was guided by Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist where six databases were searched from April to June 2020 including CINAHL Plus, MEDLINE, PsycINFO, Scopus, Web of Science and ProQuest and ProQuest Dissertations and Theses. There was no date limit to the search. Selected studies were critically appraised. A thematic synthesis approach was applied.

RESULTS

The synthesis of 29 studies identified three major findings. First, partnerships with stroke survivors/caregivers empower discharge preparation, foster competence to navigate health and social care systems and activate self-management capabilities. Second, gaps in discharge planning and the lack of timely postdischarge support contribute to unmet care needs for stroke survivors/caregivers and affect their ability to cope with poststroke changes. Third, stroke survivors/caregivers expect integrated transitional care that promotes shared decision-making and enables long-term self-management at home.

CONCLUSIONS

Hospital-to-home transition is a challenging period in the trajectory of poststroke rehabilitation and recovery. Further research is required to deepen understandings of all stakeholders' views and address unmet needs during transitional care.

RELEVANCE TO CLINICAL PRACTICE

Protocols and clinical guidelines relating to discharge planning and transitional care need to be reviewed to ensure partnership approach with survivors/caregivers in the design and delivery of individualised transitional care. Stroke nurses are in a unique position to lead timely support for survivors/caregivers and to bridge service gaps in hospital-to-home transitional care.

The role of the social network during inpatient rehabilitation: A qualitative study exploring the views of older stroke survivors and their informal caregivers

BACKGROUND

After discharge, stroke survivors and their informal caregivers need support from their social networks to resume their most valued activities. Rehabilitation professionals could help them establish a strong support system.

OBJECTIVE

Explore how older stroke survivors and their primary informal caregivers expect to resume their valued activities after discharge, and discover their ideas about involving, informing and educating their family members, friends and important others during inpatient rehabilitation so that, once home, they will have adequate support.

METHODS

We conducted semi-structured interviews with stroke survivors from three geriatric rehabilitation centres and their primary informal caregivers, used the pictures of daily activities to elicit their perspectives, and applied a descriptive and interpretive design to data analysis.

RESULTS

Many participants had no concrete idea about how to resume their activities after discharge but nevertheless were optimistic they would. They expected help to be available and saw no need for professionals to involve their network during inpatient rehabilitation. However, once they had insight into the challenges to expect after discharge, they often appreciated the idea of professionals contacting their network. To better understand the challenges after discharge, it was helpful if professionals provided concrete, honest information about the stroke's consequences for daily life. Actually doing daily activities also helped gain better insights.

CONCLUSIONS

To enhance insight in the need of social support after discharge, we suggest that rehabilitation professionals are honest about what to expect and let stroke survivors explore their valued activities in a realistic context more often.

Quickly home again: patients' experiences of early discharge after minor stroke

BACKGROUND

Patients with minor stroke experience some of the same issues as patients experiencing stroke of increased severity such as fatigue, anxiety and cognitive symptoms. It is current practice that patients with minor stroke receive accelerated treatment and care, yet studies indicate that patients find it difficult to return to their everyday lives after being discharged. We aimed to explore how patients with minor stroke experience the transitional period from the hospital through the first 2-4 weeks after an accelerated care pathway with discharge within 72 hours after stroke onset.

METHODS

A qualitative study consisting of semi-structured interviews with 11 patients experiencing first-time stroke 2-4 weeks after discharge.

RESULTS

The patients struggled to identify themselves as having had a stroke. They strived to find a new everyday life, but were challenged by existential concerns, mental fatigue and the fear of having a stroke again. Unresolved questions and misunderstandings arose, and the patients expressed a need for health professionals to support them and discuss unclear issues after discharge. Patients searched for others with similar issues in order to find a new sense of self.

CONCLUSION

Patients with minor stroke struggle with everyday life after discharge. There is a need for support after discharge from healthcare professionals with specialised knowledge of stroke. Patients also requested an opportunity to meet other patients with minor stroke.

