Thesis Chapter 1 - Post Stroke Psychology In Rehabilitation Units
Cerebrovascular accident or more commonly known as stroke is characterized by the destruction of brain tissue as a result of intracerebral hemorrhage or infarction caused by thrombosis (clotting) or embolus (obstruction in a blood vessel caused by clotted blood or other foreign matter circulating in the bloodstream); formerly called apoplexy. Cerebral hemorrhage or thrombosis occurs most often in elderly persons with constricted arteries, although either may also be caused by inflammatory or toxic damage to the cerebral blood vessels. Cerebral embolism may occur at any age, even in children. Symptoms of stroke develop suddenly. In cases of severe brain damage there may be deep coma, paralysis of one side of the body, and loss of speech, followed by death or permanent neurological disturbances after recovery. If the brain damage sustained has been slight, there is usually complete recovery, but most survivors of stroke require extensive rehabilitation. Hypertension , which is a major cause of intracranial hemorrhage and stroke, can be treated by preventive measures using diet such as increasing nutrients such as antioxidants and folate, drug therapy, and stress reduction techniques. Other preventive measures for people at high risk include daily aspirin to retard clot formation and surgical correction of the narrowed carotid artery. Sometimes surgical removal of the clot is possible on larger vessels, but it is usually pointless after the stroke or when blockage is widespread. The thrombolytic drug tissue plasminogen activator, widely used to treat heart attacks, has been approved for use within three hours of the onset of strokes caused by clots.
This chapter shall discuss the problem that the study seeks to investigate. It shall provide the conditions that are considered in conducting the study by furnishing the basis for the research. It shall also provide the objectives of the paper as well as the hypothesis that the study intends to test. Furthermore, this chapter shall also state the study’s significance as well as the operational use of the terms used in the study.
Background of the Problem
Stroke ranks as the third leading cause of death and the most common cause of permanent disability in adults; approximately half of all stroke survivors return to some form of employment, although this figure declines with age. (Black-Schaffer and Osberg, 2002) At any given time, there are about 4.6 million survivors of stroke, and 170,000 individuals die each year in this country as a direct or indirect consequence of stroke. Most recent estimates place the cost of stroke in the United States in excess of $45 billion per year. (American Heart Association, 2002) Timely recognition and treatment are imperative to reduce stroke-related morbidity and mortality.
Moreover, being subjected to the attack entails several impediments on the patient. The neurological complications of stroke include stroke progression, seen in over 25% of patients, or recurrence, which is less common with a rate dependent on the mechanism of the index event. Seizures can occur in up to 10% of patients at some point after stroke and are more common after subarachnoid or intracerebral hemorrhage and large lesions involving the cerebral cortex. Stroke-related seizures are usually easily controlled with a single anticonvulsant. Increased ICP is the most lethal post stroke complication and may be a direct effect of a hematoma or brain edema. Brain edema after ischemic stroke (usually cytotoxic) typically becomes symptomatic after 1 to 4 days. Signs and symptoms of raised ICP include depressed level of consciousness, pupillary asymmetry, abducens nerve palsy, papilledema, and periodic breathing. Treatment of raised ICP should include fluid restriction, elevation of the head of the bed, administration of osmotic diuretics, and hyperventilation. (Moretti, 2001) Some degree of vascular cognitive impairment or frank dementia can occur in up to 33 to 50% of patients. Recent evidence suggests that cholinesterase inhibitors may be of value in treating these patients. (Erkinjuntti et al., 2002) Patients should be monitored for post stroke depression, which occurs in up to 60% of patients and is treatable with antidepressants and/or psychotherapy. (Provinciali, 2002) Medical complications after stroke include cardiac abnormalities such as arrhythmia and myocardial infarction, pulmonary embolism, infection such as urinary tract and pneumonia, and gastrointestinal bleeding.
Not only does the stroke patient encounter complications physically, he/she inevitably acquires adverse psychological effects particularly during the recovery process. Patients and caregivers should thus be educated regarding both short- and long-term clinical expectations. Symptoms of post stroke depression should be reviewed and patients instructed to seek treatment if appropriate. On the other hand, one could not discount the possibility of a secondary stroke. Accordingly, applicable secondary stroke preventive strategies are required to be discussed and stroke symptoms be reviewed. These are among the inroads that the patient has to contend with in the duration of his recovery. In an attempt to recuperate to the patient’s normal movements, he/she is subjected to a psychological battle to repair the injury furnished by the cerebrovascular accident.
Statement of the Problem
The study intends to describe the post stroke psychology in rehabilitation units. Specifically, the researcher seeks to answer the following questions:
1. How does recent and past literature describe the phenomenon of cerebrovascular accidents?
2. What are the psychological effects of stroke on the persons who have experienced the disorder?
3. How does a patient recover from a stroke?
4. What is the level of effectiveness of the rehabilitation process in rehabilitation units in terms of psychological and physical development of the patient?
5. What are the roles of psychosocial factors in the recovery of the patient suffering a stroke?
6. What are the perceptions of the patients regarding their experience with the stroke?
The study intends to test the following hypothesis:
“The level of depression triggered by the mental and social changes encountered by the patient significantly affect their rehabilitation towards the recovery from cerebrovascular accident?”
