Patterns and predictors of ten-year mortality after discharge from community-based post-acute care for acquired brain injury: A retrospective cohort study (ABI-RESTaRT), Western Australia, 1991-2017

BACKGROUND

Survivors of acquired brain injury (ABI) are left with long-term disability and an increased risk of mortality years post-injury.

OBJECTIVE

To examine 10-year mortality in adults with ABI after discharge from post-acute care and identify modifiable risk factors to reduce long-term mortality risk.

METHODS

Retrospective cohort study of 586 adults with traumatic (TBI) or non-traumatic brain injury (NTBI), or neurologic condition, consecutively discharged from a post-acute rehabilitation service in Western Australia from 1-Mar-1991 to 31-Dec-2017. Data sources included rehabilitation records, and linked mortality, hospital, and emergency department data. Survival status at 10 years post-discharge was determined. All-cause and cause-specific age- and sex-adjusted standardised mortality ratios (SMR) by ABI diagnosis were calculated using Australian population reference data. Risk factors were examined using multilevel cox proportional hazards regression.

RESULTS

Compared with the Australian population, 10-year all-cause mortality was significantly elevated for all diagnosis cohorts, with the first 12 months the highest risk period. Accidents or intentional self-harm deaths were elevated in TBI (13.2, 95%CI 5.4; 12.1). Neurodegenerative disease deaths were elevated in Neurologic (21.9, 95%CI 13.0; 30.9) and Stroke (19.8; 95%CI 2.4; 27.2) cohorts. Stroke (20.8; 95%CI 7.9; 33.8) and circulatory disease deaths (6.2; 95%CI 2.3; 9.9) were also elevated in Stroke. Psychiatric comorbidity was the strongest risk factor followed by older age, geographical remoteness, and cardiac, vascular, genitourinary and renal comorbidity. Clinically significant improvement in functional independence and psychosocial functioning significantly reduced mortality risk.

CONCLUSIONS

Individuals with ABI have an elevated risk of mortality years post-injury. Comorbidity management, continuity of care, and rehabilitation are important to reduce long-term mortality risk.

[Racial inequalities in access to rehabilitation after a stroke: study of the Brazilian population]

This article aims to verify the association between race/skin color and access to post-stroke rehabilitation services. It is a cross-sectional population-based study including 966 post-stroke adults (≥18 years) that responded to the National Health Survey (PNS). The outcome, access to rehabilitation, and exposure (race/skin color) were collected in a self-reported manner. Socio-demographic variables, clinical history, healthcare plan and post-stroke limitation were considered for the adjustment. Poisson regression with robust variance estimation was used to estimate the association in the crude and adjusted analyses. Based on the sample, 51.8% are self-declared black and 61.4% require rehabilitation, with only 20% having access to the rehabilitation service. Difficulty in accessing rehabilitation was reported by 57.5% of other self-declared races, 43% blacks, and 35.4% whites. In the adjusted analysis, 4% of self-declared black (PR 1.04, CI95%1.00-1.08) and 17% of self-declared yellow and indigenous (PR 1.17, IC95%1.13-1.20) have less access to rehabilitation than their white peers. In Brazil, self-declared black and yellow and indigenous people have worst access to post-stroke rehabilitation in comparison with self-declared white people, highlighting racial inequities in rehabilitation in stroke survivors.

Age-Related Disparities in the Quality of Stroke Care and Outcomes in Rehabilitation Hospitals: The Australian National Audit

INTRODUCTION

Stroke affects all ages. Despite increased incidence in those <65 years, little is known about age-based differences in inpatient rehabilitation management and outcomes.

OBJECTIVES

To investigate management and outcomes, comparing younger (<65 years) and older (≥65 years) patients with stroke, who received inpatient rehabilitation.

METHODS

Multicentre, cross-sectional study using data from Australian hospitals who participated in the Stroke Foundation national stroke rehabilitation audit (2016-2018). Chi-square tests compared characteristics and care by age. Multivariable regression models were used to compare outcomes by age (e.g. length of stay). Models were adjusted for sex, stroke type and severity factors.