An integrative review: Challenges and opportunities for stroke survivors and caregivers in hospital to home transition care

AIM

To identify challenges and opportunities for stroke survivors and caregivers in hospital to home transition care.

BACKGROUND

Due to shortened hospital stays, stroke survivors and caregivers must take responsibility for complex care on discharge from hospital to home. Gaps exist in the literature that synthesizes studies on hospital to home transition care.

DESIGN

A systematic integrated review.

DATA SOURCES

Six databases were searched systematically between 18 June 2018 - 31 October 2018 including Medline, CINAHL, Web of Science, ProQuest, Scopus and Science Direct. The search did not have a date limit.

REVIEW METHODS

Studies that met the selection criteria were critically reviewed. Data were extracted from the studies for analyses. A convergent qualitative synthesis approach using inductive thematic synthesis was applied to the review.

RESULTS

The analysis of 23 studies identified three major findings. First, health and social care systems influence transition care by either enabling stroke survivors and caregivers to manage transition care via well-coordinated services or preventing them from accessing services. Second, health professionals' partnership with stroke survivors and caregivers largely decides tailored support for them. Successful partnerships and engagements with stroke survivors and caregivers depend on organizational resources. Third, survivors and caregivers are at different levels of readiness to cope with challenges. Individualized support for them to develop resilience is highly regarded.

CONCLUSION

Stroke survivors and caregivers encounter enormous challenges in self-management of hospital to home transition care. Further research is required to address their expectations of support during transition care.

IMPACT

There is a lack of synthesis of studies on factors affecting hospital to home transition care for stroke survivors. Health and social care system designs, health professionals' commitment to individualized care and the self-management capability of stroke survivors and their caregivers have a profound influence on the transition care experiences.

The experience of upper-limb dysfunction after stroke: a phenomenological study

BACKGROUND

Stroke can bring about a profound disruption to people's lives, but what is less understood is the effect that specific dysfunctions can have. The aim of this study was to explore stroke survivors' experiences of upper-limb dysfunction over time.

METHODS

13 adult stroke survivors engaged in a series of up to four semi-structured interviews over an 18-month period after stroke. Data were interpreted through a method based on framework analysis. An interpretive phenomenological approach guided the research.

RESULTS

Upper-limb dysfunction brought substantial challenges for people, identified in a main theme of an altered way of life. Subordinate themes that contributed to this alteration were challenges in personal care, participating in meaningful and valued activities, and managing life roles and relationships. The second main theme was the disrupted self, with subordinate themes of feeling devalued, disrupted self-image and changes in identity.

CONCLUSION

The impact of upper-limb dysfunction on people's lives after stroke should be understood and acknowledged by rehabilitation professionals. Restoring some functional upper-limb activity could play an important role in enabling a person to regain a meaningful life and a coherent sense of self after stroke.IMPLICATIONS FOR REHABILITATIONUpper-limb dysfunction after stroke, and the loss of bimanual hand function, can profoundly alter a person's life, rendering them unable to manage simple tasks of personal care, participate in valued activities and fulfil important life roles.These functional and social limitations can then disrupt their sense of self, with feelings of low self-worth, and changes in self-image and identity.It is important that these changes in stroke survivors' lives are acknowledged and understood by rehabilitation professionals. More prolonged periods of therapy for recovery of upper-limb function, or for developing compensatory strategies, should be considered so that people can regain some meaning in life and maintain a coherent sense of self.

Structuring community-based adapted dance programs for persons post-stroke: a qualitative study

PURPOSE

Dance improves physical, psychosocial, and cognitive function, while increasing community participation among community-dwelling individuals post-stroke. Yet little is known about how to structure community-based dance classes to optimize benefits and participation. This study aims to gain stakeholders' perspectives about how to optimally structure community-based dance classes for individuals with chronic stroke.

METHODS

A qualitative descriptive approach utilizing focus group methods was implemented. Two focus groups were undertaken with each of three stakeholder groups: persons post-stroke (n = 9), rehabilitation therapists (n = 6), and dance instructors (n = 8). Focus groups were audio-recorded and transcribed verbatim, providing the raw data. Analysis of the focus group transcripts were completed using the DEPICT model of collaborative qualitative analysis.

