The role of biopsychosocial factors in the rehabilitation process of individuals with a stroke

Table of Contents

1. Introduction

In many European countries, the process of ageing of societies has been observed for years. Currently, the fastest ageing country in Europe is Poland. The total size of the Polish population aged 65 and over is predicted to grow from 15% in 2015 to 24% in 2035 [1]. It is estimated that the consequence of the above will be an increased incidence of diseases strongly associated with age, including stroke (cerebrovascular accident, CVA). At present, the incidence of CVA in Poland is comparable to other European countries (about 175/100,000 among men and 125/100,000 among women), but the post-stroke mortality and disability rates are significantly higher. A particularly high rate of death is observed in the early post-stroke stage. In Poland, the mortality rate within the first 14 days after a cerebrovascular accident is 13% (in other countries, the average is 9.6%), and the total average stroke mortality per annum is 40% in men and 44% in women, whereby more patients die due to haemorrhagic (60%) than ischaemic stroke [2, 3]. Depending on the source, it is reported that 44–75% of stroke survivors remain dependent on external assistance (formal or informal care) (Rankin Scale≥3) at discharge from the hospital [2]. In 2013, over 330,000 individuals with a stroke in Poland were recognised as disabled [4].

A serious problem, reported by many studies, is an increasing incidence of stroke among young people, who are active both professionally and socially [5, 6]. In Poland, only a small percentage of stroke survivors resume their professional activity. In fact, so few people return to work after a CVA that there is no reliable data regarding their actual number [7]. Data show that about 65% of patients affected by stroke before the 65th year of life fail to resume their professional activity, whereas another 14% rearrange their working hours [8]. At the same time, the literature emphasises that the loss of a job due to a CVA, followed by the loss of social status, leads to a deterioration in quality of life; these are significant factors increasing the risk of post-stroke depression [9–13].

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Returning to work (RTW) is a primary rehabilitation goal. People who are employed report a better quality of life, less health service usage and better health status than non-employed people. More than 65% of working age adults with stroke fail to return to work [14]. In a systematic review examining the social consequences of stroke in working aged adults, Daniel et al. found that of the 8,810 stroke survivors working before stroke, only a mean 44 % (range 0–100%) returned to work [15]. Similar figures are reported in national prevalence surveys in Japan and Sweden, with higher proportions among younger stroke survivors who were working at onset [16, 17]. Only about half of the individuals with a stroke were working the same number of hours a week one-year post-stroke as they had done pre-stroke, while the other half were working less or not at all. Several studies have found that effectiveness of physiotherapy measured with Barthel Index, Modified Rankin Scale, or Functional Independence Measure scores predict return to work post-stroke [18, 19]. It is not only returning to work that presents a problem; ensuring people remain in work is also difficult. Stroke survivors may return prematurely and leave once the true impact of the stroke on their job is realized. Finally, it is known that physical, emotional, cognitive and psychological problems may result from stroke and affect work activities.

It would be of great value to determine more precisely which factors might predict poor efficacy of physiotherapy and related to this return to work post-stroke. This would enable better information and more targeted care to be provided, in order to improve the support for individuals with a stroke in the process of reintegration into working life.

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Knowledge about factors associated to the poor efficiency of the neurological rehabilitation after stroke would enable physiotherapists to quickly identify those patients who are at risk of rehabilitation breakdown, in order to provide them with special care and include them in intensive therapeutic treatments. The most valuable seem to be research projects that focus on the biopsychosocial determinants (which examine aspect of biology – e.g. age, gender, time since stroke, psychological components – e.g. depression, anxiety and social factors affecting an individual – e.g. material status, formal and informal care efficiency) of both the treatment and rehabilitation processes, as the factors linked to the efficacy of post-stroke rehabilitation might be different, depending on the realities of the country, access to high-quality physiotherapy services as well as the socio-economic situation. Therefore, the aim of this project was to assess the efficacy of post-stroke rehabilitation carried out in one of the leading rehabilitation wards in Poland, evaluated from the biopsychosocial aspect.

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About the Author: Tung Chi