RESULTS

7,165 audited cases from 127 hospitals; 23% <65 years (66% male; 72% ischaemic stroke). When compared to older patients, younger patients were more likely male (66% vs 52%); identify as Aboriginal or Torres Strait Islander (6% vs 1%); be less disabled on admission; receive psychology (46% vs 34%) input, and community reintegration support, including return to work (OR 1.47, 95% CI 1.03, 2.11), sexuality (OR 1.60, 95% CI 1.39, 1.84) and self-management (OR 1.39, 95% CI 1.23, 1.57) advice. Following adjustment, younger patients had longer lengths of stay (coeff 3.54, 95% CI 2.27, 4.81); were more likely to be independent on discharge (aOR 1.96, 95% CI 1.68, 2.28); be discharged to previous residences (aOR 1.64, 95% CI 1.41, 1.91) and receive community rehabilitation (aOR: 2.27, 95% CI 1.91, 2.70).

CONCLUSIONS

Age-related differences exist in characteristics, management and outcomes for inpatients with stroke accessing rehabilitation in Australia.

Recovering is about living my life, as it evolves: perspectives of stroke survivors in remote northwest Queensland

PURPOSE

Recovering from stroke in remote Australia has rarely been considered, even though rehabilitation services are generally scarce. The primary purpose of this study was to explore stroke recovery, from the perspective of stroke survivors in remote northwest Queensland (NWQ), to explicate the lens through which they view recovering. The secondary purpose was to explore the role of technology to support stroke survivors in remote locations along their recovery journey.

METHODS

A qualitative study was undertaken using elements of constructivist grounded theory for data collection and analysis. Semi-structured interviews were conducted with fifteen stroke survivors and two partners living, working or travelling in remote NWQ.

RESULTS

From the participants' perspective, recovering in a remote area after stroke is about living my life, as it evolves by endeavouring to recover my way and navigating my recovery in my world. Technology was only considered helpful when it supported participants to recover their way in their world.

CONCLUSION

Recovering from stroke from the perspective of stroke survivors in remote NWQ is about living their life, as they want it to be, and as it unfolds within their own context. Technology only has a place when it can support them to recover their way in their world. These findings reinforce the importance of health professionals listening, learning about, and enabling stroke survivors along their recovery journey, within their remote context and support network.Implications for RehabilitationRecovering from the perspective of stroke survivors is about living their life as it evolves.To support stroke survivors from remote areas, health professionals need to listen to and learn from each stroke survivor about what matters to them, what works for them, and about their world; including the challenges (e.g., switching between services) and enablers (e.g., community support) as the stroke survivor perceives them.Finding ways to utilise the strengths within and around them, may improve the recovery process for the stroke survivor in a remote area, ensuring they can access care that meets their needs in their world.Working together with stroke survivors, health professionals need to consider how technology could help them to live their life, while recovering their way and in their world.

Using functional electrical stimulation with stroke survivors: A survey of Victorian occupational therapists and physiotherapists

BACKGROUND/AIM

Functional electrical stimulation (FES) improves active movement of the hemiplegic upper and lower limbs following stroke. The use of FES by Australian allied health clinicians in stroke rehabilitation is, however, unknown. The purpose of this study was to understand the use of FES in clinical practice. Reasons for the use of FES and potential variables that influence decision-making were also investigated.

METHODS

Cross-sectional study of Victorian allied health clinicians, using a snowball recruitment method. Ninety-seven eligible therapists completed the anonymous online survey. Data were analysed using frequency distributions.

RESULTS

The majority of respondents were occupational therapists (n = 60; 62%). Approximately half of the respondents (n = 50; 52%) reported using FES in the past two years to improve a stroke survivor's ability to use their arm in daily activities. Respondents suggested that receiving workplace training from colleagues to learn how to use FES is the preferred method of education. Of those who received education (n = 80), 50 participants reported using FES in their practice.

CONCLUSION

There is variable use of FES in stroke rehabilitation to increase active movement after stroke. While there was moderate agreement about when to use FES and useful education approaches for learning to use FES, further research is needed to better understand strategies which could be implemented to support increased FES use in stroke rehabilitation.

"… Trial and error …": Speech-language pathologists' perspectives of working with Indigenous Australian adults with acquired communication disorders

PURPOSE

This study explored speech-language pathologists' (SLPs) perspectives about factors that influence clinical management of Aboriginal and Torres Strait Islander adults with acquired communication disorders (e.g. aphasia, motor speech disorders).

METHOD

Using a qualitative phenomenological approach, seven SLPs working in North Queensland, Australia with experience working with this population participated in semi-structured in-depth interviews. Qualitative content analysis was used to identify categories and overarching themes within the data.

RESULT

Four categories, in relation to barriers and facilitators, were identified from participants' responses: (1) The Practice Context; (2) Working Together; (3) Client Factors; and (4) Speech-Language Pathologist Factors. Three overarching themes were also found to influence effective speech pathology services: (1) Aboriginal and Torres Strait Islander Cultural Practices; (2) Information and Communication; and (3) Time.