RESULTS

This study identified three main themes/topics requiring consideration when structuring community-based dance programs: the environment, flow of the class, and qualities of the dance instructor. The study findings highlight that the pedagogical skills and teaching philosophy of the dance instructor are integral for a successful dance program, as the dance instructor directly mediates both the environment and flow of classes.

CONCLUSION

Recommendations generated from our study can inform the development of community-based dance programs that are practical, optimize health benefits, and meet the needs and interests of people post-stroke.IMPLICATIONS FOR REHABILITATIONDance is an effective way to improve physical, psychosocial, and cognitive function for persons post-stroke while also promoting meaningful social relationships within the community.A dance instructor who is a skilled communicator and is willing to adapt to the needs of the class, is the most important factor for a successful dance class.Creating a safe and inviting environment for a dance program, includes both the physical and emotional aspects of environment facilitating individuals to create connections with others and feel more confident in themselves.The structure of a dance class, based on the abilities, interests, and goals of dancers, should include elements of predictability and variability to keep dancers progressing and motivated, and be two times a week for 3 months lasting 1-2 h.

Relationships between gait variability and ambulatory activity post stroke

BACKGROUND

Fall risk and balance confidence are related to gait variability and ambulatory activity post stroke, yet whether a relationship exists between gait variability and ambulatory activity is unknown. Knowing if gait variability measured under naturalistic conditions is related to ambulatory activity could explain more about the relationship between falls and walking activity post-stroke.

OBJECTIVES

To examine relationships between spontaneous, daily ambulatory activity and gait variability during single- and dual-task walking, in low- and high-distraction settings in adults post stroke.

METHODS

Sixteen community-dwelling adults post stroke participated in a cross-sectional study. Spatiotemporal gait parameters were recorded during single- and cognitive-motor dual-task walking in low- and high-distraction settings. Coefficient of variation was calculated for stride length and stride duration. Average walking bout duration, maximum walking bout duration, and total number of steps per day were captured using an activity monitor. Correlations between ambulatory activity measures and gait variability were examined.

RESULTS

In the high-distraction setting, single-task stride duration variability was negatively related to all three ambulatory activity measures, but the strongest relationship was a negative correlation between dual-task stride duration variability and average walking duration. In the low-distraction setting, single-task stride duration variability was negatively related to maximum walking duration. None of the other variability measures were related to ambulatory activity.

CONCLUSIONS

The finding that stride duration variability in a high-distraction environment, with or without an additional cognitive task, is related to ambulatory activity in community-dwelling stroke survivors suggests that assessments incorporating attentional demands of real-world walking may be useful additions to clinical practice.

How is sexuality after stroke experienced by stroke survivors and partners of stroke survivors? A systematic review of qualitative studies

Objective:

To synthesise how post-stroke sexuality is experienced by stroke survivors and partners of stroke survivors.

Methods:

MEDLINE, PubMed, SCOPUS, CINAHL and PsycINFO were searched from inception to May 2018 using a combination of relevant Medical Subject Headings and Free Text Terms. Only papers published in English reporting original qualitative research were included. Methodological quality was assessed using the Critical Appraisal Skills Programme Qualitative Research Checklist. All text presented as ‘results’ or ‘findings’ in the included studies was extracted and subjected to a thematic analysis and synthesis which was discussed and agreed by the research team.

Results:

The initial search yielded 136 unique papers with a further 8 papers identified through reference checking. Following full-text review, 43 papers were included in the final synthesis. Two analytical themes were identified: sexuality is silenced and sexuality is muted and sometimes changed, but not forgotten. These themes were made up of six descriptive themes: struggle to communicate within relationships, health professionals don’t talk about sexuality, sexuality and disability is a taboo topic, changes to pre-stroke relationships, changed relationship with the stroke survivor’s own body and resuming sexual intimacy – adaptation and loss.

