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Rehabilitation after stroke with focus on early supported discharge and post-stroke fatigue
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Rehabilitering efter stroke med speciellt fokus på tidig koordinerad hemgång och fortsatt rehabilitering i hemmet och post-stroke fatigue (Swedish)
Abstract [en]

Background Stroke is a major cause of disability worldwide. After treatment in a specialized stroke unit, early supported discharge (ESD) followed by home rehabilitation has shown to be an effective way to improve patient outcome and quality of care for persons with mild to moderate stroke. ESD service is recommended in the national and international guidelines for stroke care, but has only partially been implemented in Sweden. Following stroke, fatigue is a common consequence that often becomes more evident when the patient comes home. Currently, there is insufficient evidence about how to measure, treat and handle post-stroke fatigue. The overall aim of this thesis was to evaluate and implement early supported discharge (ESD) based on stroke patients experience after discharge from the stroke unit and local conditions. The aim was also to evaluate post-stroke fatigue with a potentially valid and reliable scale and finally to prepare for a study to evaluate cardiorespiratory training as a part of ESD service for patients with post-stroke fatigue.

Methods In paper I, nine strategically chosen patients were interviewed of their experience of falling ill, the hospital stay, discharge, contact with health care after discharge and their request of support. Papers II-III describe and evaluate the development, content, implementation and effects of a locally adopted method for early supported discharge (Umeå Stroke Center ESD) in modern stroke care. Paper II included 153 consecutive patients and paper III, 30 232 patients with first-ever stroke registered in the Riksstroke registry in Sweden. Paper II evaluated number of patients/year, clinical and functional health status, satisfaction in relation to needs, accidental falls/other injuries and resources with the result summarized in a value compass. The implementation process was evaluated retrospectively by means of Consolidated Framework for Implementation (CFIR). Paper III evaluated patient reported outcome measurements (PROMs) at 3 months. The primary outcome in paper III was satisfaction with the rehabilitation after discharge. Secondary outcomes were information about stroke provided, tiredness/fatigue, pain, dysthymia/depression, general health status and dependence in activities of daily living (mobility, toilet hygiene and dressing). Multivariable logistic regression models for each PROM was used to analyze associations between PROMs and ESD/no ESD. In Paper IV, the Fatigue Assessment scale (FAS) was translated into Swedish and evaluated regarding psychometric properties when self-administered by persons with mild to moderate stroke. 72 consecutively patients selected from the stroke unit admission register received a letter including three questionnaires: the FAS, the Short Form Health Survey (SF-36) subscale for vitality and the Geriatric Depression Scale GDS-15. A second letter with FAS was sent within 2 weeks, for re-test evaluation. Paper V is a study protocol for a planned randomized controlled trial (RCT) of 50 consecutive stroke patients will who receive stroke unit care followed by ESD-service at Umeå Stroke Center, University Hospital, Umeå, Sweden. Paper V will investigate if a structured cardiorespiratory interval training program (CITP) added to the ESD-service may result in relieved post-stroke fatigue and increased oxygen uptake.

Results The interviews in Paper I revealed three main categories with subcategories: “Responsible and implicated”, “Depersonalized object for caring measures” and “The striving for repersonalization and autonomy”. The findings indicate that coming home gave the informants’ important insights and understanding of the stroke, its consequences and was also an important factor for the recovery. Paper II-III showed that it is possible to develop and implement an adapted ESD service for stroke patients based on the patients’ experiences and requests, evidence-based recommendations and local conditions. The ESD service reduced dependence of activity, increased mobility with seemingly no increased risk of accidental falls or other injuries. The patient satisfaction in relation to needs regarding the ESD was high. Paper III showed that patients that received ESD were more satisfied with rehabilitation after discharge, had less need for assistance with ADL and less dysthymia/depression compared to patients that did not receive ESD. Study IV showed that the Swedish FAS used at home as a selfadministered questionnaire is a reliable and valid questionnaire for measuring fatigue in persons with mild to moderate stroke. The internal consistency was good, the agreement between the test and retest reliability for individual items (weighted kappa) was for the majority of items good or moderate. The relative reliability for total scores was good and the absolute reliability was 9 points. The Swedish FAS had no floor nor ceiling effects and correlated both with the SF-36, subscale for vitality and the GDS-15 indicating convergent construct validity, but not divergent construct validity.

Conclusion It is possible to develop and implement ESD care for stroke patients based on patients’ experience and needs, evidence-based principles and local conditions. Early supported discharge (ESD) in the setting of modern stroke unit care appears to have positive effects on rehabilitation in the subacute phase. The Swedish FAS used at home as a self-administered questionnaire is reliable and valid for measuring fatigue in persons with mild to moderate stroke.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2016. , 72+2 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1817
Keyword [en]
Stroke, early supported discharge, post-stroke fatigue, patient reported outcome measurement, Fatigue assessment scale, cardiorespiratory training
National Category
Other Medical Sciences
Research subject
Physiotherapy
Identifiers
URN: urn:nbn:se:umu:diva-120127ISBN: 978-91-7601-501-8 (print)OAI: oai:DiVA.org:umu-120127DiVA: diva2:926688
Public defence
2016-06-03, Sal B, byggnad 1D, Umeå universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2016-05-13 Created: 2016-05-09 Last updated: 2016-05-26Bibliographically approved
List of papers
1. 'If only I manage to get home I'll get better' - interviews with stroke patients after emergency stay in hospital on their experience and needs
Open this publication in new window or tab >>'If only I manage to get home I'll get better' - interviews with stroke patients after emergency stay in hospital on their experience and needs
2005 (English)In: Clinical Rehabilitation, ISSN 0269-2155, E-ISSN 1477-0873, Vol. 19, no 4, 433-440 p.Article in journal (Refereed) Published
National Category
Other Medical Sciences not elsewhere specified
Identifiers
urn:nbn:se:umu:diva-120078 (URN)10.1191/0269215505cr788oa (DOI)000229372800012 ()15929513 (PubMedID)
Available from: 2016-05-09 Created: 2016-05-09 Last updated: 2017-11-30Bibliographically approved
2. Stroke unit at home: A prospective observational implementation study for early supported discharge from the hospital
Open this publication in new window or tab >>Stroke unit at home: A prospective observational implementation study for early supported discharge from the hospital
2013 (English)In: International Journal of Physical Medicine Rehabilitation, E-ISSN 2329-9096, Vol. 1, no 170Article in journal (Refereed) Published
Abstract [en]

