Factors influencing stroke survivors' reintegration into a rural community: Perspectives from a municipality in Limpopo Province, South Africa

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5 Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery. Because there remains a …

Background: Despite inpatient rehabilitation many stroke survivors struggle with community reintegration on returning home. The environment to which the stroke survivor returns affects and may limit participation in home and community-based activities. Aim: To describe stroke survivors’ lived experiences of the environmental barriers and facilitators to community reintegration in an under resourced urban metropolitan sub-district in the Western Cape, South Africa. Methods: A descriptive, qualitative study design with a phenomenological emphasis used semi-structured interviews to collect the data from purposefully selected stroke survivors who had been discharged for more than one year following inpatient rehabilitation. Supporting data were collected from interviews with two occupational therapists providing rehabilitation services to the stroke survivors. Deductive priori coding of semi-structured interviews with 11 stroke survivors, based on the environment subsystems described in the Person-Environment-Occupation-Performance (PEOP) model explored the barriers and facilitators to their community reintegration. Findings: Of the six environmental sub systems in the PEOP model the systems and policy, access to information and health education, social determinants of health in the form of poor rehabilitation planning and loss of income as well as the built and natural environment presented the greatest barriers to the stroke survivor participants community reintegration. However, reintegration was facilitated by social support and social capital, social determinants of health in the form of support groups as well as assistive technologies. Conclusion: Community reintegration continues to be a challenge for stroke survivors in an under-resourced urban sub-district due to environmental barriers associated with factors such as poor social support, inadequate implementation of policies and systems, poor compliance with home programmes, low socioeconomic status, poor access within the built and natural environment and inappropriate assistive devices. Several facilitators that occupational therapists can focus on to enable community reintegration included ensuring effective social support, access to community-based organisations, the introduction of home visits and provision of appropriate assistive devices. Implications for practice All stroke survivors must receive a comprehensive discharge plan to facilitate adequate access to continued rehabilitation and support for successful community reintegration. There must be a specific referral to primary health care rehabilitation services on discharge from hospital. Occupational therapists at community level have the responsibility to: advocate for, or assist stroke survivors to self-advocate, the removal of intersectoral environmental barriers that limit their community reintegration and community participation, where possible provide services in the home and involve midlevel workers when conducting home visits to enable successful reintegration into the home and resumption of occupational roles where possible, look to other resources in their community that can assist in facilitating the community reintegration of stroke survivors to enable access to health, education, productive activities, and social and leisure participation opportunities, improve their collaboration with the communities that they service.

Stroke is highly debilitating and requires long-term care. Informal caregivers of stroke survivors play important roles in stroke rehabilitation. Caring for stroke survivors can negatively affect the caregivers' well-being and may adversely impact on their caregiving quality and subsequently on stroke survivors' well-being. There seems to be a dearth of research on the relationships between caregivers' and stroke survivors' well-being. This study was designed to determine the relationships among informal caregivers' burden and quality of life (QOL) and stroke survivors' QOL and community reintegration. This ethically certified cross-sectional survey involved 82 stroke survivors (mean age=60.48±11.13years) and their 82 primary caregivers (mean age=36.13±13.69years) consecutively recruited from seven conveniently sampled tertiary hospitals in Nigeria. Caregivers Strain Index, Igbo-culture adapted Maleka Stroke Community Reintegration Measure and Short-Form 36-item Health Survey questionnaires were used to assess the caregivers' burden, survivors' community reintegration and QOL (of survivors and caregivers), respectively. Data were analysed using descriptive statistics, Spearman rank, Mann-Whitney U and Kruskal-Wallis tests at alpha level of 0.05. The mean stroke survivors' community reintegration and QOL were 34.05±21.54% and 34.93±16±49%, respectively. The mean caregivers' QOL and burden scores were 74.49±12.61% and 9.13±3.18, respectively. About 80.5% of the caregivers experienced significant burden. Stroke survivors' QOL and community reintegration, and caregivers' QOL and burden significantly correlated with one another (p<0.05). Poststroke duration, survivor-caregiver cohabitation duration, survivors' community-dwelling duration and daily care-giving hours significantly correlated with each of stroke survivors' community reintegration and QOL, and caregivers' burden and QOL (p<0.05). Stroke survivors' community reintegration and QOL were poor while caregivers' had moderate QOL and high prevalence of significant burden. Significant correlations exist between caregivers' well-being and stroke survivors' QOL and community reintegration. Interventions targeted at reducing caregivers' burden may help improve both caregivers and survivors' well-being.