Significance of the Study
The study will be a valuable addition to the array of references regarding the case of cerebrovascular accidents. This would provide further information regarding the psychological effects of stroke. Moreover, the recommendations of this study will be able to provide possible breakthroughs in the treatment of stroke particularly in increasing the motivation and morale of the recovering patients through their rehabilitation.
Definition of Terms
inability recognising familiar objects or symbols by the senses : sight (visual agnosia, may fail to recognise colour, faces, may put inappropriate objects in mouth) or touch (tactile agnosia) or sound (auditory agnosia - e.g., can't recognise a sound such as doorbell). For tactile agnosia, the problem is present in both hands. Agnosias are due to disturbance of function in the cerebral cortex. Visual agnosia can occur with and without an hemianopia. In visuospatial agnosia the person has difficulty putting two objects together e.g., cup on saucer.
loss of ability to express thoughts in writing.
24 hour monitor worn around the waist to check the pulse and electrical activity of the heart.
weakness in a blood vessel wall, which bulges outwards and can burst.
when the patient denies anything being wrong with the stroke side. The lack of awareness or denial of disease. May occur with damage to the parietal lobe in the region of the supramarginal gyrus.
inability to express thoughts by speech or writing and/or to understand the spoken or written word. This is a disorder of language.
inability to perform a movement or action despite having normal power, co-ordination, sensation and understanding. It is a problem of motor planning.
injection of a radio-opaque dye (usually) into an artery to look for a blockage or site of bleeding. E.g., carotid arteriogram - of the carotid circulation.
an abnormal collection of small blood vessels which can leak or burst.
inability to identify an object by touch. Present in one hand only, on the side opposite to which the brain is damaged. Stereognosis is a higher mental function of the parietal lobe of the brain. It should only be tested for when the lower sensory tracts are undamaged as damage here also causes inability to recognise an object.
fat deposited in the wall of medium and larger sized arteries, Associated with the laying down of calcium and fibrous tissue, causing narrowing of the artery. Atherosclerosis and arteriosclerosis are often used interchangeably.
when the patient doesn't recognise the affected limb(s) as belonging to him/her. A perceptual problem. The impaired recognition of body parts, may occur with damage to the posteroinferior part of the parietal lobe.
CAT scan, CT scan
computerised X-ray of the brain. Usually performed to exclude a cerebral haemorrhage. May show nothing in the early stages of a cerebral infarct. can show brain tumours.
Cerebrovascular accident, CVA
a neurological deficit of vascular origin. Damage to the brain caused by a sudden reduction in blood supply.
partial or total blockage of a blood vessel in the brain, caused by a clot breaking off and travelling up an artery.
bleeding into the brain tissue.
death/damage of part of the brain caused by a sudden insufficiency of blood supply.
narrowing, sometimes to the point of complete blockage, of a blood vessel in the brain, usually already damaged and narrowed by atheroma. A platelets collect and a clot forms on the damaged surface. If the blood supply is interrupted enough it causes an ischaemic ( = lack of blood) stroke.
a waxy substance, produced naturally by the liver and also found in foods, that circulates in the blood and helps maintain tissues and cell membranes. Excess cholesterol in the body can contribute to atherosclerosis and high blood pressure.
double vision. Suggests a brainstem lesion, lesion of a nerve(s) to the eye, secondary pressure effect on the cranial nerves involved in eye movement
Disability decreased ability to perform an activity normally e.g., walking, eating. Due to an impairment caused by the stroke.
inability to dress despite no obvious weakness, loss of co-ordination, sensory loss, visual or neglect problems.
Duplex carotid scan
an 'ultrasound' scan of the blood vessels in the neck. Painless. Carried out to see if there is narrowing in an artery in the neck severe enough to require an operation.
difficulty in articulation.
the limitation, caused by disability or impairment, imposed on the person by the stroke, to perform or fulfil a previously normal role for them e.g., to continue in a particular employment.
loss of sensation down one side of the body.
loss of vision in one half of the visual field of one or both eyes.
paralysis, weakness on one side of the body.
loss of vision in both the left halves or both right halves of the visual field. E.g., the person may bump into things on his/her right hand side. See visual problems in PtFAQs.
loss or abnormality of physiological, psychological or anatomical structure or function (e.g., muscle weakness, dysphasia, sensory loss) caused by the stroke.
cell death due to lack of blood supply caused by an embolus or thrombosis (clot blocking a blood vessel).
MRI scan - magnetic resonance imaging.
Very useful for bone, brain and spinal cord lesions. Uses a very strong fluctuating magnetic field so anyone with any metal in them can't have the test. CAT scan is the most commonly used in stroke.
weakness, paralysis of both legs. Can happen with bilateral strokes or spinal cord problems.
Sensory inattention or extinction
failure to recognise a tactile stimulus to one side of the body when both sides of the body are touched simultaneously. When each side is touched separately there is no problem. This is a form of visuospatial disturbance.
awareness of where one is in space, where the different parts of the body are in relation to one another, where objects are sited e.g., in a room, and how they are related to each other in space (e.g., estimate of distance apart, shape).
Visual inattention or extinction
failure to register a visual stimulus in one homonymous visual field when the stimulus is presented to both fields at the same time and the person has no visual field loss.