Ingrid Lindgren

Determinants of Quality of Life in Stroke Survivors and Their Informal Caregivers

Background and Purpose— We examined longitudinal changes of quality of life (QOL) covering physical and mental factors in an unselected group of stroke patients and their informal caregivers. Our hypothesis was that informal caregivers would have better QOL than patients at both follow-ups, and that changes, if any, would be related to the patients’ status. Methods— QOL of 304 consecutive stroke patients and their 234 informal caregivers from the population-based Lund Stroke Register was assessed 4 months after stroke onset with the Short Form 36 (SF-36) questionnaire. SF-36 was repeated for both groups after 16 months together with Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS-20) for patients. Results— The patients’ mean QOL scores improved between 4 and 16 months after stroke in the socio-emotional and mental SF-36 domains and decreased in the domain physical function. Multivariate analyses showed that the patients’ most important determinants of QOL after 16 months were GDS-20 score, functional status, age, and gender. Informal caregivers had better QOL than patients except for the domain role emotional and the mental component summary. The caregivers’ most important determinants of QOL were their own age and the patients’ functional status. Conclusions— Our study highlights depressive symptoms in determining QOL of stroke patients. Despite self-perceived deterioration in physical function over time, several other components of QOL improved, suggesting internal adaptation to changes in their life situations. Informal caregivers of stroke patients may be under considerable strain as suggested by their lower emotional–mental scores.

Can sensory stimulation improve the functional outcome in stroke patients

After obtaining informed consent, we randomized 78 patients with severe hemiparesis of the left or right side within 10 days of stroke onset: 40 to a control group receiving daily physiotherapy and occupational therapy, and 38 to a group that, in addition, we treated with sensory stimulation (acupuncture) twice a week for 10 weeks. The median age was 76 years for both groups. Motor function, balance, and ADL (Barthels Index) were assessed before the start of treatment and at 1 and 3 months after stroke onset; ADL was also assessed after 12 months. We assessed the quality of life (QL) using the Nottingham Health Profile 3, 6, and 12 months after stroke onset. Patients given sensory stimulation recovered faster and to a larger extent than the controls, with a significant difference for balance, mobility, ADL, QL, and days spent at hospitals/nursing homes. Whether acupuncture per se is responsible for the differences requires further study.

Shoulder Pain After Stroke A Prospective Population-Based Study

Background and Purpose— Shoulder pain is a well-known complication after stroke, but data on prevalence, predictors, and outcome in unselected stroke populations are limited. Methods— During a 1-year period, 416 first-ever stroke patients were included in the population-based Lund Stroke Register. After 4 months, 327 patients were followed up and 1 year later, the surviving 305 patients were followed up again. General status (National Institutes of Health Stroke Scale score) was registered at stroke onset. Shoulder pain intensity (visual analog scale, score 0 to 30=no–mild and 40 to 100=moderate–severe pain); arm motor function; restricted dressing and/or ambulating; and functional status (Barthel Index) were registered at both follow ups. Results— Shoulder pain onset within 4 months after stroke was reported by 71 patients (22%). Among the 61 patients able to score the visual analog scale, 79% had moderate–severe pain. One year later, 8 of these 71 patients had died, 17 had no remaining pain, and 28 additional patients had developed shoulder pain since the first follow up. Lost or impaired arm motor function and high National Institutes of Health Stroke Scale score were predictors of shoulder pain. Shoulder pain restricted daily life often or constantly when dressing for 51%/31% and when ambulating for 29%/13% of the patients at 4 and 16 months, respectively. Conclusion— Almost one third of the 327 patients developed shoulder pain after stroke onset, a majority with moderate– severe pain. Shoulder pain restricts patients’ daily life after stroke. The increased risk of shoulder pain for patients with impaired arm motor function and/or low general status needs close attention in poststroke care.