Conclusion:

Stroke has a profound impact on how sexuality is experienced by both stroke survivors and partners of stroke survivors. Despite this, post-stroke sexuality is rarely discussed openly. Stroke survivors and partners value sexuality and may benefit from strategies to support adjustment to post-stroke sexuality.

Long-term unmet needs and associated factors in stroke or TIA survivors

Objective:

To extensively investigate long-term unmet needs in survivors of stroke or TIA and to identify factors associated with these unmet needs.

Methods:

Community-dwelling adults were invited to participate in a survey ≥2 years after discharge for stroke/TIA. Unmet needs were assessed across 5 domains: activities and participation, environmental factors, body functions, post–acute care, and secondary prevention. Factors associated with unmet needs were determined with multivariable negative binomial regression.

Results:

Of 485 participants invited to complete the survey, 391 (81%) responded (median age 73 years, 67% male). Most responders (87%) reported unmet needs in ≥1 of the measured domains, particularly in secondary prevention (71%). Factors associated with fewer unmet needs included older age (incident rate ratio [IRR] 0.62, 95% confidence interval [CI] 0.50–0.77), greater functional ability (IRR 0.33, 95% CI 0.17–0.67), and reporting that the general practitioner was the most important in care (IRR 0.69, 95% CI 0.57–0.84). Being depressed (IRR 1.61, 95% CI 1.23–2.10) and receiving community services after stroke (IRR 1.45, 95% CI 1.16–1.82) were associated with more unmet needs.

Conclusions:

Survivors of stroke/TIA reported considerable unmet needs ≥2 years after discharge, particularly in secondary prevention. The factors associated with unmet needs could help guide policy decisions, particularly for tailoring care and support services provided after discharge.

Levels of Community Ambulation Ability in Patients with Stroke Who Live in a Rural Area

BACKGROUND

Community ambulation is essential for patients with stroke. Apart from treatments, an assessment with a quantitative target criterion is also important for patients to clearly demonstrate their functional alteration and determine how close they are to their goal, as well as for therapists to assess the effectiveness of the treatments. The existing quantitative target criteria for community ambulation were all derived from participants in a developed country and ability was assessed using a single-task test. To explore cutoff scores of the single-task and dual-task 10-meter walk test (10MWT) in ambulatory patients with stroke from rural areas of a developing country.

METHODS

Ninety-five participants with chronic stroke were interviewed concerning their community ambulation ability, and assessed for their walking ability using the single- and dual-task 10MWT.

RESULTS

A walking speed of at least 0.47 m/s assessed using the single-task 10MWT, and at least 0.30 m/s assessed using the dual-task 10MWT, could determine the community ambulation ability of the participants.

CONCLUSION

Distinct contexts and anthropometric characteristics required different target criteria for community walking. Thus, when establishing a target value for community ambulation, it needs to be specific to the demographics and geographical locations of the patients.

Psychological distress, social support and medication adherence in patients with ischemic stroke in the mainland of China