BackgroundExergames are increasingly being used among survivors of stroke with chronic upper extremity (UE) sequelae to continue exercising at home after discharge and maintain activity levels. The use of virtual reality exergames combined with a telerehabilitation app (VirTele) may be an interesting alternative to rehabilitate the UE sequelae in survivors of chronic stroke while allowing for ongoing monitoring with a clinician.ObjectiveThis study aimed to determine the feasibility of using VirTele in survivors of chronic stroke at home and explore the impact of VirTele on UE motor function, quantity and quality of use, quality of life, and motivation in survivors of chronic stroke compared with conventional therapy.MethodsThis study was a 2-arm feasibility clinical trial. Eligible participants were randomly allocated to an experimental group (receiving VirTele for 8 weeks) or a control group (receiving conventional therapy for 8 weeks). Feasibility was measured from the exergame and intervention logs completed by the clinician. Outcome measurements included the Fugl-Meyer Assessment-UE, Motor Activity Log-30, Stroke Impact Scale-16, and Treatment Self-Regulation Questionnaire-15, which were administered to both groups at four time points: time point 1 (T1; before starting the intervention), time point 2 (after the intervention), time point 3 (1 month after the intervention), and time point 4 (T4; 2 months after the intervention).ResultsA total of 11 survivors of stroke were randomized and allocated to an experimental or a control group. At the onset of the COVID-19 pandemic, participants pursued the allocated treatment for 3 months instead of 8 weeks. VirTele intervention dose was captured in terms of time spent on exergames, frequency of use of exergames, total number of successful repetitions, and frequency of videoconference sessions. Technical issues included the loss of passwords, internet issues, updates of the system, and problems with the avatar. Overall, most survivors of stroke found the technology easy to use and useful, except for 9% (1/11) of participants. For the Fugl-Meyer Assessment-UE and Motor Activity Log-30, both groups exhibited an improvement in >50% of the participants, which was maintained over time (from time point 3 to T4). Regarding Stroke Impact Scale-16 scores, the control group reported improvement in activities of daily life (3/5, 60%), hand function (5/5, 100%), and mobility (2/5, 40%), whereas the experimental group reported varied and inconclusive results (from T1 to T4). For the Treatment Self-Regulation Questionnaire-15, 75% (3/4) of the experimental group demonstrated an increase in the autonomous motivation score (from T1 to time point 2), whereas, in the control group, this improvement was observed in only 9% (1/11) of participants.ConclusionsThe VirTele intervention constitutes another therapeutic alternative, in addition to conventional therapy, to deliver an intense personalized rehabilitation program for survivors of chronic stroke with UE sequelae.International Registered Report Identifier (IRRID)RR2-10.2196/14629

Background: Although stroke prevalence is increasing and large proportions of stroke survivors are expected to live many years after stroke onset, research on the long-term consequences of stroke for instrumental activities of daily living (IADL) is limited.Aim: To explore performance of IADL seven years post-stroke onset and identify predictors of long-term IADL performance based on commonly employed acute measures and demographic characteristics in young and middle-aged stroke survivors.Methods: Data on stroke survivors were collected from SAHLSIS. IADL performance was assessed at 7 years using the Frenchay Activities Index (FAI). Demographic data and baseline measures were assessed as predictors of FAI outcome, using logistic regression.Results: 237 stroke survivors with a median age of 63 at follow-up were included. Participants had predominantly suffered a mild stroke and >90% lived at home with no community services. Mean FAI was 25.7(score range 0-45), indicating reduced levels of participation in IADL. Frequency of performance of IADL was lowest for work/leisure activities. Gender, cohabitation status, initial stroke severity and baseline score on mRS were independently associated with IADL outcome.Conclusions: Reduced levels of participation in IADL persist many years after stroke onset and indicate a need to adapt a long-term perspective on stroke rehabilitation.