CONCLUSION

This study identified many complex and inter-related factors which influenced SLPs' effective clinical management of this caseload. The findings suggest that SLPs should employ a flexible, holistic and collaborative approach in order to facilitate effective clinical management with Aboriginal and Torres Strait Islander people with acquired communication disorders.

Study Protocol:Missing Voices– Communication Difficulties after Stroke and Traumatic Brain Injury in Aboriginal Australians

Background:Aboriginal and Torres Strait Islander Australians experience stroke and traumatic brain injury (TBI) with much greater frequency than non-Aboriginal Australians. Acquired communication disorders (ACD) can result from these conditions and can significantly impact everyday life. Yet few Aboriginal people access rehabilitation services and little is known about Aboriginal peoples’ experiences of ACD. This paper describes the protocol surrounding a study that aims to explore the extent and impact of ACD in Western Australian Aboriginal populations following stroke or TBI and develop a culturally appropriate screening tool for ACD and accessible and culturally appropriate service delivery models.

Method/Design:The 3-year, mixed methods study is being conducted in metropolitan Perth and five regional centres in Western Australia. Situated within an Aboriginal research framework, methods include an analysis of linked routine hospital admission data and retrospective file audits, development of a screening tool for ACD, interviews with people with ACD, their families, and health professionals, and drafting of alternative service delivery models.

Discussion:This study will address the extent of ACD in Aboriginal populations and document challenges for Aboriginal people in accessing speech pathology services. Documenting the burden and impact of ACD within a culturally secure framework is a forerunner to developing better ways to address the problems faced by Aboriginal people with ACD and their families. This will in turn increase the likelihood that Aboriginal people with ACD will be diagnosed and referred to professional support to improve their communication, quality of life and functioning within the family and community context.

Communication disorders after stroke in Aboriginal Australians

PURPOSE

Limited research exists on acquired communication disorders (ACD) in Aboriginal Australians despite their high rates of stroke. Their uptake of rehabilitation services is low, and little information is available on functional consequences for this population. This pilot study explored consequences of ACD for Aboriginal Australians after stroke, including their experiences of services received.

METHOD

Semi-structured interviews were collected with 13 Aboriginal people with ACD, and family members, in Perth. Ages ranged from 30 to 78 years and time post stroke from 0.5 to 29 years. A qualitative, thematic analysis of interview transcripts was undertaken.

RESULTS

The key themes which emerged were "getting on with life", coping with change, independence/interdependence, the importance of communication for maintaining family and community connection, role and identity issues and viewing the stroke consequences within the broader context of co-morbidities.

CONCLUSIONS

While similar life disruptions were found to those previously reported in the general stroke population, this study highlighted differences, which reflect the particular context of ACD for Aboriginal people and which need to be considered when planning future services. While implications are limited due to small numbers, the findings emphasise the importance of a holistic approach, and integration of communication treatments into community-led social activities. Implications for Rehabilitation Aboriginal Australians frequently experience a range of concurrent and complex co-morbidities and demanding social or family circumstances at the same time as coping with communication disorders post-stroke. A holistic approach to post stroke rehabilitation may be appropriate with services that accommodate communication disorders, delivered in collaboration with Aboriginal organisations, emphasising positive attitudes and reintegration into community as fully as possible. Communication and yarning are important for maintaining family and community connection and identity, and family and community context should be incorporated into all assessment and treatment activities.

Living with aphasia: three Indigenous Australian stories

The incidence of cardiovascular disorders and stroke in Australian Aboriginal communities is more than twice as high as non-Indigenous Australians. Approximately 30% of people who survive stroke are left with some level of aphasia, and yet Indigenous Australians appear to be infrequent users of speech-language pathology services, and there is virtually no research literature about the experiences of aphasia for this group of people. This paper presents the stories of living with aphasia for three Indigenous Australian men living in Perth, Western Australia. Their narratives were collected by an Indigenous researcher through in-depth, supported interviews, and were explored using both within-case and cross-case analyses for common and recurring themes. It is argued that there is value for speech-language pathologists, and other health professionals, to be aware of the broad experiences of living with aphasia for Indigenous Australians because their stories are rarely heard and because, as with people with aphasia generally, they are at risk of social isolation and tend to lack visibility in the community. This study explores the key issues which emerge for these three men and highlights the need for further research in this area.