Stroke research and rehabilitation have traditionally focused on the physical and functional impact of a stroke. Less attention has been given to the psychosocial factors associated with this chronic condition. By the few studies that have specifically focused on psychosocial factors in the context of stroke, poststroke depression is demonstrated to significantly influence stroke outcomes. Associations of stroke with psychological symptoms other than depression have rarely been evaluated. This study was aimed to investigate the changes of psychological stress, social support and medication adherence in patients with ischemic stroke in the mainland of China. In this study, 90 patients with hemiplegia one year after first-ever middle cerebral artery infarction (stroke group) in the Zhongnan Hospital of Wuhan University from June 2008 to June 2011 were recruited for interview. Ninety age- and sex-matched normal volunteers (control group) were also examined at the same period. The psychological distress was assessed by the Symptom Checklist 90 (SCL-90), the social support by the Social Support Rating Scale (SSRS), and medication adherence by Morisky's self-reported inventory, respectively. Group differences were analyzed using unpaired-t test and chi-squared test. The results showed that total mean scores of the SCL-90 in the stroke group were higher than those in the control group (P<0.01). Except two dimensions, paranoid ideation and psychoticism, mean scores of the rest dimensions (including somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, and phobic anxiety) of SCL-90 were significantly higher in the stroke group than those in the control group (P<0.05, or P<0.01). The objective support, subjective support, support availability and total social support scores in the stroke group were significantly higher than those in the control group (P<0.05, or P<0.01). Those in the "SCL-90 total scores >150 group" were significantly higher than in the "SCL-90 total scores <100 group" and the "SCL-90 total scores between 100 to 150 group" (P<0.05, or P<0.01). Those in the "SCL-90 total scores between 100 to 150 group" were significantly higher than in the "SCL-90 total scores <100 group" (P<0.05). In 90 patients with ischemic stroke, 26 (28.89%) patients obtained high medication adherence, 47 (52.22%) patients medium medication adherence, and 17 (18.89%) patients low medication adherence, respectively. Among these stroke patients, there were 17 (50.00%) patients with high medication adherence in the "SCL-90 total scores >150 group", 28 (75.67%) patients with medium medication adherence in the "SCL-90 total scores between 100 to 150 group", and 12 (61.16%) patients with low medication adherence in the "SCL-90 total scores <100 group", respectively. There was significant difference in the medication adherence rate among the different SCL-90 scores groups in these stroke patients (P<0.05 or P<0.01). It was led to conclude that ischemic stroke patients one year after hemiplegia have psychological distress, low level of social support and poor medication adherence in the mainland of China. Therefore, it is necessary to mobilize the government, medical institutions and various social support groups to offer psychological interventions to relieve the stress of patients with ischemic stroke, and improve their medication adherence.

Factors associated with community reintegration in the first year after stroke: a qualitative meta-synthesis

PURPOSE

Although acute stroke care has improved survival, many individuals report dissatisfaction with community reintegration after stroke. The aim of this qualitative meta-synthesis was to examine the barriers and facilitators of community reintegration in the first year after stroke from the perspective of people with stroke.

METHODS

A systematic literature search was conducted. Papers that used qualitative methods to explore the experiences of individuals with stroke around community reintegration in the first year after stroke were included. Two reviewers independently assessed the methodological quality of papers. Themes, concepts and interpretations were extracted from each study, compared and meta-synthesised.

RESULTS

From the 18 included qualitative studies four themes related to community reintegration in the first year after stroke were identified: (i) the primary effects of stroke, (ii) personal factors, (iii) social factors and (iv) relationships with professionals.

CONCLUSIONS

This review suggests that an individual's perseverance, adaptability and ability to overcome emotional challenges can facilitate reintegration into the community despite persisting effects of their stroke. Appropriate support from family, friends, the broader community and healthcare professionals is important. Therapeutic activities should relate to meaningful activities and should be tailored to the individual stroke survivor.

IMPLICATIONS FOR REHABILITATION

Stroke survivors feel that rehabilitation in familiar environments and therapeutic activities that reflect real-life could help their community re-integration. In addition to the physical sequelae of stroke, emotional consequences of stroke should be addressed during rehabilitation. Healthcare professionals can provide clear and locally relevant advice to facilitate aspects of community reintegration, including the return to driving and work.

Developing the Bridges self-management programme for New Zealand stroke survivors: A case study

Background/aim

This case study describes the adaptation of the UK-developed Bridges stroke self-management programme (Bridges SMP) into a version relevant and acceptable to the New Zealand (NZ) context.

Methods

Stakeholder consultation and qualitative methodology explored the acceptability and relevance of the Bridges SMP in NZ. Focus group discussions were held with stroke survivors (n=60) and neurorehabilitation therapists (n= 17). Semi-structured interviews were conducted with 22 stroke survivors. Based on data gathered the authors culturally and contextually adapted the accompanying Bridges SMP workbook. This study piloted the adapted programme with six stroke survivors and used semi-structured interviews to explore their perceptions of it.

