Effect of Rehabilitation on Long-term Outcomes After Stroke: Results From a Population-based Study
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Stroke is one of the leading causes of adult disability internationally and in New Zealand (NZ). The neurological sequelae commonly associated with stroke can severely impact long-term outcomes increasing reliance on others and reducing quality of life (QoL). While there is an abundance of research on physical outcomes from rehabilitation, little is known on the impact that inpatient and community rehabilitation has on long-term functional and QoL outcomes, especially within a NZ population. The purpose of this thesis was to determine the association between inpatient and community rehabilitation, and long-term functional and QoL outcomes in a cohort of four-year stroke survivors in Auckland, NZ. This population-based follow-up study uses a quantitative approach and includes a sample drawn from the fourth Auckland Regional Stroke Outcomes Study (ARCOS- IV). Two hundred and forty-one stroke survivors completed outcome measures of functional independence (Barthel Index [BI]; and the Modified Rankin Scale [mRS]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), cognitive functioning (Montreal Cognitive Assessment [MoCA]), fatigue (Fatigue Severity Scale [FSS]; and the Visual Analogue Fatigue Scale [VAFS]), self-reported health status (Medical Outcomes Study Short Form 36 [SF-36]), and health related QoL (EuroQol Quality of Life Scale [EQ-5D]) at baseline, and/or 1 month, 6, 12 (previously collected) and 48 months post-stroke onset. The data analysed within this study is data attained at 48 months (four years post-stroke). Data collected at baseline includes sociodemographic information, stroke-related characteristics, and medical history. Self-reported access to inpatient and community rehabilitation, taking into consideration hours, frequency, and also type of rehabilitation was attained also. At four years post-stroke, the greatest proportion of the sample (83.4%) demonstrated below average cognitive functioning as assessed by the MoCA (M=20.68, SD=4.7), a large amount of participants (56.8%) presented with high levels of fatigue on the FSS (M=5.22, SD=1.76), with average scores on the VAFS representing debilitating levels of fatigue among the sample also (M=54.61, SD=17.96). At four years on the SF-36, stroke survivors exhibited below the mean of the NZ population in constructs involving physical functioning (51.9%, M=60.44, SD=36.6), role functioning physical (27%, M=74.07, SD=41.16), role functioning emotional (30.3%, M=73.86, SD=42.1), energy and fatigue (74.3%, M=55.64, SD=22.7), social functioning (22%, M=83.61, SD=22.61), general health (53.2%, M=64.5, SD=27.31), and health change (75.9%, M=49.48, SD=21.22). In regards to inpatient rehabilitation it was established that 37.8% (n=91) of stroke survivors received inpatient rehabilitation involving physical, occupational and speech therapy as required. Stroke survivors that received inpatient rehabilitation did not present with significantly better outcomes in QoL and functional independence in comparison to those who did not receive inpatient rehabilitation. At four years stroke survivors who did receive inpatient rehabilitation were still significantly impaired in areas of self-care (p=0.01) and usual activities (p=0.01) according to the EQ-5D outcome measure, demonstrating impairment in functional independence, which is understood to impact QoL post-stroke. In terms of community rehabilitation, 31.5% (n=76) of the participants received community rehabilitation involving physical, occupational and speech therapy. A relationship was found between negatively perceived health change on the SF-36 in 183 (75.9%) participants and those who did not receive community rehabilitation (p=0.03), potentially demonstrating more negative perceptions of health long-term post- stroke in those who did not have community rehabilitation support. Findings from this study did not provide substantial evidence supporting positive outcomes from inpatient or community rehabilitation in long-term stroke survivors in Auckland, NZ. However, the findings have provided evidence that current inpatient and community rehabilitation being offered is not addressing the areas of persistent impairment, which stroke survivors are experiencing well after their stroke event. This includes disability in cognitive functioning, fatigue, emotional well-being (anxiety and depression), roles in physical and emotional functioning, social functioning and participation, general health and perceived health change. There was no evidence of cognitive or psychological interventions throughout inpatient and community rehabilitation services, which potentially could have contributed towards the impairment presented throughout this current sample at four years. Current care as usual post-stroke in the inpatient and community rehabilitation setting in Auckland, NZ needs improvements in order to benefit stroke survivors’ long-term outcomes in functional independence and QoL. Cognitive and psychological components incorporated into inpatient and community rehabilitation for stroke survivors could potentially improve long-term QoL and functional independence outcomes post-stroke.