The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke: Difference between revisions

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|'''Physiotherapy'''
|'''Physiotherapy'''
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|when we talk about role of physical therapists and physical activity, it has been proven that physical therapy and physical activity improve the mental health condition of these patients. So what interventions can be given? So the exercises which are proven to be best for psychological health of the patients are any form of aerobic activity, particularly aquatic exercises because they become easy for the patients and it has been proven that they give most benefit to the patient. Then any form of resistance training, yoga, relaxation training, other allied therapies such as Tai chi, self-help mindfulness, and acupuncture are proven to provide the patients with improvement in the symptoms of psychological disorders.
* "diagnose and manage movement dysfunction as it relates to the restoration, maintenance, and promotion of optimal physical function and the health and well-being"
* miximise an patient's ability to "engage with and respond to their environment, emphasizing movement-related interventions to optimize functional capabilities and performance.<ref>APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 18/July/2023. [[/guide.apta.org/|https://guide.apta.org]]</ref>"
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* Use of physical activity to improve the mental health condition to include: (1) aerobic activity, (2) aquatic exercises, (3) resistance training, (4) yoga, (5) relaxation training, and (6) other allied therapies such as Tai chi, mindfulness<ref name=":4" />
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|'''Speech Language Pathology'''
|'''Speech Language Pathology'''
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|patient to a speech-language therapist if they face aphasia, because patients with aphasia will have more difficulties because they have difficulty in conveying what they feel. So, speech therapists are experts, professionals, who help the patient in developing and enhancing communication by developing a stroke story along with activities to promote positivity and provide them with some social support.
* "engages in professional practice in the areas of communication and swallowing across the life span"
The next is also very important, the role of speech-language therapist because the patient with aphasia who will not be able to convey their problems efficiently to you, so they'll not receive proper treatment. So it is very important to engage them into speech-language therapy. Now, what happens is these speech-language therapists are experts and specialists who will maximise an individual's language and communication ability. They will maximise their activity level, participation, and help with overall rehabilitation outcomes. So what they do is, they assess, diagnose, and wherever appropriate, they treat the aphasia resulting due to stroke. They help the patient in communicating a message by developing a language which can be spoken, which can be written, or non-verbal, or a combination of these with data, and they help them to incorporate this language into their day-to-day activities. And this language, which incorporates a spoken language or written verbal, non-verbal, or combination of any of this is known as functional communication, which only these experts can develop. So it is very important to refer them to these experts.
* ''Communication'' includes speech production and fluency, language, cognition, voice, resonance, and hearing
* ''Swallowing'' includes all aspects of swallowing, including related feeding behaviors<ref>American Speech-Language-Hearing Association. Scope of Practice in Speech-Language Pathology. Available from: https://www.asha.org/policy/sp2016-00343/ (accessed 18/July/2023).</ref>"
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* Develop and enhance communication ability and strategies, verbal or nonverbal
* Develop a stroke story with activities to promote positivity and social support
* Maximise an individual's language and communication ability  
* Maximise their activity level and participation, and help with overall rehabilitation outcomes<ref name=":4" />
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|'''Spiritual Care'''
|'''Spiritual Care'''
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|The next, which is very interesting, and towards the end of the course, that is role of spiritual care for patients with post-stroke mental illnesses and caregivers also. So it has been found that the patients who are into spiritual engagement, or you could say spiritual rehabilitation or spiritual programmes, right, these are also specialist professionals. It is important to refer them to these professionals, which helps the patient in developing a positive attitude, instils hope, and helps in better adjustment after stroke, right? So this sometimes, like not what any interventions can do, that hope can do. So it is very important to engage the patient into spiritual care, which is going to help overall which is going to help all of us in our respective treatment outcomes.
* "make spiritual care more accessible to clients, families and staff"
* "aware of and has a working knowledge of relevant healthcare policies ... and understands why this is important for chaplaincy<ref>Spiritual Care Association. Scope of Practice. Available from: https://www.spiritualcareassociation.org/docs/research/scope_of_practice_final_2016_03_16.pdf (accessed 18/July/2023).</ref>"
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* Helps the patient develop a positive attitude, instills hope, and helps in better adjustment post-stroke
* Engage the patient in spiritual care<ref name=":4" />
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Revision as of 04:27, 19 July 2023

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Original Editor - User Name

Top Contributors - Stacy Schiurring, Jess Bell, Kim Jackson and Matt Huey  

Introduction[edit | edit source]

So as we know that stroke, or cerebrovascular accident, is particularly characterised by sensory and motor difficulties and which presents as hemiplegia or hemiparesis, leading to difficulty in balance, gait, activities of ADL. (Activities of Daily Living) So now what happens is that we address all of these difficulties, but the mental health aspect remains overlooked. So, as a result of which, what happens that the patient performs poorly in all of these other interventions. And it is very important to identify that this poor performance is because some psychological issues are present which are not been assessed or treated. So psychiatric disorders are very common complications following stroke and which are associated with low quality of life, worsening of treatment outcomes, also increasing the burden on the caregivers, and deterioration of the functional status of the patient.