Background: Randomized controlled trials on early supported discharge (ESD) service in stroke have demonstrated favorable results. However, there are difficulties in transferring research results regarding ESD to the clinic. The aim of this study is to describe the method, content, implementation and outcome of ESD in its natural habit for stroke patients.

Methods: A prospective observational implementation study of 153 consecutive stroke patients with mild to moderate severity with ESD and rehabilitation by a specially trained interdisciplinary team in the patient’s home, directly after discharge from the stroke unit. The interdisciplinary team in the ESD team is similar to the work at the stroke unit. Number of patients/year, clinical and functional health status, patient satisfaction, accidental falls/other injuries and resources were evaluated.

Results: The number of patients/year in the ESD service has gradually increased from 2005 to 2009.The stroke patients subjected to Umea ESD service in January 2008 until May 2009 had a mean of 8.6 days of in-hospital care. The ESD service included 11 visits and 18 h per patient during 23 days (mean values). Compared with time of enrollment, patients exhibited reduced functional dependency (ADL- stairs 3 (1 - 5) vs. 1 (0–3), median, Q1–Q3, p <0.001, two-sided Wilcoxon Signed Ranks test) and increased mobility (Rivermead Mobility Index, (RMI) 11 (9–13) vs. 13 (12–15), p <0.001) at the time of discharge from the ESD service. Patient satisfaction regarding ESD was high. The long-term risk of accidental falls and other injuries appeared not to be increased.

Conclusions: It is possible to locally develop and implement ESD care for stroke patients based on evidencebased principles. Our locally adapted ESD care, a stroke unit in the patients’ home, appears to be an appropriate alternative to conventional rehabilitation for patients with mild to moderate stroke.

Keyword
Stroke, early supported discharge, home rehabilitation, implementation
National Category
Other Medical Sciences
Identifiers
urn:nbn:se:umu:diva-120077 (URN)10.4172/2329-9096.1000170 (DOI)
Available from: 2016-05-09 Created: 2016-05-09 Last updated: 2017-11-30Bibliographically approved
3. Effect of early supported discharge after stroke on patient reported outcome: observational study from the Swedish Riksstroke registry
Open this publication in new window or tab >>Effect of early supported discharge after stroke on patient reported outcome: observational study from the Swedish Riksstroke registry
(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-120124 (URN)
Available from: 2016-05-09 Created: 2016-05-09 Last updated: 2016-05-12
4. Reliability and validity of the Swedish Fatigue Assessment Scale when self-administrered by persons with mild to moderate stroke
Open this publication in new window or tab >>Reliability and validity of the Swedish Fatigue Assessment Scale when self-administrered by persons with mild to moderate stroke
2016 (English)In: Topics in Stroke Rehabilitation, ISSN 1074-9357, E-ISSN 1945-5119, Vol. 23, no 2, 90-97 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To examine internal consistency, test-retest reliability, floor/ceiling effects and construct validity of the Fatigue Assessment Scale (FAS), when self-administrated by persons with mild to moderate stroke.

Method: The FAS was translated into Swedish and tested for psychometric properties when self-administrated by persons with mild to moderate stroke. Participants, consequently selected from the stroke unit admission register received a letter with three questionnaires: the FAS, Short Form Health Survey (SF-36) subscale for vitality and Geriatric Depression Scale, GDS-15. Within two weeks, a second letter with FAS was sent for re-test.

Result: Seventy-tree persons with mild to moderate stroke participated in the study. Internal consistency was good (Cronbach’s alpha 0.82). The test and retest reliability of individual items showed that five items out of 10 items were good (weighted kappa > 0.60), four were moderate (0.40-0.60), and one was fair (0.22). The relative reliability between total scores was good (ICC 3.1 = 0.73) and the absolute reliability was nine points, meaning that a change of at least nine points in total score implies a real change of fatigue level. Correlation analysis showed that the Swedish FAS correlated with the SF-36 subscale for vitality (rs = - 0.73) and GDS-15 (rs = 0.62), suggesting convergent construct validity. There were no floor or ceiling effects.

Conclusion: The Swedish translation of the FAS used as a self-administrated questionnaire is reliable and valid for measuring fatigue in persons with mild to moderate stroke.

Keyword
Stroke, Fatigue, Questionnaire, Reliability, Floor/ceiling effects, Construct validity
National Category
Health Sciences
Identifiers
urn:nbn:se:umu:diva-117798 (URN)10.1080/10749357.2015.1112057 (DOI)000373737600003 ()26883993 (PubMedID)
Available from: 2016-03-03 Created: 2016-03-03 Last updated: 2017-11-30Bibliographically approved
5. Does a cardiorespiratory interval training program at home improve post-stroke fatigue? Study protocol of a randomized controlled trial
Open this publication in new window or tab >>Does a cardiorespiratory interval training program at home improve post-stroke fatigue? Study protocol of a randomized controlled trial
(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-120125 (URN)
Available from: 2016-05-09 Created: 2016-05-09 Last updated: 2016-05-12

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