Tableaux de données probantes et liste de reference (en anglais)
The post-discharge period is a difficult time of adjustment for both patients and their families, as they return to vocational and social life roles. For persons returning home, the transition period may be challenging as the social, emotional, and practical support offered by inpatient care is lost.
Return to Work
Return to work (RTW) is one of the most important issues for those who were working at the time of their stroke. Following stroke, the reported rates of RTW vary widely. Using the results from 29 studies, Edwards et al. (2017) reported that the overall frequency of return to either full or part-time work, assessed up to 12 years following stroke ranged from 7.3%1-74.5%. Up to 6 months following stroke, 41% of persons had returned to work, increasing to 66% at 4-6 years. Hackett et al. (2012) reported that 75% of persons previously employed at the time of stroke had returned to work at one year. Hannerz et al. (2011) reported that of 19,985 persons included in the Danish Occupational Hospitalization Register who were 20-57 years and had sustained a stroke, 62.1% were employed 2 years post stroke. At 4 years following stroke, Trygged et al. (2011) reported that 4,867 (69%) of 7,081 Swedes who had been employed prior to stroke, aged 40-59 years had successfully returned to work. The most commonly-cited predictors of successful RTW include independence in activities of daily living (ADLs), younger age, milder stroke severity higher cognitive functioning, fewer neurological deficits, strong family support, having realistic and flexible vocational goals, higher income and education, havng a white-collar job and being male (Edwards et al. 2017, Wang et al. 2014, Hannerz et al. 2011), while hemorrhagic stroke, increasing age and stroke severity, and depression, have been citing as factors associated with a decreasing probability of RTW Wang et al. 2014, Hannerz et al. 2011).
Interventions to help improve the odds of successful RTW have not been well studied. Ntsiea et al. (2015) reported that a 6-week individualized workplace intervention program group was associated with an increase in the number of persons who had returned to work following a recent stroke (<8 weeks), compared with persons receiving usual care, at 6 months (60% vs. 20%, p<0.001). Baldwin & Brusco (2011) included the results from 6 studies, which examined rehabilitation programs that included vocational training post stroke. Vocational rehabilitation programs were defined as those that included medical, psychological, social, physical and/or occupational rehabilitation activities with the purpose to return to work. Following completion of the programs, the RTW rates varied among the studies from 12% to 49%. The pre-stroke vocation status was reported in 3 studies and ranged from 48% to 100%.
Many people recovering from stroke are unable to resume their previous leisure activities. Factors including physical limitations, attributable to residual disability, decreased motivation, environmental barriers including transportation and affordability have been cited as reasons for decreased participation.
A variety of programs and interventions have been evaluated to help improve participation following stroke, although few have used an assessment of leisure as the primary outcome. A systematic review by Dorstyn et al (2014) including the results from 8 RCTs that examined the benefit of a community-based intervention focusing on leisure therapy, leisure therapy + physical activity or leisure education, which provided an average of 17 sessions over 23 weeks. The majority of participants had experienced a mild or moderately-disabling stroke within the previous year. While no pooled analyses were conducted, within individual trials significant improvement was noted at the end of treatment on measures of quality of fife, mood and satisfaction with leisure activity. An 8-week peer-volunteer facilitated exercise and education program was associated with significantly greater improvement in median perceived Subjective Index of Physical and Social Outcome (physical component) scores at both at the end of treatment and at one year, compared with participants who received standard care (Harrington et al. 2010). Desrosiers et al. (2007) included 62 participants residing in the community with a history of stroke within the previous 5 years and who were experiencing some limitations in leisure participation or satisfaction. The intervention involved 8-12, 60-minute, weekly education sessions, while participants in the control groups received home visits from a recreational therapist following the same schedule as the intervention group. At the completion of the study, participants in the intervention group reported significantly more time spent in active leisure activities (MD=14.0 minutes, 95% CI 3.2-24.9, p=0.01) and involvement in a greater number of different activities (MD= 2.9, 95% CI 1.1-4.8, p=0.002). Participants in the intervention group had also gained significantly more points on the Leisure Satisfaction Scale (MD= 11.9, 95% CI 4.2-19.5, p=0.003) and in the satisfaction of leisure needs and expectations (MD=6.9, 95% CI 1.3-12.6, p=0.02).
Reports of sexual dysfunction following stroke are common. Among several surveys including small samples, declines in sexual activity have been reported. Stein et al. (2013) surveyed 35 persons who agreed to participate, out of 268 who were included in a stroke rehabilitation research registry. Of those, 100% of men and 58% of women met the criteria for sexual dysfunction, 42% indicated their sexual functioning was worse following stroke, 94% reported that physical limitations impacted their sexual activity and 58.8% reported feeling less sexually desirable following stroke. Buzzelli et al. (2007) also reported that among 60 patients (83.3%) reported a decline in sexual activity during the first year following stroke. Variables associated with disruption of sexual activity included fear of relapse, belief that one must be healthy to have a sex life and partner who is “turned off” at the prospect of sexual activity with a “sick person”.
Only a few small trials examining interventions designed to address issues relating to sexuality post stroke have been published. Sampson et al. (2015) reported no significant differences between groups on median Sexual Function Questionnaire Short-Form (CSFQ‑14) scores following a single 30-minute structured sexual rehabilitation session, conducted by a rehabilitation physician, compared with persons who received a fact sheet. Guo et al. (2015) reported that the percentage of stroke rehabilitation inpatients given the opportunity to talk about sexual issues increased from 0% at months 1-3 to 80% at month 10 following an intervention designed to ensure patients had opportunity to discuss sexual health with one of their healthcare providers. A study assessing a sexuality education intervention found that patients who received a short (40-50 minute) education session that outlined the changes that they can expect in their sexuality post-stroke, addressed frequently asked questions and provided tips to avoid sexual dysfunction were more sexually active and experienced greater sexual satisfaction than patients who did not. (Song et al. 2011).
Return to Driving
Since driving was part of many persons daily routine prior to stroke, returning to driving is often a high priority; however, motor, sensory, and cognitive impairments and visual fields defects can limit a person’s ability to drive safely. Beyond its use for completing everyday tasks and travelling to work, driving is often seen as a symbol of independence and freedom. For those who have had a minor stroke or TIA, temporary restrictions place on driving may be confusing and seem unwarranted. Independent predictors of successful return to driving following stroke include independence in activities of daily living and the return to paid work (Yu et al. 2016).Performance of cognitive measures such as the Trail Making Test and the Snellgrove Maze Test have been shown to predict fitness to drive (Barco et al. 2014, Devos et al. 2011). In one recent study that included 359 participants, 26.7% returned to driving after one month (Yu et al. 2016).
Interventions to help improve driving skills after stroke have not been well studied. A Cochrane review (George et al. 2014) included the results from 4 RCTs. The interventions examined included driving simulators (n=2) and skills development using the Dynavision device (n=1) and Useful Field of View training (n=1). No pooled analyses of the primary outcome, performance (pass/fail) during on-road assessment, were possible due to heterogeneity. Based on the results from a single trial, there was no significant difference in the mean on-road scores between groups at 6 months (MD=15.0, 95% CI -4.6 34.6, p=0.13), although participants in the intervention group had significantly higher scores on road sign recognition test (MD=1.69, 95% CI 0.51-2.87, p=0.0051).