Identifying Rehabilitation Needs For Stroke Survivors And Caregivers: A Critical Appraisal

Authorship

Discuss about the Combined Perceptions Of People With Stroke.

All stroke survivors require some or full assistance in activities of daily living after stroke. Stroke rehabilitation is needed in the early stage to achieve better recovery in the first month after stroke and reduce disability in the long term (Veerbeek et al., 2011). The essay is concerned with identifying ways to meet rehabilitative needs of Sue-Anne, who finds it hard to perform her usual activities of daily living. The main research question related to the scenario is ‘How may a caregiver effectively support family member in identifying activities of daily living for a stroke?’.  The research study by Ekstam et al. (2015) is found relevant to answer the research question and the essay mainly provides a critical appraisal of research article to discuss how rehabilitation needs for stroke survivors like Anne can be met. 

The research article was developed by group of six authors. Two of the authors were from Department of Occupational Therapy and the rest were from Department of Clinical research, Department of Neuroscience and Rehabilitation Medicine, Division of Physiotherapy and Department of Clinical Neuroscience. Based on the field in which each authors are working, it can be said that work is reliable as all of them have expertise and knowledge regarding the rehabilitation. Occupation therapy, neuroscience and physiotherapy are all interrelated fields and expertise in this field may help to enhance the quality of the study. The author can easily interpret patient’s perception and link them to rehabilitation needs.

The conflict of interest or bias that has been found in this study is that author’s were reliant on previously prepared rehabilitation questionnaire. Although the research question related to dyadic perception was novel, however selection of existing instead of developing questionnaire related to study objective would have enhanced the quality of the study.

The main research question for the study by Ekstam et al. (2015) was to investigate about the association between the perception of stroke survivors and their caregivers regarding rehabilitation needs 1 year after stroke. The main rational for conducting research in this area is understood from the background information given in the article. The study gave the background information that patient-centered rehabilitation is necessary for stroke patient, however 33-49% of patient perceive unmet rehabilitation needs after 1 year (Dworzynski, Ritchie & Playford, 2015). Ullberg et al. (2016) also supports the fact that unmet rehabilitation needs 12 months after stroke has not covered in studies. The author clarified that sense of coherence is needed to adjust personal resources and fulfill unmet needs. The author pointed out to the gap in research that association between sense of coherence and perceived needs for rehabilitation has not been covered in detail in past research.

Research Question

The author argued that family caregivers play an important role in rehabilitation as they can easily identify unmet rehabilitation needs in their family member. However, the issue that has been found for stroke survivor is that most of the informal caregivers are elderly and they need support to cope with care giving burden. Hence, exploring the perspective of both patients as well family caregiver regarding unmet rehabilitation need was important as dyadic perception has not been explored before. By conducting research on dyad’s perception related to rehabilitation, Ekstam et al. (2015) aims to obtain information related to everyday personal life experience of stroke survivors and their caregivers and the strategies they adapt to manage stroke after 1 years. The research in this area is significant as the study can give an understanding about how personal factors, severity and care giving burden can influence rehabilitation process and identify caregivers who are in need of rehabilitation support.

The study by Ekstam et al. (2015) is a secondary study as it used data from prospective observational study of the rehabilitation process after stroke to conduct the research. The name of the observation study was ‘Life after Stroke phase 1’ (LAS-1), and the sample group in the LAS who answered questions related to rehabilitation needs after 1 year follow-up were included in the research.  by the use of mixed method study design was used to explore stroke survivor’s and family caregivers perception related to rehabilitation needs 1 year after stroke. Both qualitative and quantitative date was used for analysis. Use of mixed method is suitable as per the research objective as the research aimed to explore both participant’s perception towards rehabilitation as well as judge stroke severity level. Hence, rehabilitation needs and sense of coherence (SOC) were judged by means of quantitative approach and experience related to rehabilitation was collected by the use of primary research method. Use of open-ended questions during the interview stage favored analysis of experience related to life changes post stroke. Therefore, the study had appropriate research design to gain full-understanding about research problem. Creswell & Creswell (2017) states that use of both quantitative and qualitative research promotes breadth and depth of understanding related to the research problem. It favored analysis of research question from different angles.

