Psychological impacts of stroke and rehabilitation

• Impacts of severe illness

  • pathology
  • impairment
  • limitation
  • restriction
  • dependency
  • well-being
  • life evaluation
• Key challenges common across conditions

  • treatment and hospitalisation
  • disruption to daily living
  • uncertainty, threat to future
  • burden of ongoing self-care, lifestyle changes
• Impacts of illness vary in different domains

  • perceived health
  • physical functioning
  • occupational/role functioning
  • social functioning
  • emotional functioning
  • cognitive functioning
• Common impairments after first stroke include:

  • aphasia
  • apraxia of speech
  • arm/hand/leg weakness
  • cognitive impairment
  • dysarthria
  • dysphagia
  • facial weakness
  • gait, balance and coordination problems
  • perceptual impairments, including visuospatial dysfunction
  • sensory loss
  • upper limb impairment
  • visual problems
• Common activity limitations after first stroke:

  • bathing
  • communicatioN
  • dressing and groomning
  • eating and drinking
  • participation restrictions
  • psychological
  • sexual function
  • toileting
  • transferring
  • urinary and/or faecal incontinence
  • walking and mobility
• Common complications for stroke patients:

  • anxiety
  • confusion
  • depression
  • emotionalism
  • falls
  • fatigue
  • infection
  • malnutrition
  • pain
  • pressure sore/skin break
  • recurrent stroke
  • shoulder pain
  • shoulder subluxation
  • spasticity
  • venous thromboembolism
• There are many challenges and impacts of living with severe illness. Often, you can only gain insight into these by directly asking the patient, or their family/carers
• Common emotional responses to illness:

  • emotionalism/emotional lability/instability
  • frustration, anger
  • anxiety (fear, worry)
  • depression (persistent low mood, loss of interst/pleasure)
• Emotionalism/emotional lability

  • lessening of control over emotions
  • leads to greater tendency to cry or laugh
  • can be acutely embarassing, may interfere with treatment, rehabilitation
  • symptoms generally get better with time, though can be longer lasting for some individuals
• Frustration and Anger

  • frustration about not being able to do things = normal understandable reaction
  • may escalate into anger, often directed at others (professionals, carers) e.g. blame
  • can complicate relationships, focus concerns away from illness, lead to reactance
  • common post-stroke may affect longer term adherence to rehab#
• Anxiety

  • consequences of illness/treatment, unavoidable
  • procedures, can be reduced with good clinical care
  • results in disturbing beliefs, attention to symptoms, alters perception, interpretation of info and memory recall
  • initially can be positive as motivates, helps patients overcome initial adjustment but problematic if prolonged/disproportionate, and linked to depression
• Depression

  • common reaction indicated by persistent low mood, loss of interest or pleasure in normal activities
  • more common if
  • life threatening or chronic illness, unpleasant or demanding treatment, low social support/adverse social circumstances, history of depression/alcohol or drug abuse, treatment side effect
  • can have huge negative effects: suicide, poor adherence, lack of motivation, alienation of others
• Some conditions (e.g. stroke) have key impacts on cognitive functioning (e.g. attention, memory, perception, communication), cognitive deficits also common following ICU stay. All conditions require cognitive adjustment around what it means to be ill
• Illness cognitions

  • a patient's own implicit commonsense beliefs about their illness
  • mental representation for recognising symptoms and responding to illness experience
  • developed through own and others' experiences, media, education etc.
  • qualitative and quantitative research to investigate
• Five dimensions of beliefs about illness

  • identity: label, signs, symptoms
  • cause: biological, psychological, multi-factorial
  • timeline: duration, pattern
  • consequences: short and long term effects on life
  • curability/controllability: by themselves/others
• Emotional impacts/responses to severe illness (especially anxiety and depression) are common and understandable. Can become problematic and compromise future care, health and survival
• Stressors = physical, psychological threat to wellbeing, placing demands that require adaptation
• Stress response = biological and psychological (behavioural, cognitive, emotional) response associated with internal state of strain/tension/arousal
• Stress as an interaction between stressor and response, perceived when discrepancy between demands vs resources and ability to cope
• Self-regulatory model = common sense model