BackgroundWith an upward trend in the number of people who return home to independent living after stroke, the ability to perform more complex activities is becoming an increasingly important long-term outcome after stroke. Although associations between Instrumental Activities of Daily Living (IADL) and cognitive dysfunction, emotional problems, and fatigue have been reported, less is known about the long-term impact of these stroke consequences on the performance of everyday activities in young and middle-aged stroke survivors.ObjectiveTo explore the impact of cognitive dysfunction, emotional problems, and fatigue on long-term performance of instrumental activities of daily living in young and middle-aged stroke survivorsMethodData on stroke survivors, aged 18–69 at index stroke, were collected from the Sahlgrenska Academy Study on Ischaemic Stroke. IADL outcome was assessed using the Frenchay Activities Index (FAI), and the impact of chosen variables was assessed using Spearman´s rank-order correlation and logistic regression.ResultsSeven years after index stroke, 296 stroke survivors (median age of 64) were included in this study. Cognitive dysfunction showed the strongest correlations with FAI outcome and independently explained worse outcome on FAI summary score and the domain of work/leisure activities. Fatigue was independently explanatory of worse outcome on FAI summary score and domestic chores, while depressive symptoms independently explained worse outcome on work/leisure activities. In a subgroup with only those participants who had no or minimal residual neurological deficits at follow-up (NIHSS score 0), cognitive dysfunction independently explained worse outcome on FAI summary score and work/leisure activities. Depressive symptoms independently explained worse outcome on FAI summary score and domestic chores.ConclusionOur results show that in young and middle-aged stroke survivors, cognitive dysfunction, depressive symptoms, and fatigue negatively impact performance of IADL even at seven years post stroke onset. Further, we have shown that an impact of both cognitive dysfunction and depressive symptoms can be found also among stroke survivors with mild or no remaining neurological deficits.

Background: Post-stroke depression (PSD) is the commonest psychiatric morbidity observed among stroke survivors and it has a significant negative impact on the rehabilitation process. Aims: This study aimed to identify the prevalence of PSD, its associated factors, and the relationship between the severity of depression and functional impairment among stroke survivors during the first six months of rehabilitation. Methods: A descriptive cross-sectional study using a convenient sampling method was carried out at the Rheumatology and Rehabilitation Hospital (RRH), Ragama, among patients during the first six months following stroke. PSD was screened with Sinhala and Tamil translations of the Patient Health Questionnaire-9 (PHQ-9) and functional ability was measured using the validated Lawton Instrumental Activities of Daily Living (IADL) scale. Pearson’s correlation coefficient, ANOVA, independent-sample t-test, and binary logistic regression were used for statistical analysis. Results: Among 70 participants of ages 33-79 years (mean ± SD: 56.3 ± 11.31) depressive symptoms were observed among 74.3%. A negative correlation (- 0.428) was observed between PSD and functional ability. There was a statistically significant association (p&lt;0.05) between PSD and female gender, stroke affecting the dominant side of the body and previous history of stroke. A low score on IADL (OR = 0.506, 95% CI: 0.274 - 0.936) and stroke affecting the dominant side of the body (OR = 0.013, 95% CI: 0.01 - 0.270) was observed to be significant risk factors to be screened positive for major depression as per the PHQ-9. Conclusion: We detected a high prevalence of PSD among the participants as per the PHQ 9 and a negative correlation between PSD and functional ability. Screening for depression and appropriate management of PSD in stroke survivors should be practised during the early rehabilitation period.

Virtual reality stroke rehabilitation - hype or hope?

