Developing low level

psychological care in stroke

Dr Ian Kneebone
Consultant Clinical Psychologist
& Visiting Reader

Managing emotional problems

Other major problems
What rehabilitation therapists/ nurses
can do can do

Anxiety
Anxiety disorders include a range of
conditions: panic attacks , phobias,
PTSD, OCD to GAD - generalised
anxiety disorder
Fear of falling is a risk after stroke

Anxiety
Persistent, excessive worry and anxiety
an individual finds hard to control
Often includes feeling keyed up, on
edge, fatigued, irritable, physically
tense, unable to concentrate or
unable to sleep

Anxiety
GAD evident in around 23% of people after
stroke (Campbell Burton et al., 2011)
Fear of falling likely to affect at least 60% of
people post-stroke (Watanabe, 2005)
PTSD affects between 10 and 30% of
patients (Bruggimann et al, 2006; Field et al,
2008; Sembi et al, 1998)

Anger
Irritability
Verbal and physical aggression
Intermittent explosive disorder - serious assaults,
destruction of property, technically personality
change due to a general medical condition,
aggressive type or dementia with behavioural
disturbance when it occurs post-stroke

Anger
Acute stroke, 17-35% report significant
aggressiveness (Aybek et al, 2005; Santos
et al, 2006)
Post acute 32%, inability to control anger or
aggression (Kim et al, 2002)
Often associated with executive disorder
i.e., frontal involvement on scans

Distress

What can you do?

Rehabilitation staff can play a role in
prevention and management of
psychological adjustment
Assessment
Empathy (allow mourning)
Activity (Thomas et al., under submission)
Achievement feedback

What can you do?

Rehabilitation staff can play a role in the
prevention and management of psychological
adjustment
Promote control (planning, decision-making)
Education/information giving, to patient and family
(Smith et al., 2008)

Problem solving (House, 2000)

Snacks, desirable food
Relaxation, sleep hygiene
Using incentives, behaviour management

Management of psychological
adjustment
Activity, empathy, peer support are
considered important
Develop a support group on an inpatient stroke unit
(Hull, Hartigan & Kneebone, 2007)

Relaxation
Autogenic relaxation my right arm
is very heavy, limp and relaxed
Progressive muscle relaxation tense your right
arm until is almost trembling.slowly let the
tension goenjoy the feeling of relaxation
that replaces the previous feeling of
tension

Relaxation
-Relaxation is an effective intervention for anxiety
(Ayers et al., 2007) and has no side effect profile!
-It is also effective for Depression, Anger, PTSD, Pain
Management and Lowering BP
-It is viewed positively by stroke survivors
(Carin-Levy et al., 2009)

Relaxation
Organised an interest group representing
nursing and the major therapies
Agreed to a feasibility trial
Group led by TCP with an OT Technical
Instructor assisting

Relaxation
Trial has established recommendations on,
exclusion criteria, organisation, timing, type
of relaxation to be used, means of
evaluating effectiveness and aids that might
be used to facilitate practice
(Kneebone, Walker-Samuel, & Swanston, 2011)

Patient Experience
Patients not actively evaluatingbetter to
consider whether they experience the things
important to them or not, rather than
satisfaction
A research programme to develop a means
of assessing this routinely in neuro-rehab
(Kneebone, Hull et al., in press)

Patient Experience
A draft Neurological Rehabilitation Experience
Questionnaire (NREQ) was generated based on:
themes established from qualitative interviews
with in-patients (Wain, Kneebone & Billings,
2008)
a literature review
questions from established inventories
and with reference to the nature of the
population under consideration

Patient Experience
- Subject to face validity testing via interview and
focus groups with patients and staff
- Revised version subject to formal assessment of
reliability and validity

Neurorehabilitation Experience Questionnaire NREQ

NREQ
(Kneebone, Hull et al., in press)
Security for belongings
Privacy for
conversations
Non therapy activities
Unit atmosphere
Caring staff
Team work
Staff approachable

Partnership working
Client centred
Being kept informed
Family/carer
involvement
Amount of therapy
Discharge preparation
Satisfaction with
progress

Patient Experience
Internal reliability (time 1 =.76, time 2 = .80), test retest
reliability (r = 0.70), and concurrent validity (r = 0.32 and r
= 0.56) were established
Whereas responses were associated with positive mood (r
= 0.30), they appeared not to be influenced by negative
mood, age, education, length of stay, sex, functional
independence, or whether a participant had been a patient
on a unit previously.

The future for non psychology rehabilitation

staff?

Specific training to directly impact

motivation?
E.g., Motivational interviewing

The future for rehabilitation staff?

Motivational Interviewing
to support and build a patients
motivation to adjust and adapt
working with patients dilemmas and
ambivalencesupporting and
reinforcing optimism and self-efficacy

The future for rehabilitation staff?

Elicit persons own solutions
Elicit persons usual coping style that was
successfully used in the past
Explore application in the present & the
future

The future for rehabilitation staff?

An RCT, has shown Motivational
Interviewing can improve mood after
stroke (Watkins et al., 2007)
Administered by nurses with specific
training and supervision

References

Kneebone, I. (1999). Post-stroke depression and the non-mental health therapist. British Journal of
Therapy and Rehabilitation, 6, 476 481.

Kneebone, I. I., Hull, S., McGurk, R., & Cropley, M. (in press). Reliability and validity of the
Neurorehabilitation Experience Questionnaire for inpatients. Neurorehabilitation and Neural Repair.

Kneebone, I. I., Walker-Samuel, N., & Swanston, J. (2011, September). Relaxation training to treat anxiety
after stroke. 15th International Congress of the International Psychogeriatric Association, The Hague, The
Netherlands.

Lincoln, N., Kneebone, I. I., Macniven, J., & Morris, R. (2012). Psychological management of stroke. Wiley:
Chichester, UK.

Wain, H. R., Kneebone, I. I., & Billings, J. R. (2008). Patient experience of neurologic rehabilitation: A
qualitative investigation. Archives of Physical Medicine and Rehabilitation, 89, 1366-1371.

Watkins, C. L., Auton, M. F., Deans, C. F., Dickinson, H. A., Jack, C. I. A., Lightbody, C. E., et al. (2007).
Motivational interviewing early after acute stroke: A randomized, controlled trial. Stroke, 38, 1004-1009.

References

Developing low level

psychological care in stroke

Questions?
i.kneebone@nhs.net