Postural balance, anxiety and motor function after stroke, at a very early supported discharge with continued rehabilitation

Abstract

The overall aim of this thesis was to investigate postural balance, anxiety and motor function the first year after stroke and whether postural balance, anxiety and motor function was different at the intervention of Very Early Supported Discharge (VESD) com-pared to routine discharge during the first year post stroke.

Methods. In paper I a systematic review and a meta-analysis was performed in order to study presence of anxiety after stroke. Papers II and IV included material from the GOTVED-study (Gothenburg Very Early Supported Discharge study), a random-ised controlled study where 140 patients with stroke admitted to a stroke unit at Sahlgrenska University Hospital were consecutively included. Paper II investigated whether VESD affects the anxiety assessed with the Hospital Anxiety and Depression Scale (HADS) and the overall disability measured with the modified ranking scale (mRS) for the stroke patient compared with ordinary discharge routines. In paper III data from two different data sources was merged to investigate if there was any association between function in the affected arm and postural balance. The dependent variables were Berg Balance Scale (BBS) and Timed Up and Go (TUG). As in-dependent variable was Fugl-Meyer assessment-Upper extremity (FMA-UE) scale was used. In Paper IV the correlation between self-confidence in postural balance, observer assessed postural balance and anxiety during the first year after stroke was investi-gated. The impact of the intervention on the correlation was also examined. The self-confidence in postural balance was measured using the Fall Efficacy Scale (FES(S)). Postural balance was as-sessed with Berg Balance Scale (BBS) and Time Up and Go (TUG). Anxiety was assessed with HADS. Assessments were made 5 days after stroke onset, 1 day and 1 month after discharge, 3- and 12 months post stroke.

Main results. The systematic review showed that the overall pooled prevalence of anxiety after stroke was 29.3 %. There was no difference in anxiety if you received VESD or ordinary rehabili-tation, but the VESD led to a faster improvement of overall disa-bility compared to ordinary rehabilitation. The motor function in the affected arm significantly correlated with the postural balance the first year post-stroke. There was a significant correlation be-tween self-confidence in postural balance and observer assessed postural balance. Between anxiety and self-confidence in postural balance, there was only a small correlation.

Conclusions and clinical implications. Anxiety is common af-ter stroke with about a third of patients experiencing it in the first year. Since anxiety influence quality of life and is a predictor of depression, routine screening would be worth considering in the stroke care. VESD did not show any harm or unintendent effects, but on the contrary led to a faster improvement in overall disabil-ity. We therefore suggest that coordinated VESD for patients with mild to moderate stroke should be considered as part of the ser-vice from a stroke unit. The result that motor function in the af-fected arm associated with the postural balance in a late stage after stroke can be of clinical importance to be aware of in assessment and planning the rehabilitation of postural balance. Patients with mild stroke seemed able to assess their confidence in postural bal-ance, involved in daily activity performance, in line with observer assessed postural balance. Assessment of self-confidence can pro-vide important information useful in rehabilitation planning and support patients regarding physically active after discharge.