So neuropsychiatric disorders following stroke also increase the mortality.

Always have a detailed assessment of the mental health aspect. And because this more or less affects the rehabilitation outcome, be it any rehabilitation protocol, it can be speech, it can be physiotherapy, it can be occupational therapy. So, these psychological problems following stroke should be very carefully assessed. Also by the medium of this course, that whenever you are seeing a patient, either in an inpatient or outpatient setting, with quite a lot of affection in their mental health it is important to remember that it is not that only one rehabilitation professional can deal with it. So we require a team of rehabilitation professionals from different disciplines so that we can give the patient a better clinical outcome. So, identifying the features and the disciplines which are expert in dealing with them.

This article will overview three common mental health disorders following stroke, discuss the pathophysiological changes which occur after stroke with may contribute to these mental health concerns, and outline clinical features, and give a basic overview preventative measures from a multidisciplinary team perspective.

To learn more about specific mental health diagnoses commonly associated with stroke, please read this article.

Risk Factors of Mental Health Disorders Following Stroke[edit | edit source]

The occurrence of mental health disorders following stroke is becoming more recognized by the medical community. Currently, most of the literature and research has focused on specific concerns such as (1) depression, (2) dementia, (3) anxiety, and (4) suicide. Other mental disorders, such as substance abuse disorders, have less evidence-based support[1].

Due to the time-intensive nature of rehabilitation assessments, treatments, and interventions, rehabilitation professionals are ideal members of the multidisciplinary team (MDT) to aide in screening and preventive education of stroke survivors.

Common risk factors of mental health disorders following stroke include:

  • Age: <70 years for PSD [2], younger populations for poststroke anxiety (PSA) and PTSD[3]
  • Previous history of mental health issues[2]
  • Family history of mental illness[2]
  • Neuroticism[2] ("broad personality trait dimension representing the degree to which a person experiences the world as distressing, threatening, and unsafe"[4])
  • Severity of stroke[2]
  • Location of the stroke, PSD more common with left frontal lobe and basal ganglia strokes,[2] PSA more common with right hemispheric lesions[3]
  • Resulting level of handicap following stroke[2]
  • Level of independence following stroke[2]
  • previous history of smoking[5]
  • lower socioeconomic status[5]
  • decreased social support[2]
  • decreased level of education[2][5]

A meta-analysis performed in 2017 found that having a predisposing illness, such as hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, and myocardial infarction, was not associated with diagnosis of poststroke depression (PSD)[2].

Screening[edit | edit source]

The American Stroke Association's 2019 Guidelines for the Early Management of Patients With Acute Ischemic Stroke recommend screening for PSD in the acute phase of stroke recovery, starting 2-weeks post-stroke[6]. Further research is needed to to determine the optimal timing, setting, and follow-up for screening[7]. While PSD is a major focus of recent research, this statement can be generalised to include other, less studied common mental health disorders which are known to occur after stroke.

Please see below for more information on recommended screening tools.

Prevention[edit | edit source]

An important component of preventive strategies is to identify those patients at greatest risk and any potential modifiable risk factors. Rehabilitation professionals should use their clinical assessment skills and referral network to identify, diagnose, and appropriately manage mental health symptoms[8].

Interventions to improve mental health following stroke include:[8]

  • Psychosocial interventions: art therapy, music therapy, mindfulness, motivational interviewing, problem solving therapy
  • Physical exercise
  • Lifestyle medication interventions: yoga, tai chi, pilates, Feldenkrais method, qigong, acupuncture, nutritional care
  • Pharmacological

Stroke can also lead some to suicide ideation, attempts, and completion. A 2021 meta-analysis found a risk of suicide in stroke survivors to be nearly twice that of the general population[9]. It is important for rehabilitation professionals be aware of the risk factors for suicide, refer patients for the treatment of mood disorders, and provide education on limiting access to the means of self-harm as able[8].Risk factors for suicide ideation following stroke:[9]

  • Severe acute disability post-stroke
  • Longer hospital stay post-stroke
  • Ischemic stroke survivors
  • History of depression
  • History of hypertension

Special Topic: Stroke Rehabilitation in Low and Middle Income Countries[edit | edit source]

sources: https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.119.023565

https://bmjopen.bmj.com/content/12/8/e063181

https://www.sciencedirect.com/science/article/pii/S2405650216300119

Assessment[edit | edit source]

Below is a list of assessment components which can easily added to a rehabilitation evaluation or assessment to capture information regarding a patient's risk of mental health disorders[3].