Findings

The Bridges SMP was considered acceptable and beneficial for developing skills to self-manage recovery following stroke. The main recommended adaptation was the inclusion of NZ stories into the accompanying workbook. Four themes reflected the six pilot study participants' perceptions of the programme: you are not alone, reflection and taking action, life continues after stroke, and taking responsibility.

Conclusions

The Bridges SMP was considered relevant and only required moderate adaptation for use in NZ. The process the authors undertook to contextualise Bridges SMP for NZ will provide guidance to the programme's introduction into other international regions.

Reflections on life: experiences of individuals with brain injury during the transition from hospital to home

BACKGROUND

The transition from hospital to home has been described as a distinct rehabilitation phase for individuals with brain injury. As most research to date has quantitatively measured outcomes or used a sample with mixed brain injury diagnoses, less is known about the experience of transition following traumatic brain injury (TBI).

AIMS

This study aimed to examine the lived experiences of individuals with TBI during the first 6 months following discharge from hospital.

DESIGN

A qualitative investigation was conducted with 16 individuals with TBI using semi-structured interviews.

DATA ANALYSIS

Data were analysed thematically using a Framework approach.

RESULTS

Transition experiences were characterized by a desire to return to normality and a changed perspective on life, by accepting change or altering priorities. The process of transition was dynamic as individuals experienced the dominant themes in cyclical patterns.

CONCLUSIONS

Research has highlighted the significant adjustment for individuals with TBI, particularly in relation to identity change, appraisal and coping. The themes of wanting normality and changing life perspective which were dominant in the current study highlight the significance of the transition phase in the process of adjustment and that transition is characterized by adapting to a new normality.

Body, coping and self-identity. A qualitative 5-year follow-up study of stroke

OBJECTIVE

The purpose of this article is to identify, from a long-term perspective, stroke survivors' self-identity, their views of any associated disabilities and how they manage their lives after stroke.

METHODS

The interviews and analyses were conducted using a phenomenological qualitative method. A total of 10 men and 5 women, aged 42-84, participated. All had suffered first-time stroke 5 years earlier.

RESULTS

After 5 years, participants had greater acceptance of their situation compared with immediately after participating in the rehabilitation programme. However, they described how they still had to deal with the consequences of stroke. They had suffered further illnesses and additions to side effects of the stroke. In dealing with their disabilities and changes to self-identity and life patterns, they seemed to be in a continuous process of change that never truly stabilised. They coped with this continuous process in at least two different ways, including resignation or personal growth.

CONCLUSION

Stroke survivors suffered considerable ongoing and changing difficulties in relation to disability, self-perception and to coping with a new life. This continuous process of change could be seen to drain their energy. The study shows that many survivors live a more home-centred life with fewer social relations and less active participation in their community. This can entail the risk of depression and loneliness. The study also shows, however, that adopting an optimistic approach to life can lead to continued learning about abilities and limitations, to the development of new skills and to the fashioning of a new self-identity.

Transition of care for the elderly after cerebrovascular accidents - from hospital to the home

OBJECTIVE: to examine the transition of care in families caring for elderly persons who suffered the first episode of a cerebrovascular accident. METHODOLOGY: an instrumental ethnographic case study was used. The sample comprised 20 subjects: 10 caregivers and 10 elderly persons aged 65 or over, of both sexes, with diagnoses of first episode of cerebrovascular accident, capable of communicating, and requiring care from a main carer in their family. The data was collected through interviews, observation, existing documentation and field notes. Qualitative analysis techniques were used to codify and classify the data and to formulate significant categories, which generated typologies of care. RESULTS AND DISCUSSION: The central idea was the Transition of Care and showed the context in three typologies: The care process for the dependent elderly person, Strategies for the care process and Impact and acceptance of the limitations. CONCLUSION: The data indicates that caring for an elderly person after a cerebrovascular accident is a challenge for the family. The data permitted it possible to elaborate a proposal for a model for the organization of the work, with a view to holistic care delivery in the health services, forming a care network, which constitutes an advance for the area of nursing.