  • suggests how illness beliefs interact with emotional response to influence actions
  • symptoms and illness dealt with like other problems:
  • interpretation: understanding problem/stressor
  • coping: address problem to reestablish normality
  • appraisal: assessing success of coping
  • reinterpretation, additional coping as necessary
• Coping is a process in which patients/carers are active agents in managing stress. Constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding resources. Range of strategies important to meet different challenges, at different times. Coping is a process that develops and changes over time to hopefully achieve adjustment.
• Adjustment

  • similar stages of adjustment after various major life events
  • not necessarily linear process, may get stuck, move back in light of new challenges
  • frameworks can be useful for assessing adjustment, providing reassurance, guiding need for an timing of intervention/information/support
• Stages of adjustment

  • major event
  • shock and denial
  • anger
  • depression
  • coming to terms
  • acceptance
  • moving on
• Post-stroke adjustment

  • beliefs held about the world and your place in it
  • stroke and post-stroke experience
  • beliefs about the world and yourself challenged
  • stress
  • changes in your thinking skills
  • attempts to cope
• Positive social support provides emotional and practical assistance to enhance effective coping, adjustment. Presence of support alone not enough: carers may not be coping themselves, burdens associated with relationships (protection, guilt, expectations).
• Clinicians have key role in forming supportive relationships by providing opportunities for disclosure, effective listening, ensuring continuity and follow up. Clinicians can also facilitate support outside clinical context by involving carers and support groups.
• Acute, severe and chronic illness can be major stressors in people's lives. Cognitions and emotions interact to influence people's response to stress through their coping. There are typical stages of adjustment to illness and major life events, if people struggle to adjust they may need additional support, including social support.
• Patients may be offered/referred to rehabilitation or other psycho-educational programmes to support coping with impacts, adjustment, recovery. Rehab aims to enhance functional activities and participation in society and thus improve quality of life,
• Rehabilitation - a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments.
• A stroke rehabilitation service comprises a multidisciplinary team of people who work together towards goals for each patient, involve and educate the patient and family, and have relevant knowledge and skills to help address most common problems faced by their patients.
• Rehabilitation ideally cyclical including:

  • multi-disciplinary assessment to identify/measure patients' difficulties and needs
  • treatment planning including goal setting for long/medium/short term improvements
  • interventions to support change and assist in achievement of goals
  • evaluation via re-assessment to assess progress against agreed goals
• Inpatient stroke rehabilitation

  • stroke unit with multi-disciplinary team, plus access to other services as needed. Focus on mobilisation, education
• Early post discharge stroke rehabilitation

  • multidisciplinary stroke team in community with links to GP and social care where necessary, plus training and support for carers with daily activities
• Ongoing stroke rehabilitation

  • structured exercise training with educational and psychological support and advice based on goal setting with stroke patient and family/carers. Initially 45 mins 5 days per week later tailored to needs/ability
• Goal setting is a key psychological technique. Goals for rehab agreed with patient should be:

  • meaningful and relevant to individual
  • focus on activity and participation
  • challenging but achievable
  • both short and long term
  • communicated, understood and supported
  • reviewed regularly
  • part of a broader, individualised rehab plan
• Emotional support during rehabilitation

  • support and educate re emotional adjustment, changing psychological needs
  • new or persistent emotional needs after 6 months need referral for detailed assessment and treatment
  • manage depression and anxiety in line with general NICE guidelines
• Appropriate referral to health and clinical psychology services should be considered for patients and carers to promote good recovery/adaptation and prevent and treat abnormal adaptation to the consequences of stroke
• Cognitive support during rehabilitation: interventions may be offered for

  • visual neglect affecting functions such as mobility, dressing, eating
  • memory
  • attention
• Communication support during rehabilitation

  • many stroke patients have aphasia (difficulty with production or understanding language) at initial assessment
  • communication support as part of rehab led by speech and language therapists
• Provide opportunities for people with communication difficulties after stroke to have conversation and social enrichment with people who have the training, knowledge, skills and behaviours to support communication