First Year After Stroke

Over time there have been many advancements in acute care management after the event of a stroke. However, stroke episodes continue to have associated complex adverse sequelae that require ongoing attention beyond the initial inpatient acute and rehabilitation phases. Gradual functional decline frequently occurs poststroke and has been associated with inactivity, fatigue, cognitive issues, additional health comorbidities, and enduring low mood status. In particular, poststroke depression (PSD) is a common adverse sequelae of stroke, with a prevalence pooled estimate of 31%. There are many risk factors associated with the development of PSD, and its presence can greatly impact rehabilitation outcomes, including behavioral consequences, such as diminished motivation and reduced engagement in activities. Rehabilitation interventions that specifically aim to reduce PSD have not been extensively investigated to date. Physical exercise has been identified as one factor that may potentially influence PSD, especially when conducted at higher intensities. Poststroke programs that aim to target identified needs, with particular attention to engagement in activities considered to be of value to the individual, have also shown to have a positive effect on emotional well-being. However, many stroke rehabilitation programs continue to focus on the amelioration of basic mobility and self-care deficits, with less emphasis on home and community participation tasks, including social roles and leisure activities. The notion of recovery poststroke is a complex and individual phenomenon, and there is a need for rehabilitation services to assist a person to construct a new sense of self into the chronic phase, while continuing to acknowledge and strive for the prestroke self. There are many theoretical frameworks that exist to try to inform rehabilitation practice, with Background and Purpose—Depression is a common issue after stroke. A focus on assisting people to achieve their personal participation goals may reduce levels of depression. The aim of this study was to investigate the effectiveness of a personcentered, integrated approach on facilitating goal achievement in the first year poststroke on depressive symptoms. Methods—This study was a randomized controlled trial that addressed ways to enhance participation in patient-valued activities and intermittently screen for adverse sequelae postdischarge from rehabilitation. Collaborative goal setting was undertaken in both groups at discharge from inpatient rehabilitation. The control group received standard management as determined by the treating team. In addition, the intervention group received a multimodal approach, including telephone contacts, screening for adverse sequelae, written information, home visits, review of goal achievement, and further referral to relevant health services. The main outcome measure was depressed mood, measured by the 15-item Geriatric Depression Scale. Results—One hundred ten participants were recruited. No group differences were identified at baseline on any demographic and clinical variables. Using multiple linear regression analysis, there was a significant difference between the 2 groups with respect to the severity of depressive symptoms at 12 months poststroke (R=0.366; F (6, 89)=8.57; P<0.005), with the intervention group recording lower depressive scores. Conclusions—This model of community-based rehabilitation proved effective in reducing poststroke depressive symptoms. An integrated approach using pursuit of patient-identified activities should form part of routine poststroke management. Clinical Trial Registration—URL: http://www.anzctr.org.au. Unique identifier: ACTRN12608000042347. (Stroke. 2016;47:2820-2827. DOI: 10.1161/STROKEAHA.116.013081.)