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Weekly UpdatesABSTRACT
Stroke is a leading cause of serious long-term disability in the United States. The neurological insult following a stroke may leave the survivor with a chronic illness encompassing a lifetime of recovery. Recovery for the stroke survivor entails more than the return of function. A synopsis of the literature indicates that there are three domains of stroke recovery: physical, psychological, and social. There are [six categories that comprise the three domains: cognition, function, health perception, self-concept, relationships, and role change. Stroke is a multifaceted and complex disease. Individual aspects of stroke recovery do not occur in isolation and cannot be separated from one another. In the future, studies involving the integration of the domains of stroke recovery are needed to understand the interactive processes that support recovery.
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Stroke recovery is a complex phenomenon involving a person whose world was suddenly changed as a new, unexplored world evolves. In this new world, the stroke survivor faces life-altering changes. Unlike other disease processes that may affect only a specific organ or organ systems, the stroke survivor must cope with physical, functional, and cognitive changes. These changes to their physical self also affect their self-concept, health perception, role identity, and relationships. Many health professionals assist the stroke survivor in coping with these. The sum of their efforts leads, it is hoped, to a meaningful recovery for stroke survivors and their families.
Research studies often focus on one aspect of stroke recovery and its relationship to stroke survivor outcomes. A comprehensive holistic explanation of the personal processes of stroke recovery is lacking. The purpose of this article is to identify and describe the domains of stroke recovery as synthesized from the literature. Literature from the disciplines of medicine, nursing, physical therapy, occupational therapy, and speech/language pathology is included. The complexity of stroke survivorship is revealed with three domains of stroke recovery identified: physical, psychological, and social. Two principal components comprise each domain: Cognition and function comprise the physical domain, self-concept and health perception the psychological domain, and role and relationships the social domain (Fig 1). Opportunities abound for multifaceted, interdisciplinary research related to stroke rehabilitation and stroke survivor recovery.
Stroke
Stroke as a Disease Process
Stroke was first cataloged as apoplexy by Hippocrates more than 2,000 years ago (McHenry, 1969). Although not knowing the pathophysiology of apoplexy, he accurately described the presenting symptoms of stroke as sudden onset of paralysis and change in health. In 1928, apoplexy became defined as a cerebrovascular accident or CVA and was differentiated into hemorrhagic or ischemic. Over time, the term CVA has been replaced with stroke because the disruption of blood flow to the brain is not an accident, but is caused by diseases of the circulatory system (Adams, del Zoppo, & von Kummer, 1998). During the "Decade of the Brain" in the 1990s (Jones & Mendell, 1999), stroke began to receive national attention in both the professional healthcare and public communities. In 1994, Camarata, Heros, and Latchaw presented the concept of "brain attack" to raise awareness that stroke is considered a medical emergency Their article became the foundation for the Brain Attack Coalition formed in the summer of 1994 (American Association of Neurological Surgeons Neurosurgeon in Action, 1995). In 2003, the formal definition of stroke, "a sudden impairment of brain function, sometimes termed 'brain attack' that results from interruption of circulation to one or another part of the brain following either occlusion or hemorrhage of an artery supplying that area," was published (U.S. Department of Health and Human Services Centers for Disease Control and Prevention, 2003, p. 15).
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Stroke is the third cause of death and a leading cause of serious and long-term disability in the United States (American Heart Association [AHA], 2008). Remarkably, stroke deaths have declined between 1994 and 2004 (AHA, 2008). Yet, the incidence of stroke is increasing as the population ages (Bagg, Pombo, & Hopman, 2002) and the numbers of stroke survivors are increasing as a result of greater availability of acute stroke interventions. Noninstitutionalized stroke survivors increased 60% (from 1.5 million to 2.4 million) between the early 1970s and the early 1990s (American Heart Association [AHA], 2005). It is estimated that there are 5.8 million stroke survivors experiencing functional limitations on a daily basis (AHA, 2008).
The burden of stroke is both financial and personal. The financial burden of having a stroke in 2008 is estimated to be $65.5 billion (Rosamond et al., 2008). Brown et al. (2006) predict that the cost of stroke from 2005 to 2050 will exceed $1.52 trillion for Whites, $313 billion for Hispanics, and $379 billion for Blacks. The loss of earnings will be the greatest contribution to these exorbitant costs. The financial cost of stroke is minimal compared with the personal price. The personal burden of being a stroke survivor includes physical, mental, emotional, and social changes that can be devastating to both the survivor and his or her family (Doswell et al., 2000).