Training dual-task walking in community-dwelling adults within 1 year of stroke: a protocol for a single-blind randomized controlled trial

BACKGROUND

Community ambulation is a highly complex skill requiring the ability to adapt to increased environmental complexity and perform multiple tasks simultaneously. After stroke, individuals demonstrate a diminished ability to perform dual-tasks. Current evidence suggests that conventional rehabilitation does not adequately address gait-related dual-task impairments after stroke, which may be contributing to low levels of participation and physical inactivity in community-dwelling stroke survivors. The objective of this study is to investigate the efficacy of dual-task gait training in community-dwelling adults within 1 year of stroke. Specifically, we will compare the effects of dual-task gait training and single-task gait training on cognitive-motor interference during walking at preferred speed and at fastest comfortable speed (Aim 1), locomotor control during obstacle negotiation (Aim 2), and spontaneous physical activity (Aim 3).

METHODS/DESIGN

This single-blind randomized controlled trial will involve 44 individuals within 12 months of stroke. Following baseline evaluation, participants will be randomly allocated to single- or dual-task gait training. Both groups will receive 12, 30-minute sessions provided one-on-one over 4-6 weeks in an outpatient therapy setting. Single-task gait training involves practice of gait activities incorporating motor relearning principles. Dual-task gait training involves an identical gait training protocol; the critical difference being that the dual-task gait training group will practice the gait activities while simultaneously performing a cognitive task for 75% of the repetitions. Blinded assessors will measure outcomes at baseline, post-intervention, and 6 months after completion of the intervention. The primary outcome measure will be dual-task effects on gait speed and cognition during unobstructed walking. Secondary outcomes include spatiotemporal and kinetic gait parameters during unobstructed single- and dual-task walking at preferred and fastest comfortable walking speeds, gait parameters during high and low obstacle crossing, spontaneous physical activity, executive function, lower extremity motor function, Timed Up and Go, balance self-efficacy, number of falls, and stroke-related disability. Hypotheses for each aim will be tested using an intention-to-treat analysis with repeated measures ANOVA design.

DISCUSSION

This trial will provide evidence to help clinicians make decisions about the types of activities to include in rehabilitation to improve dual-task walking after stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01568957.

A Mixed Methods Study of the Experience of Transition to the Community of Working-Aged People with Non-Traumatic Brain Injury

Background and aims: The ‘transition’ phase from hospital to home following brain injury is well established as a critical period of adjustment for individuals and their families. There is, however, a lack of knowledge about the experience of transition following nontraumatic brain injury (e.g., stroke, aneurysm) for individuals of working age. The purpose of this study was to explore the transition experiences of individuals with nontraumatic brain injury using mixed methods approach.

Methods: Six individuals with nontraumatic brain injury were recruited from a larger study using maximum variation sampling criteria. Individuals participated in semistructured interviews at 6-months postdischarge and completed quantitative measures of psychosocial outcomes predischarge and at 6-months postdischarge. Results: Qualitative content analysis of interviews identified three themes: (1) changes in role performance, (2) support and services and (3) coping with life after brain injury. The transition experience was characterised by loss of valued roles including driving and work, identified as major barriers to regaining independence postdischarge. Informal support provided by family and friends were relied on, while formal supports were accessed infrequently. Life post-injury presented a number of challenges including adjusting to changes in physical and cognitive abilities and a fear of reinjury. Qualitative data were supported by an overall trend of improved functioning on the quantitative measures over the 6 months.

Conclusions: Key life circumstances of working age adults with nontraumatic brain injury influence the transition experience. Clinically, the findings support the need for individualised, structured transition services pre- and postdischarge for this group.