BackgroundThe South African health system has policies and strategies to ensure effective rehabilitation and reintegration of individuals who have survived a cerebrovascular accident into their respective communities. However, implementation of such guidelines remains an issue.AimThis study sought to explore cerebrovascular accident (CVA) survivors’ experiences of community integration.SettingThe study was located in a peri-urban community within the KwaZulu-Natal Province, South Africa.MethodsAn explorative qualitative study with eight purposively selected CVA survivors was conducted via semi-structured individual interviews. Data were audio-recorded and manually transcribed prior to thematic analysis. Trustworthiness of the study was maintained by strategies such as analyst triangulation, an audit trail and use of thick descriptions. Ethical principles of autonomy, informed consent, confidentiality and privacy were also maintained in the study.ResultsSix themes emerged that highlighted (1) loss of autonomy and roles, (2) barriers to community reintegration, (3) social isolation of participants, (4) finding internal strength, (5) enablers of community reintegration including the positive influence of support and the benefits derived from rehabilitation and (6) recommendations for rehabilitation.ConclusionThe study revealed both positive and negative influences that impact CVA survivors’ ability to effectively reintegrate into their respective communities following a CVA. Recommendations include the need for education and awareness around access to rehabilitation services for CVA survivors, advice on how to improve CVA survivors’ ability to mobilise in the community and make environmental adaption to facilitate universal access, provision of home programmes and caregiver training for continuity of care and for inclusion of home-based rehabilitation into current models of care.

INTRODUCTION: There are various personal and environmental factors that hinder the stroke survivors' participation in meaningful occupations within a rural and semi-rural community context. Thus, occupational therapists need to consider such barriers in order to provide holistic treatment AIM: This study intended to explore the barriers experienced by stroke survivors on their participation in meaningful occupations in a rural and semi-rural community METHOD: An explorative qualitative study was conducted, using a purposive sampling method to recruit participants at a public healthcare district hospital. Data were collected at the participants' homes using individual semi-structured interviews. The researcher made use of open-ended questions guided by the Occupational Therapy Practice Framework 3rd edition and the Person Environment Occupation Performance model FINDINGS: Four themes related to the barriers experienced by stroke survivors on their participation in meaningful occupations emerged: (i) physical barriers, (i) psychological barriers, (iii) financial and (iv) environmental barriers CONCLUSION: The barriers explored in this study compelled the stroke survivors to accept varying degrees of assistance from their caregivers. The findings of this study could assist occupational therapists to consider the factors that hinder the stroke survivors' participation in meaningful occupations in rural and semi-rural South African communities, and inform treatment aims that are relevant to the respective communities. If occupational therapists consider these barriers when planning treatment, this could assist with maximizing independence in all areas of stroke survivors' lives, lessening the burden of care on their caregivers and decreasing the patient load on clinical and community occupational therapists Implications for practice Stroke survivors dwelling in the semi-rural and rural community contexts experience barriers which are unique to such settings. Thus, occupational therapist should be aware of the differences of barriers experienced not only in the hospital setting, but in the community context that stroke survivors are reintegrated to. Such consideration could contribute to intervention focussed on the individual's specific needs with regard to participation in meaningful occupations within the semi-rural and rural contexts they reside in.

Introduction: There are various personal and environmental factors that hinder the stroke survivors’ participation in meaningful occupations within a rural and semi-rural community context. Thus, occupational therapists need to consider such barriers in order to provide holistic treatment. Aim: This study intended to explore the barriers experienced by stroke survivors on their participation in meaningful occupations in a rural and semi-rural community. Method: An explorative qualitative study was conducted, using a purposive sampling method to recruit participants at a public healthcare district hospital. Data were collected at the participants’ homes using individual semi-structured interviews. The researcher made use of open-ended questions guided by the Occupational Therapy Practice Framework 3rd edition and the Person Environment Occupation Performance model. Findings: Four themes related to the barriers experienced by stroke survivors on their participation in meaningful occupations emerged: (i) physical barriers, (i) psychological barriers, (iii) financial and (iv) environmental barriers. Conclusion: The barriers explored in this study compelled the stroke survivors to accept varying degrees of assistance from their caregivers. The findings of this study could assist occupational therapists to consider the factors that hinder the stroke survivors’ participation in meaningful occupations in rural and semi-rural South African communities, and inform treatment aims that are relevant to the respective communities. If occupational therapists consider these barriers when planning treatment, this could assist with maximizing in- dependence in all areas of stroke survivors’ lives, lessening the burden of care on their caregivers and decreasing the patient load on clinical and community occupational therapists. Implications for practice Stroke survivors dwelling in the semi-rural and rural community contexts experience barriers which are unique to such settings. Thus, occupational therapist should be aware of the differences of barriers experienced not only in the hospital setting, but in the community context that stroke survivors are reintegrated to. Such consideration could contribute to intervention focussed on the individual’s specific needs with regard to participation in meaningful occupations within the semi-rural and rural contexts they reside in.