Stroke recovery is a lifelong process that necessitates understanding. The chronic nature of stroke means that we must identify interventions to sup port stroke survivorship as an unremitting illness. To support the stroke survivor in the ongoing process of recovery, it is important for research to be focused on the factors that contribute to recovery and independence.
Deficits and Rehabilitation
Deficits
The deficits created by stroke affect the survivor's whole being. The resulting disabilities fall into six areas: (1) cognition, which is the ability to understand, remember, and be aware of deficits (Hartman-Maeir, Soroker, Ring, & Katz, 2002; Larson et al., 2003; McKinney et al., 2002; Patel, Coshall, Rudd, & Wolfe, 2002); (2) function, which refers to the ability to perform basic and/or independent activities of daily living (Ahmed et al., 2003; Bagg et al., 2002; Pettersen, Dahl, & Wyller, 2002; Roth & Lovell, 2003; Studenski, Wallace, Duncan, Rymer, & Lai, 2001); (3) self-concept (Doswell et al., 2000; MacKenzie & Chang, 2002; Moore, Maiocco, Schmidt, Guo, & Estes, 2002; Paul et al., 2005; Ringler, Studenski, Wallace, Reker, & Duncan, 2002); (4) health perception, which is the perceived effects of disease on abilities (Hanger, Fogarty, Wilkinson, & Sainsbury, 2000; Ringler et al., 2002); (5) role change (Hopman & Verner, 2002; MacKenzie & Chang, 2002; Moore et al., 2002; Studenski et al., 2001); and (6) relationships (Alexander, Bugge, & Hagen, 2001; Derosier, Rochette, Noreau, Bravo, & Boutin, 2002; Studenski et al., 2001). Each of these areas has been researched independently or in conjunction with one or two other deficits. Often these research results suggest that progressive decline occurs after rehabilitation (Hilton, 2002; White & Johnstone, 2000), but little research has been conducted to explain the interrelated factors that continue to contribute to recovery.
Stroke Rehabilitation
The goal of rehabilitation is to return the stroke survivor to society with the abilities to function by adapting to stroke deficits that may include deficits in cognition and functional abilities (Bendz, 2003; Burton, 2000; World Health Organization [WHO], 2002).The key concepts of stroke disability include disease (stroke) as cause of physical and neurological symptoms that create impairments that lead to disability and ultimately a handicapped individual (Burton, 2000). The concept of transitioning disability into functional disability is linear in nature and is the ultimate outcome of rehabilitation (WHO, 2002).
Many stroke survivors begin rehabilitation within days after experiencing the event in an effort to regain mobility that will allow them to be functionally safe in their home environment. However, studies have demonstrated the long-term success of rehabilitation for stroke survivors lacks substantial clinical evidence to support its efficacy over time (Alexander et al., 2001; Patel et al., 2002; Pettersen et al., 2002; White & Johnstone, 2000).
Stroke has its greatest physical impact on cognition and physical function. These deficits are the focus of intensive rehabilitation strategies with the goal for the stroke survivor to regain function and cognition or to adjust to their new body. Beyond rehabilitation, these deficits influence the survivor's self-image and personal sense of being.
Stroke Recovery Domains
There are six areas of consistency demonstrated from the evidence. First, only a small percentage (19%) of stroke patients improves and maintains functional abilities 3 years after rehabilitation (Pettersen et al., 2002). Next, those survivors who cannot perform activities of daily living on discharge from rehabilitation demonstrate congruence with both future cognitive and functional decline (Patel et al., 2002). Health perception plays an important role in determining future abilities because a lower perception of well-being is related to lower functional abilities (Hanger et al., 2000; Paul et al., 2005; Ringler et al., 2002). Role change has also been associated with the development of depression (Derosier et al., 2002; Grant, 2004; Li, Wang, & Lin, 2003; Pound, Gompertz, & Ebrahim, 1998) and lowered self-concept (Doswell et al., 2000; Moore et al., 2002). Stress caused by caregiving is an additive factor that contributes to stroke survivor decline (Doswell et al., 2000; Pierce et al., 2004). Finally, several studies have concluded that changes in relationships and lack of social support are significant factors in the perpetuation of decline after rehabilitation (Derosier et al., 2002; Li et al., 2003; MacKenzie & Chang, 2002; Wang, Van Belle, Kukull, & Larson, 2002). It is from these studies that three distinct domains are formulated, each consisting of two conceptual contexts (Fig 1).
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