Developing low level psychological care in stroke

Dr Ian KneeboneConsultant 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 in- patient stroke unit

(Hull, Hartigan

& Kneebone, 2007)

Relaxation

Autogenic relaxation my right armis 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

Developing low level psychological care in strokeManaging emotional problemsAnxietyAnxietyAnxietyAngerAngerDistressWhat can you do?What can you do?Management of psychological adjustmentRelaxationRelaxationRelaxationRelaxationPatient ExperiencePatient ExperiencePatient ExperienceNeurorehabilitation Experience Questionnaire -NREQ NREQ (Kneebone, Hull et al., in press)Patient ExperienceThe future for non psychology rehabilitation staff?The future for rehabilitation staff?The future for rehabilitation staff?The future for rehabilitation staff?ReferencesReferences Developing low level psychological care in strokeSlide Number 29