Prevalence and intensity of pain after stroke: a population based study focusing on patients’ perspectives

Objective: To determine prevalence and intensity of pain after stroke, focusing on patients’ perspectives. Methods: During a one year period, 416 first-ever stroke patients were included in the population based Lund Stroke Register. After 4 and 16 months (median), 297 patients (98% of survivors) were followed up. Worst pain intensity during the previous 48 hours was assessed on a visual analogue scale (VAS), range 0 to 100: a score of 0 to 30 was defined as no or mild pain; 40 to 100 as moderate to severe pain. NIH stroke scale (NIHSS) score and HbA1c were assessed at baseline. At 16 months, screening for depression was done using the geriatric depression scale (GDS-20), and cognition with the mini-mental state examination (MMSE). Predictors of pain were determined by multivariate analyses. Results: Moderate to severe pain was reported by 96 patients (32%) after four months (VAS median = 60). Predictors of pain were younger age (p = 0.01), female sex (p = 0.006), higher NIHSS score (p<0.001), and raised HbA1c (p = 0.001) at stroke onset. At 16 months, only 62 patients (21%) had moderate to severe pain, but pain intensity was more severe (median VAS score = 70; p<0.016). Higher pain intensity correlated with female sex, worse GDS-20 score, better MMSE score, and raised HbA1c. Pain was persistent in 47%, disturbed sleep in 58%, and required rest for relief in 40% of patients. Conclusions: Although prevalence of pain after stroke decreased with time, after 16 months 21% had moderate to severe pain. Late pain after stroke was on average more severe, and profoundly affected the patients’ wellbeing.

Weight Loss After Stroke A Population-Based Study From the Lund Stroke Register

Background and Purpose— Data on the prevalence and indicators of weight loss in population-based groups of stroke survivors are scarce. We aimed to find the predictors and indicators of weight loss >3 kg as a possible marker of malnutrition after stroke. Methods— We registered weight at baseline, after 4 months, and 1 year later in 305 survivors from a population-based cohort of first-ever stroke patients. Characteristics of the patients were registered at baseline and follow-ups, including glycosylated hemoglobin at baseline and follow-up II, eating difficulties at both follow-ups, and screening for depression at follow-up II. We used univariate and multivariate analyses to find baseline predictors and follow-up indicators related to weight loss >3 kg from baseline. Results— Among the 305 patients, 60% were male, the mean age was 72.5 years, and mean body mass index was 25.8 kg/m2. The main stroke types were cerebral infarction (89%), intracerebral hemorrhage (7%), and subarachnoid hemorrhage (4%). Weight loss >3 kg was found in 74 (24%) patients (mean, −6.6 kg) after 4 months and in 79 patients (26%; mean, −8.3 kg) 1 year later. Severe stroke and elevated glycosylated hemoglobin levels were baseline predictors of weight loss >3 kg. Indicators associated with short-term weight loss (at follow-up I) were eating difficulties, low prealbumin value, and dependence (Barthel Index), whereas indicators associated with long-term weight loss (follow-up II) were eating difficulties, hemorrhagic stroke, and low prealbumin value. Conclusions— Weight loss >3 kg after stroke indicates the need for closer observation regarding nutritional status. Monitoring of body weight may be useful, particularly among patients with severe stroke, eating difficulties, low prealbumin values, and impaired glucose metabolism.

Left-Sided Hemiparesis, Pain Frequency, and Decreased Passive Shoulder Range of Abduction Are Predictors of Long-Lasting Poststroke Shoulder Pain

To determine the proportion of persons with poststroke shoulder pain 4 months after onset of the stroke in whom long‐lasting shoulder pain develops and to assess the extent to which age, side of paresis at stroke onset, pain frequency and pain intensity, passive shoulder range of motion, resistance to passive movements, motor function, and subluxation at 4 months after stroke predict shoulder pain 1 year later.

Somatosensory impairments are common after stroke but have only a small impact on post-stroke shoulder pain.