History of present illness

  • Screen for possible psychological symptoms in the acute phase post-stroke
  • History of onset of symptoms
    • psychological symptoms
    • somatic symptoms (anxiety)
  • Detailed history of stroke

Past medical history

  • Age
  • Sex
  • previous episodes of stroke or transient ischaemic attack (TIA)
  • Previous history of any psychological disorder (e.g.depression, anxiety, etc)
  • treatment outcomes for any of the previous conditions should be assessed, if the patient was on certain medications for a longer duration of time, anything. Also, it is very important to assess for vascular risk factors such as angina pectoris, hypertension, because they're independent predictors of post-stroke depression.
  • Family history of mental health disorders

Social and Vocational

  • Personal and social support
  • Family income/insurance

Formal Assessment Tools/Scales[edit | edit source]

Clinical Assessment Tools by Topic[edit | edit source]

Behavioural Assessments

YouTube Video Kawa Model

Motor Function Assessment

Orientation and Alertness Assessment

Pre-morbid Intellectual Functioning Assessment

Rehabilitation Experience

Vocational Assessments

Assessment Tools for Specific Mental Health Diagnoses[edit | edit source]

Assessment Scales for Depression

Assessment Scales for Anxiety

Assessment Scales for Post Traumatic Stress Disorder (PTSD)

Management and Interventions[edit | edit source]

When to refer

it is very important that these therapies are given by experts, professionals. So the aim here is to make you aware that these therapies are available and when your patients show these clinical symptoms, they're in need of these clinical therapies. So you need to refer the patient to these specialists for particular interventions.

MDT Role in Management

MDT Member Scope of practice Role in mental health care
Case Management
  • facilitates communication and care coordination among the MDT
  • protects the patient’s right to self-determination
  • goals of Case Management include the "achievement of optimal health, access to services, and appropriate utilisation of resources[10]"
  • Coordinate care and communication among the MDT
  • Coordinate how patient will receive services and interventions per the MDT care plan[3]
Clinical Psychologistand/or

Neuropsychology

  • a psychological specialty that provides "continuing and comprehensive mental and behavioural health care"
  • the scope of clinical psychology "encompasses all ages, multiple diversities, and varied systems[11]"
  • Speciality in stroke management in preferred
  • One-to-one therapy for cognitive rehabilitation whtch io include cognitive behavioural therapy (CBT), motivational interviewi,ng and problem-solving thera
  • Specialist interventions, brief psychological interventions, goal setting
  • Pharmacological interventions such as antidepressant medications
  • Assess for suicide risk
  • Improve access to psychological therapy using telemedicine[3]
Nursing Within the scope of practice as a nurse, mental health nursing:
  • treats the patient as a holistic individual
  • educates on how to manage mental health and improve overall health.
  • emphasize health education, wellness promotion, and prevention of disease
  • may have prescriptive ability depending on education and licensing[12]
 According to the American Psychiatric Nurses Association:
  • "Partner with individuals to achieve their recovery goals
  • Provide health promotion and maintenance
  • Conduct intake screening, evaluation, and triage
  • Provide Case management
  • Teach self-care activities
  • Administer and monitor psychobiological treatment regimens
  • Practice crisis intervention and stabilisation
  • Engage in psychiatric rehabilitation and intervention
  • Educate patients, families, and communities
  • Coordinate care"[12]
Occupational Therapy
  • therapeutic use of everyday life occupations
  • skilled care provided to promote and preserve the occupational identity of patients at risk for developing "an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction.[13]"
  • Play a major role in elevating the symptoms of psychological issues due to training in assessing cognition and functional ability
  • Identify specific individual environmental changes needed to achieve patient goals
  • Train the patients in strength-based strategies to improve functional abilities
  • Improve the ability to complete activities of daily living (ADLs) with greater independence to mitigate the impact of mental health issues
  • Develop and improve coping skills and transition strategies from a clinical setting to the patient's discharge environment
  • Engage the patient in healthy roles and routines[3]
Physiotherapy
  • "diagnose and manage movement dysfunction as it relates to the restoration, maintenance, and promotion of optimal physical function and the health and well-being"
  • miximise an patient's ability to "engage with and respond to their environment, emphasizing movement-related interventions to optimize functional capabilities and performance.[14]"
  • Use of physical activity to improve the mental health condition to include: (1) aerobic activity, (2) aquatic exercises, (3) resistance training, (4) yoga, (5) relaxation training, and (6) other allied therapies such as Tai chi, mindfulness[3]
Speech Language Pathology
  • "engages in professional practice in the areas of communication and swallowing across the life span"
  • Communication includes speech production and fluency, language, cognition, voice, resonance, and hearing
  • Swallowing includes all aspects of swallowing, including related feeding behaviors[15]"
  • Develop and enhance communication ability and strategies, verbal or nonverbal
  • Develop a stroke story with activities to promote positivity and social support
  • Maximise an individual's language and communication ability
  • Maximise their activity level and participation, and help with overall rehabilitation outcomes[3]
Spiritual Care
  • "make spiritual care more accessible to clients, families and staff"
  • "aware of and has a working knowledge of relevant healthcare policies ... and understands why this is important for chaplaincy[16]"
  • Helps the patient develop a positive attitude, instills hope, and helps in better adjustment post-stroke
  • Engage the patient in spiritual care[3]