Introduction: There are various personal and environmental factors that hinder the stroke survivors’ participation in meaningful occupations within a rural and semi-rural community context. Thus, occupational therapists need to consider such barriers in order to provide holistic treatment. Aim: This study intended to explore the barriers experienced by stroke survivors on their participation in meaningful occupations in a rural and semi-rural community. Method: An explorative qualitative study was conducted, using a purposive sampling method to recruit participants at a public healthcare district hospital. Data were collected at the participants’ homes using individual semi-structured interviews. The researcher made use of open-ended questions guided by the Occupational Therapy Practice Framework 3rd edition and the Person Environment Occupation Performance model. Findings: Four themes related to the barriers experienced by stroke survivors on their participation in meaningful occupations emerged: (i) physical barriers, (i) psychological barriers, (iii) financial and (iv) environmental barriers. Conclusion: The barriers explored in this study compelled the stroke survivors to accept varying degrees of assistance from their caregivers. The findings of this study could assist occupational therapists to consider the factors that hinder the stroke survivors’ participation in meaningful occupations in rural and semi-rural South African communities, and inform treatment aims that are relevant to the respective communities. If occupational therapists consider these barriers when planning treatment, this could assist with maximizing in- dependence in all areas of stroke survivors’ lives, lessening the burden of care on their caregivers and decreasing the patient load on clinical and community occupational therapists. IMPLICATIONS FOR PRACTICE: Stroke survivors dwelling in the semi-rural and rural community contexts experience barriers which are unique to such settings. Thus, occupational therapist should be aware of the differences of barriers experienced not only in the hospital setting, but in the community context that stroke survivors are reintegrated to. Such consideration could contribute to intervention focussed on the individual’s specific needs with regard to participation in meaningful occupations within the semi-rural and rural contexts they reside in.

Lille Apathy Rating Scale-Patient Version in Stroke Survivors: Psychometric Properties and Diagnostic Accuracy

Prevalence and factors influencing cognitive impairment among older adult stroke survivors in Taiwan: A national cross-sectional study.

Stroke survivors in post-acute care frequently experience physiological dysfunction and reduced quality of life. This study aims to assess the impact of the Post-Acute Care Interprofessional Collaborative Practice (PAC-IPCP) program across different care settings, and to identify sensitive tools for assessing physiological functions among post-acute stroke survivors. This retrospective study involved 210 stroke survivors in Taiwan. Participants who self-selection for their preferred between hospital care setting and home care setting under PAC-IPCP. Multiple assessment tools were utilized, including the Barthel Index (BI), Functional Oral Intake Scale (FOIS), Mini Nutritional Assessment (MNA), EQ-5D-3L, and Instrumental Activities of Daily Living (IADL). The logistic regression was used to estimate the odds ratios of various functional assessment tools between hospital and home care settings. Additionally, the area under the ROC curves was used to determine which functional assessment tools had higher accuracy in measuring the association between care settings. Of the study population, 138 stroke survivors (65.71%) selection hospital care setting and 72 stroke survivors (34.29%) selection home care setting. The PAC-IPCP program was equally effective in both care settings for physical function status and quality of life improvements. Specifically, the BI emerged as the most sensitive tool for assessing care settings, with an adjusted OR of 1.04 (95% CI:1.02-1.07, p < 0.0001; AUC = 0.7557). IPCP-based hospital and home care models are equally effective in facilitating improved functional outcomes in post-acute stroke survivors. The PAC-IPCP program is versatile and effective across care settings. The BI stands out as a robust assessment tool for physiological functions, endorsing its broader clinical application. Future studies should also consider swallowing and nutritional status for a more holistic approach to rehabilitation.