Social isolation poststroke: relationship between race/ethnicity, depression, and functional independence

Research suggests that individuals recovering from a stroke often experience social isolation, which is linked to increased depressive symptomatology and decreased ability to manage activities of daily living. Research also indicates that different racial and ethnic groups are more adversely affected than whites. This article uses poststroke narratives to explore the relationship between social isolation, depressive symptomatology, and the ability to manage activities of daily living poststroke for white, African American, and Puerto Rican veterans. Findings suggest those who were socially isolated during the first year of poststroke recovery reported higher levels of depressive symptoms and a decreased ability to manage daily activities. Implications for stroke rehabilitation practice are discussed.

Recovering from a stroke: a longitudinal, qualitative study of older Norwegian women

AIM

To illuminate older women's experiences and the characteristics of the recovery process following a stroke.

BACKGROUND

Patients with stroke face serious challenges related to bodily changes, existential aspects and daily life after stroke. Few qualitative longitudinal studies have examined the recovery process from the perspective of the patient. Knowledge about older women's experiences in coping with life after a stroke is limited.

DESIGN

Prospective, longitudinal, case-study design.

METHODS

Six women aged 68-83 suffering from first-time stroke were recruited from two stroke units. Each participant was interviewed in-depth 12-14 times during the first two years post stroke. The interviews addressed how they experienced their body, their self-understanding, daily life and how this had changed over time. Most interviews took place in the participants' homes. Gadamer's philosophical hermeneutics informed the analyses.

RESULTS

Post stroke recovery was slow and complex and evolved through four distinct phases. In the first phase (0-2 months post stroke), the participants' main concerns were their bodily changes; in the second phase (2-6 months), activities of daily life; in the third phase (6-12 months), self-understanding and in the fourth phase (12-24 months), going on with life. The transition between phases was gradual.

CONCLUSION

Recovery from stroke evolves over time through four distinct phases, which differ depending on significant experiences and associated meanings. Psychological and social resources are equally critical in the women's process of recovery.

RELEVANCE TO CLINICAL PRACTICE

The four phases of rehabilitation suggest at what points various concerns require increased therapeutic attention. Psychological and social resources must be vitalised at an early phase similar to bodily resources. This knowledge may assist professionals in offering adequate help throughout the recovery process even beyond the established rehabilitation period.

Measuring outcomes in people who have had a stroke and their carers: can the telephone be used?

PURPOSE

Telephone interviews may be a cost-effective alternative to administering stroke outcome measures for people who are living in the community following a stroke, but there is a lack of research that has compared the different modes of administering outcome measures. The aim of this study was to determine whether telephone administration of selected stroke outcome measures resulted in significantly different results to face-to-face administration of the same outcome measures.

METHOD

Nineteen participants who were taking part in a randomised controlled trial (RCT) evaluating the effectiveness of a postdischarge education and support package for stroke patients and their carers were recruited for this study. Participants had the RCT follow-up outcome measures, at 3 months post discharge, administered by both telephone and face-to-face. Participants were randomised to receive either the telephone or face-to-face administration first and a period of 2 weeks separated the two administrations. Outcome measures were the Knowledge of Stroke Questionnaire, a stroke self-efficacy questionnaire, Hospital Anxiety and Depression Scale, Stroke and Aphasia Quality of Life Scale, and the Caregiver Strain Index.

RESULTS

There were no significant differences between scores obtained on any of the outcome measures that were administered by telephone and face-to-face (P > .05).

CONCLUSION

The telephone can be used to administer the outcome measures that were evaluated in this study to stroke patients and carers. These findings may be of benefit to stroke researchers and clinicians who wish to incorporate the use of telephone measures into the follow-up care of stroke patients and their carers.

The role of nursing in the rehabilitation of stroke survivors: an extended theoretical account

This article provides a critique and theoretical extension of a work that sought to describe the contribution of nurses to stroke rehabilitation. At the time, the role of nursing was considered important but therapeutically nonspecific. Stroke nursing research has increased significantly and so has research focusing on the patient experiences of the adjustment and rehabilitation processes following a stroke. These developments provide significant new insights that may refine and extend the original understanding of the role of nursing in stroke rehabilitation. This article proposes an extended theoretical framework of the role of nursing in stroke recovery and rehabilitation.