As study used data from LAS-1, the participant of the LAS-1 such as people with stroke and their informal caregivers were sample population group of the study. Data was collected regarding sex, strike and severity at baseline from medical record. Evidence based tool call the Barthel index was used to categorize stroke severity into mild or severe case. Furthermore, in accordance with the research question, Ekstam et al. (2015) used questionnaires to interview participants regarding need for and satisfaction with health care service. The strength of the data collection method is that it used evidence based questionnaire that covered difference dimensions of patient’s satisfaction with care. The advantage of the research questionnaire was it covered questions related to rehabilitation needs too. Bothe quantitative and descriptive approach helped to collect data and address the research question. Quantitative data was also collected for SOC by means of the SOC scale. In addition, open-ended questions were used to collect data on daily activities with stroke and strategies to manage stroke. Hence, quantitative and qualitative approach in data collection helped to collect comprehensive data related to the research question. Wisdom and Creswell (2013) suggest that the main characteristic of a well-designed mixed method study is collection and analysis of data by means of close-ended and open-ended questionnaire. The rigorous process in collecting data is also understood from the above data collection method.

Research Design

The data analysis was done by means of statistical tools like Wallis ANOVA test and the Mann Whitney U test. Response to open-ended questions was done by content analysis. Overall, the limitation found in data collection process is that the use of set questions used in previous research decreased specificity of data according to the research question. It provided generalized information and lacked details regarding specific rehabilitation needs. In addition, the sample size was too small which reduced the reliability of the research. However, the strength of the data collection process is the selection right sample group as the cohort was representative of the population of interest.

In the research study, 67% of participants had mile stroke and 33% had moderate/severe stroke. The analysis of research data revealed that 52% perceived fulfillment of stroke rehabilitation needs at 12 months and there were 13% who believed that stroke rehabilitation was necessary. Furthermore, the comparative analysis of dyads revealed that people with mild stroke were in the dyads who perceived rehabilitation needs were met. In those groups, no changes in daily life activities were found. However, for dyads with unmet or discordant response, it was found that they were more dependent on daily life activities. They also reported significant changes in their daily life pattern. In relation to the dyad’s perspective on strategies used to manage the change, it was found that people mainly used strategies like physical exercise, partner aids, cycling to overcome the issue. The burden of care was also less for those groups which reported that their rehabilitation needs were met (Ekstam et al., 2015). Hence, the study gave the indication that rehabilitation perception differs based on stroke severity and major life events. The outcome is consistent with the research study by Lynch et al. (2015). It gave implication for practice change by suggesting inclusion of family caregivers in the rehabilitation system.

While reporting about research finding, it is necessary for authors to discuss about research findings. Limitation related to the work was given by the researcher and this gave implications for future research. As proper comparison regarding dyad’s perception about rehabilitation need was not done, Ekstam et al. (2015) suggested exploring effects of using a dyadic perspective throughout the rehabilitation process.

Certain methodological limitations found in the work act as barriers in applying the evidence to clinical practice. Although the study gave unique perceptive of using systemic approach  in rehabilitation process by utilizing dyad’s perspective, however the study cannot be applied because lack of rich data on comparison between partners or dyads in the study. The difference in perception has been found regarding severity, however difference in perception related to rehabilitation needs for patients and caregiver has not been adequately covered. The research has missing data which cannot be applied in clinical practice.

Conclusion:

The report gave a critical analysis of a research paper to understand how caregiver can support family members in identifying activities of daily living following stroke. The critical review of the research article by Ekstam et al. (2015) gave the indication that perception related to rehabilitation needs differs based on severity of stroke. Hence, the study showed that care giving burden and unmet need perception is high for dyads with unmet needs. The study gave the implication that inclusion of caregiver in rehabilitation system is necessary to support them and reduce care giving burden.

Reference:

Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications.

Dworzynski, K., Ritchie, G., & Playford, E. D. (2015). Stroke rehabilitation: long-term rehabilitation after stroke. Clinical Medicine, 15(5), 461-464.

Ekstam, L., Johansson, U., Guidetti, S., Eriksson, G., & Ytterberg, C. (2015). The combined perceptions of people with stroke and their carers regarding rehabilitation needs 1 year after stroke: a mixed methods study. BMJ open, 5(2), e006784.

Lynch, E. A., Luker, J. A., Cadilhac, D. A., & Hillier, S. L. (2015). Rehabilitation assessments for patients with stroke in Australian hospitals do not always reflect the patients’ rehabilitation requirements. Archives of physical medicine and rehabilitation, 96(5), 782-789.

Ullberg, T., Zia, E., Petersson, J., & Norrving, B. (2016). Perceived unmet rehabilitation needs 1 year after stroke: an observational study from the Swedish stroke register. Stroke, 47(2), 539-541.

Veerbeek, J. M., Kwakkel, G., van Wegen, E. E., Ket, J. C., & Heymans, M. W. (2011). Early prediction of outcome of activities of daily living after stroke: a systematic review. Stroke, 42(5), 1482-1488.

Wisdom, J., & Creswell, J. W. (2013). Mixed methods: integrating quantitative and qualitative data collection and analysis while studying patient-centered medical home models. Rockville: Agency for Healthcare Research and Quality.