Tableaux de données probantes et liste de reference (en anglais)
The post-discharge period is consistently reported by stroke survivors and their families to be a difficult time of adjustment. Reintegration to former vocational and social life roles is an important goal for the stroke survivor. Using the results from 42 studies published from 1974-2011 Wang et al. (2014) reported positive and negative predictive factors of return to work (RTW) following stroke. Factors that were positively associated with RTW included higher ADL function, a good match between current capabilities and job tasks, strong family support, stroke survivors with realistic goals, availability of vocational services, a flexible work environment, white collar work and disability benefits. Depression and increasing stroke severity were negative factors. The rates of RTW vary widely. In a study including 441 patients, recruited from 20 hospitals, aged 18-64 years, 202 (75%) 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 patients, aged 40-59 years had successfully returned to work. Interventions to help improve the odds of successful RTW have not been well studied. Baldwin & Brusco (2011) included the results from 6 studies, which examined rehabilitation programs that included vocational training post stroke. Vocational rehabilitation program 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%.
The resumption of pre-stroke social and leisure pursuits is an additional component of reintegration back into pre-stroke life. Interventions to help improve participation following stroke have been examined in several trials. Desrosiers et al. (2007) randomized 62 participants residing in the community who’d had a stroke within the past 5 years and were experiencing some limitations in leisure participation or satisfaction to an intervention or control group. 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 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) but not on the satisfaction with use of spare time section (p=0.22). In the Trial of Occupational Therapy & Leisure (TOTAL), Parker et al. (2001) included 465 patients, recruited from 5 hospitals that attended an outpatient clinic within 6 months of stroke onset and were living in the community. Participants were randomized to a leisure therapy group, an ADL group or a control group. The two treatment groups received home-based occupational therapy (OT) for up to 6 months with a minimum of 10, ≥30 minute sessions. At 6 and 12 months there were no significant differences among groups in any of the primary outcomes assessed (General Health Questionnaire, Nottingham Extended ADL, and Nottingham Leisure Questionnaire).
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 patients 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 were: 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”. When compared with age-matched norms, Carlsson et al. (2007), reported that life satisfaction, assessed at 1 week and one year following stroke by both patients and spouses using the LiSat-9, was significantly worse. A greater percentage of patients indicated they were not satisfied with: life as a whole (39% vs. 77%, p<0.05), ability in self-care (71% vs. 93%, p<0.05), sex life (34% vs. 58%, p<0.05), leisure time (38% vs. 71%, p<0.05), and vocation (45% vs. 67%, p<0.05). Compared with the norm group, a greater percentage of spouses indicated they were not satisfied with life as a whole (64% vs. 77%, p<0.05), closeness with partner (67% vs. 86%, p<0.05), sex life (41% vs. 58%, p<0.05) and leisure time (52% vs. 71%, p<0.05).
Return to driving is also an important component of community reintegration, given that cognitive impairment and visual field deficits will restrict a patients’ ability to drive safely following stroke. Performance of cognitive measures such as the Trail Making Test and the Snellgrove Maze Test have been used to predict fitness to drive (Barco et al. 2014, Devos et al. 2011). Interventions to help stroke survivors improve driving skills 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).
Navigating through the post-stroke continuum has been highlighted as a frequent source of dissatisfaction, for patients and informal caregivers, particularly during the transition from hospital to community. Several studies have been conducted to evaluate the benefit of individuals who coordinate access to appropriate services for patients recovering from stroke, who go by many names including stroke navigator, case manager, care coordinator, or system navigator). Manderson et al. (2011) conducted a systematic review including 15 publications, representing 9 RCTs examining system navigation models for older adults living with multiple chronic diseases making transitions across healthcare settings. The services provided included care planning, coordination of care, phone support, home visits, liaison with medical and community services, and patient and caregiver education. In most of the studies, economic, psychosocial and functional benefits were associated with system navigation. While the services of a registered occupational therapist, who functioned as a community stroke navigator, resulted in significant improvements in the mean daily functioning subscale of the Reintegration to Normal Living Index RNLI among 51 patients at the end of four months, (54.1 to 59.3, p=0.02), there were no significant improvements in other outcomes (2-minute walk test, depression outcomes), or any caregiver outcomes (Egan et al. 2010).