Patricia C. Clark

Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient: A Scientific Statement From the American Heart Association

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

Factors Influencing Stroke Survivors’ Quality of Life During Subacute Recovery

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 …

Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomised trial

Background and Purpose— Health-related quality of life (HRQOL) is an important index of outcome after stroke and may facilitate a broader description of stroke recovery. This study examined the relationship of individual and clinical characteristics to HRQOL in stroke survivors with mild to moderate stroke during subacute recovery. Methods— Two hundred twenty-nine participants 3 to 9 months poststroke were enrolled in a national multisite clinical trial (Extremity Constraint-Induced Therapy Evaluation). HRQOL was assessed using the Stroke Impact Scale (SIS), Version 3.0. The Wolf Motor Function Test documented functional recovery of the hemiplegic upper extremity. Multiple analysis of variance and regression models examined the influence of demographic and clinical variables across SIS domains. Results— Age, gender, education level, stroke type, concordance (paretic arm=dominant hand), upper extremity motor function (Wolf Motor Function Test), and comorbidities were associated across SIS domains. Poorer HRQOL in the physical domain was associated with age, nonwhite race, more comorbidities, and reduced upper-extremity function. Stroke survivors with more comorbidities reported poorer HRQOL in the area of memory and thinking, and those with an ischemic stroke and concordance reported poorer communication. Conclusions— Although results may not generalize to lower functioning stroke survivors, individual characteristics of persons with mild to moderate stroke may be important to consider in developing comprehensive, targeted interventions designed to maximize recovery and improve HRQOL.

Family influences on heart failure self-care and outcomes.

BACKGROUND The aim of constraint-induced movement therapy (CIMT) is to promote use of a limb that is functionally impaired after a stroke. In one form of CIMT to treat upper limb impairment, use of the less severely affected arm is restricted for many hours each weekday over 2 consecutive weeks. The EXCITE trial has previously shown the efficacy of this intervention for patients 3-9 months poststroke who were followed-up for the next 12 months. We assessed the retention of improvements 24 months after the intervention. METHODS In the EXCITE trial, 106 of 222 participants who had mild to moderate poststroke impairments were randomly assigned to receive CIMT rather than usual and customary care. We assessed this group of patients every 4 months for the primary outcome measure of impaired upper limb function, as measured with the Wolf motor function test (WMFT) and the motor activity log (MAL). Health-related quality of life, measured with the stroke impact scale (SIS), was a secondary outcome measure. Analysis was per protocol. This trial is registered with ClinicalTrials.gov, number NCT00057018. FINDINGS The effects at 24 months after treatment did not decline from those at 12 months for time taken to complete the WMFT (-0.32 s, 95% CI -3.70 to 3.06), for weight lifted in the WMFT (-1.39 kg, -2.74 to -0.04), for WMFT grip strength (-4.39 kg, -6.91 to -1.86), for amount of use in the MAL (-0.17, -0.38 to 0.04), or for how well the limb was used in the MAL (-0.14, -0.34 to 0.06). The additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT, p<0.0001. INTERPRETATION Patients who have mild to moderate impairments 3-9 months poststroke have substantial improvement in functional use of the paretic upper limb and quality of life 2 years after a 2-week CIMT intervention. Thus, this intervention has persistent benefits.

FAMILY EDUCATION AND SUPPORT INTERVENTIONS IN HEART FAILURE: A PILOT STUDY

Many patient education guidelines for teaching heart failure patients recommend inclusion of the family; however, family-focused interventions to promote self-care in heart failure are few. This article reviews the state of the science regarding family influences on heart failure self-care and outcomes. The literature and current studies suggest that family functioning, family support, problem solving, communication, self-efficacy, and caregiver burden are important areas to target for future research. In addition, heart failure patients without family and those who live alone and are socially isolated are highly vulnerable for poor self-care and should receive focused attention. Specific research questions based on existing science and gaps that need to be filled to support clinical practice are posed.

Evidence for Stroke Family Caregiver and Dyad Interventions: A Statement for Healthcare Professionals From the American Heart Association and American Stroke Association

BACKGROUND Self-management of dietary sodium restriction by persons with heart failure (HF) is difficult and usually occurs within the home setting and within a family context. OBJECTIVE To compare a patient and family education (EDUC) intervention with a combined education and family partnership intervention (EDUC + FPI) for effects on improving dietary sodium self-management in persons with HF. METHODS Patients with HF and a family member (FM) were randomized to EDUC (n = 29 dyads) or EDUC + FPI (n = 32 dyads). Participants with HF were primarily White males with a mean age of 61 years (+/-12). The FMs were primarily women and spouses and had a mean age of 54 years (+/-17). Self-reported dietary sodium (Diet NA) intake and 24-hr urinary sodium (Urine NA) were measured at baseline (BL) and 3 months (3M) after intervention. Data were analyzed with descriptive statistics, generalized least squares regression, paired t test, and chi-square test. RESULTS Groups did not differ by age, gender, or clinical variables; however, family functioning (Family APGAR) scores were slightly higher in the EDUC + FPI group at BL. Both groups decreased Diet NA and Urine NA from BL to 3M; the EDUC + FPI group showed greater decrease in Urine NA and had a greater percentage of those who decreased Urine NA by at least 15% (p = .04). Regression analysis to predict Urine NA revealed a significant Group x Time interaction (p = .03) when accounting for time-varying measures of body mass index (p = .001). DISCUSSION A family-focused intervention may be useful in reducing dietary sodium intake in persons with HF. The Urine NA results support the importance of incorporating family-focused education and support interventions into HF care.