Stepped Care Model

INSERT IMAGE OF PYRAMID HERE

https://www.nice.org.uk/media/default/sharedlearning/531_strokepsychologicalsupportfinal.pdf

https://www.mhm.org.uk/pages/faqs/category/stepped-care

Cognitive Behavioral Therapy with Exposure and Response Prevention Therapy

Interpersonal Therapy,

Behavioural Activation Therapy,

couples therapy,

counselling,

short-term psychomotor or psychodynamic therapy,

antidepressants,

combined interventions, and

collaborative care,

self-help groups

Resources[edit | edit source]

  • bulleted list
  • x

or

  1. numbered list
  2. x

References[edit | edit source]

  1. ↑ Skajaa N, Adelborg K, Horváth-Puhó E, Rothman KJ, Henderson VW, Thygesen LC, Sørensen HT. Stroke and risk of mental disorders compared with matched general population and myocardial infarction comparators. Stroke. 2022 Jul;53(7):2287-98.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Shi Y, Yang D, Zeng Y, Wu W. Risk factors for post-stroke depression: a meta-analysis. Frontiers in aging neuroscience. 2017 Jul 11;9:218.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Banerjee, S. Stroke. The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke. Physioplus. 2023.
  4. ↑ Britannica. neuroticism. Available from: https://www.britannica.com/science/neuroticism (accessed 17/July/2023).
  5. ↑ 5.0 5.1 5.2 Khedr EM, Abdelrahman AA, Desoky T, Zaki AF, Gamea A. Post-stroke depression: frequency, risk factors, and impact on quality of life among 103 stroke patients—hospital-based study. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2020 Dec;56:1-8.
  6. ↑ American Heart Association/American Stroke Association. 4.10. Depression Screening. Available from: https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000211 (accessed 17/July/2023).
  7. ↑ Towfighi A, Ovbiagele B, El Husseini N, Hackett ML, Jorge RE, Kissela BM, Mitchell PH, Skolarus LE, Whooley MA, Williams LS. Poststroke depression: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017 Feb;48(2):e30-43.
  8. ↑ 8.0 8.1 8.2 Chun HY, Ford A, Kutlubaev MA, Almeida OP, Mead GE. Depression, anxiety, and suicide after stroke: a narrative review of the best available evidence. Stroke. 2022 Apr;53(4):1402-10.
  9. ↑ 9.0 9.1 Selvaraj S, Aggarwal S, de Dios C, De Figueiredo JM, Sharrief AZ, Beauchamp J, Savitz SI. Predictors of suicidal ideation among acute stroke survivors. Journal of Affective Disorders Reports. 2022 Dec 1;10:100410.
  10. ↑ American Case Management Association. Scope of Services. Available from: https://www.acmaweb.org/section.aspx?sID=136 (accessed 18/July/2023).
  11. ↑ American Psychological Association. Clinical Psychology. Available from: https://www.apa.org/ed/graduate/specialize/clinical (accessed 18/July/2023).
  12. ↑ 12.0 12.1 American Psychiatric Nurses Association. About PMH-APRNs. Available from: https://www.apna.org/about-psychiatric-nursing/about-pmh-aprns/?_gl=1*1tmyof4*_up*MQ..*_ga*MTY1OTIxMzcxOC4xNjg5Njk3Mzg2*_ga_79D3LBQT2E*MTY4OTY5NzM4NS4xLjEuMTY4OTY5NzYzOS4wLjAuMA..*_ga_4HD7QYR6T9*MTY4OTY5NzM4NS4xLjEuMTY4OTY5NzYzOS4wLjAuMA.. (accessed 18/July/2023).
  13. ↑ American Occupational Therapy Association. Occupational Therapy Scope of Practice . Available from: https://research.aota.org/ajot/article/75/Supplement_3/7513410020/23136/Occupational-Therapy-Scope-of-Practice (accessed 18/July/2023).
  14. ↑ APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 18/July/2023. https://guide.apta.org
  15. ↑ American Speech-Language-Hearing Association. Scope of Practice in Speech-Language Pathology. Available from: https://www.asha.org/policy/sp2016-00343/ (accessed 18/July/2023).
  16. ↑ Spiritual Care Association. Scope of Practice. Available from: https://www.spiritualcareassociation.org/docs/research/scope_of_practice_final_2016_03_16.pdf (accessed 18/July/2023).
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