OBJECTIVE To investigate whether somatosensory impairments are more common in individuals with post-stroke shoulder pain than in those without post-stroke shoulder pain and healthy controls. DESIGN Descriptive analysis of a convenience sample. PARTICIPANTS Forty-nine individuals with stroke, 24 with and 25 without post-stroke shoulder pain (median age 65 years), and 11 age- and sex-matched healthy controls. METHODS Perception and pain thresholds for cold, warm and heat (thermal thresholds), and pain thresholds for pressure and pin prick (mechanical thresholds) were assessed using quantitative sensory testing (QST). Passive range of motion, motor function, resistance to passive movements, light touch and proprioception were assessed in the upper extremities. Shoulder pain characteristics were recorded in the post-stroke shoulder pain group. RESULTS There were no significant differences between the group with post-stroke shoulder pain and the group without post-stroke shoulder pain in any of the QST assessments, but more participants in the post-stroke shoulder pain group reported abnormal cold sensation in the affected side. Both stroke groups had generally higher thermal thresholds and more extreme low or high mechanical thresholds than the healthy controls. CONCLUSION Somatosensory impairments are common among individuals with stroke compared with healthy controls. The non-significant differences in QST thresholds between the group with post-stroke shoulder pain and the group without post-stroke shoulder pain indicate that somatosensory impairments have only a small impact on post-stroke shoulder pain.

Poststroke Shoulder Pain and Its Association With Upper Extremity Sensorimotor Function, Daily Hand Activities, Perceived Participation, and Life Satisfaction

To assess the differences in upper extremity sensorimotor function, daily hand activities, and perceived participation and life satisfaction between individuals with and without poststroke shoulder pain (PSSP), and to determine how PSSP is associated with these variables.

Shoulder pain after stroke – experiences, consequences in daily life and effects of interventions: a qualitative study

Abstract Purpose: To describe experiences of shoulder pain after stroke, how pain affects daily life and perceived effects of interventions. Method: A qualitative interview study including 13 community-dwelling persons (six women; median age 65 years) with persistent shoulder pain after stroke. Results: Three categories emerged from the content analysis. In “Multiple pain characteristics” an insidious pain onset was reported. The pain existed both day and night and could be located around the shoulder girdle but also have radiation to the arm and hand. An explanation of the pain was seldom given. In “Limitations caused by the pain” it was described how the pain negatively influenced personal care, household activities and leisure, but also could lead to emotional reactions. In “Multiple pain interventions with various effects” a variety of interventions were described. Self-management interventions with gentle movements were perceived most effective. A restraint attitude to pain medication due to side effects was reported. Conclusions: Shoulder pain after stroke can lead to a variety of pain characteristics. As the pain is complex and may affect many important areas in a person’s life, multidisciplinary rehabilitation interventions are important. Implications for rehabilitation Shoulder pain after stroke can lead to a variety of pain characteristics with radiation to the arm and hand Shoulder pain often influence personal care, household activities and leisure negatively, which may lead to emotional reactions Self-management interventions with gentle movements are perceived most effective As the shoulder pain after stroke is complex, interventions by a multidisciplinary team may be needed

Measurement variability of quantitative sensory testing in persons with post-stroke shoulder pain.

OBJECTIVE To evaluate the measurement variability of quantitative sensory testing (QST) in persons with post-stroke shoulder pain. DESIGN A test-retest design. PARTICIPANTS Twenty-three persons with post-stroke shoulder pain (median age 65 years). METHODS Thermal detection thresholds (cold and warm), pain thresholds (cold and heat) and mechanical pain thresholds (pressure and pin prick) were assessed twice in both arms, 2-3 weeks apart. Measurement variability was analysed with the intraclass correlation coefficient (ICC2.1), the change in mean (đ) with 95% confidence interval (logarithmic scales), and the relative standard error of measurement (SEM%; re-transformed scales). RESULTS The ICCs for thermal thresholds ranged from 0.48 to 0.89 in the affected (painful) arm and from 0.50 to 0.63 in the unaffected arm, and for mechanical pain thresholds from 0.66 to 0.90 in both arms. No systematic changes in the mean (đ) were found. The SEM% ranged from 4% to 10% for thermal detection and heat pain thresholds, and from 17% to 42% for cold pain and mechanical pain thresholds in both arms. CONCLUSION QST measurements, especially cold pain thresholds and mechanical pain thresholds, vary in persons with post-stroke shoulder pain. Before QST can be used routinely to evaluate post-stroke shoulder pain, a test protocol with decreased variability needs to be developed.