Influence of Stroke Survivor Characteristics and Family Conflict Surrounding Recovery on Caregivers' Mental and Physical Health

Stroke is a leading cause of severe, long-term disability. Most stroke survivors are cared for in the home by a family caregiver. Caregiver stress is a leading cause of stroke survivor institutionalization, which results in significant costs to the healthcare system. Stroke family caregiver and dyad intervention studies have reported a variety of outcomes. A critical analysis of 17 caregiver intervention studies and 15 caregiver/stroke survivor dyad intervention studies was conducted to provide evidence-based recommendations for the implementation and future design of stroke family caregiver and dyad interventions.

A Trial of Family Partnership and Education Interventions in Heart Failure

Background:Stroke recovery is a dynamic process for stroke survivors, and shorter lengths of stay in healthcare settings shift the care of the survivors to family caregivers. The physical and mental sequelae after stroke and the family’s response to this catastrophic event may have deleterious effects on caregivers. Objective:To examine the influence of stroke survivors’ motor function, their memory and behavior changes, and the family conflict surrounding stroke recovery on the mental and physical health of caregivers during the subacute recovery period. Methods:This cross-sectional, correlational study used baseline data from family caregivers (n = 132) and first-time stroke survivors enrolled in a larger multisite study. Results:The caregivers were primarily White (71%), female (74%), college-educated (73%) spouses (80%) of survivors. Most of the caregivers (66%) reported family conflict. The caregivers from families with lower family functioning scores reported worse mental health.The caregivers reported lower mental health when they were caring for stroke survivors with a combination of high memory/behavior changes and low motor function (R2 =.30). Family conflict appears to exacerbate the impact of memory and behavior changes on caregiver mental health. Higher caregiver education and no major health problems were associated with better caregiver physical health (R2 =.36). Caregiver physical health was not associated with family functioning or stroke survivor memory and behavior changes. Conclusions:These results indicate that memory and behavior changes of stroke survivors and family conflict surrounding stroke recovery are important considerations for assessment during the poststroke recovery period.

Pain, Fatigue, and Intensity of Practice in People With Stroke Who Are Receiving Constraint-Induced Movement Therapy

BACKGROUND Lowering dietary sodium and adhering to medication regimens are difficult for persons with heart failure (HF). Because these behaviors often occur within the family context, this study evaluated the effects of family education and partnership interventions on dietary sodium (Na) intake and medication adherence (MA). METHODS AND RESULTS HF patient and family member (FM) dyads (n = 117) were randomized to: usual care (UC), patient-FM education (PFE), or family partnership intervention (FPI). Dietary Na (3-day food record), urinary Na (24-hour urine), and MA (Medication Events Monitoring System) were measured at baseline (BL) before randomization, and at 4 and 8 months. FPI and PFE reduced urinary Na at 4 months, and FPI differed from UC at 8 months (P = .016). Dietary Na decreased from BL to 4 months, with both PFE (P = .04) and FPI (P = .018) lower than UC. The proportion of subjects adherent to Na intake (≤2,500 mg/d) was higher at 8 months in PFE and FPI than in UC (χ(2)(2) = 7.076; P = .029). MA did not differ among groups across time. Both FPI and PFE groups increased HF knowledge immediately after intervention. CONCLUSIONS Dietary Na intake, but not MA, was improved by PFE and FPI compared with UC. The UC group was less likely to be adherent with dietary Na. Greater efforts to study and incorporate family-focused education and support interventions into HF care are warranted.

Development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test.

Background and Purpose. There is little available information about changes in pain and fatigue status among people receiving constraint-induced movement therapy (CI therapy). This study examined such changes. Subjects. All participants were a subset of individuals with stroke enrolled in the Extremity Constraint-Induced Therapy Evaluation (EXCITE) trial and received 2 weeks of CI therapy either 3 to 9 months after stroke (subacute therapy group, n=18) or 1 year later (chronic therapy group, n=14). Methods. Pain, fatigue, and intensity of therapy were evaluated. The Wolf Motor Function Test (WMFT) and the pain scale of the Fugl-Meyer Assessment for the upper extremity were administered before and after training. Single-item measures for pain and fatigue were administered twice daily during therapy. Results. All participants reported low mean pain (X̅=2.0, SD=0.93) and fatigue (X̅=2.7, SD=1.23) scores. Generally, differences between the subacute and the chronic therapy groups for pain, fatigue, intensity, and WMFT change scores were nonsignificant. Discussion and Conclusion. For selected patients with stroke, the intensive practice associated with CI therapy may be administered without exacerbation of pain or fatigue, even early during the recovery process.