Meeting Rehabilitation Needs for Stroke Survivors: A Critical Appraisal of Ekstam et al. (2015)

This essay critically appraises Ekstam et al.'s (2015) research on meeting rehabilitation needs for stroke survivors. The study explores the perceptions of stroke survivors and their caregivers regarding rehabilitation needs after 1 year of stroke. The essay discusses the research question, authorship, research design, methods, results, and limitations of the study.

Running head: BACHELOR NURSING ASSIGNMENT
Bachelor nursing assignment
Name of the student:
Name of the University:
Author’s note

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Introduction:
All stroke survivors require some or full assistance in activities of daily living after
stroke. Stroke rehabilitation is needed in the early stage to achieve better recovery in the first
month after stroke and reduce disability in the long term (Veerbeek et al., 2011). The essay is
concerned with identifying ways to meet rehabilitative needs of Sue-Anne, who finds it hard to
perform her usual activities of daily living. The main research question related to the scenario is
‘How may a caregiver effectively support family member in identifying activities of daily living
for a stroke?’. The research study by Ekstam et al. (2015) is found relevant to answer the
research question and the essay mainly provides a critical appraisal of research article to discuss
how rehabilitation needs for stroke survivors like Anne can be met.
Part A:
Authorship:
The research article was developed by group of six authors. Two of the authors were
from Department of Occupational Therapy and the rest were from Department of Clinical
research, Department of Neuroscience and Rehabilitation Medicine, Division of Physiotherapy
and Department of Clinical Neuroscience. Based on the field in which each authors are working,
it can be said that work is reliable as all of them have expertise and knowledge regarding the
rehabilitation. Occupation therapy, neuroscience and physiotherapy are all interrelated fields and
expertise in this field may help to enhance the quality of the study. The author can easily
interpret patient’s perception and link them to rehabilitation needs.
The conflict of interest or bias that has been found in this study is that author’s were
reliant on previously prepared rehabilitation questionnaire. Although the research question

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related to dyadic perception was novel, however selection of existing instead of developing
questionnaire related to study objective would have enhanced the quality of the study.
Research question:
The main research question for the study by Ekstam et al. (2015) was to investigate about
the association between the perception of stroke survivors and their caregivers regarding
rehabilitation needs 1 year after stroke. The main rational for conducting research in this area is
understood from the background information given in the article. The study gave the background
information that patient-centered rehabilitation is necessary for stroke patient, however 33-49%
of patient perceive unmet rehabilitation needs after 1 year (Dworzynski, Ritchie & Playford,
2015). Ullberg et al. (2016) also supports the fact that unmet rehabilitation needs 12 months after
stroke has not covered in studies. The author clarified that sense of coherence is needed to adjust
personal resources and fulfill unmet needs. The author pointed out to the gap in research that
association between sense of coherence and perceived needs for rehabilitation has not been
covered in detail in past research.
The author argued that family caregivers play an important role in rehabilitation as they
can easily identify unmet rehabilitation needs in their family member. However, the issue that
has been found for stroke survivor is that most of the informal caregivers are elderly and they
need support to cope with care giving burden. Hence, exploring the perspective of both patients
as well family caregiver regarding unmet rehabilitation need was important as dyadic perception
has not been explored before. By conducting research on dyad’s perception related to
rehabilitation, Ekstam et al. (2015) aims to obtain information related to everyday personal life
experience of stroke survivors and their caregivers and the strategies they adapt to manage stroke

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after 1 years. The research in this area is significant as the study can give an understanding about
how personal factors, severity and care giving burden can influence rehabilitation process and
identify caregivers who are in need of rehabilitation support.
Research design:
The study by Ekstam et al. (2015) is a secondary study as it used data from prospective
observational study of the rehabilitation process after stroke to conduct the research. The name
of the observation study was ‘Life after Stroke phase 1’ (LAS-1), and the sample group in the
LAS who answered questions related to rehabilitation needs after 1 year follow-up were included
in the research. by the use of mixed method study design was used to explore stroke survivor’s
and family caregivers perception related to rehabilitation needs 1 year after stroke. Both
qualitative and quantitative date was used for analysis. Use of mixed method is suitable as per
the research objective as the research aimed to explore both participant’s perception towards
rehabilitation as well as judge stroke severity level. Hence, rehabilitation needs and sense of
coherence (SOC) were judged by means of quantitative approach and experience related to
rehabilitation was collected by the use of primary research method. Use of open-ended questions
during the interview stage favored analysis of experience related to life changes post stroke.
Therefore, the study had appropriate research design to gain full-understanding about research
problem. Creswell & Creswell (2017) states that use of both quantitative and qualitative research
promotes breadth and depth of understanding related to the research problem. It favored analysis
of research question from different angles.
Research methods:

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As study used data from LAS-1, the participant of the LAS-1 such as people with stroke
and their informal caregivers were sample population group of the study. Data was collected
regarding sex, strike and severity at baseline from medical record. Evidence based tool call the
Barthel index was used to categorize stroke severity into mild or severe case. Furthermore, in
accordance with the research question, Ekstam et al. (2015) used questionnaires to interview
participants regarding need for and satisfaction with health care service. The strength of the data
collection method is that it used evidence based questionnaire that covered difference dimensions
of patient’s satisfaction with care. The advantage of the research questionnaire was it covered
questions related to rehabilitation needs too. Bothe quantitative and descriptive approach helped
to collect data and address the research question. Quantitative data was also collected for SOC by
means of the SOC scale. In addition, open-ended questions were used to collect data on daily
activities with stroke and strategies to manage stroke. Hence, quantitative and qualitative
approach in data collection helped to collect comprehensive data related to the research question.
Wisdom and Creswell (2013) suggest that the main characteristic of a well-designed mixed
method study is collection and analysis of data by means of close-ended and open-ended
questionnaire. The rigorous process in collecting data is also understood from the above data
collection method.
The data analysis was done by means of statistical tools like Wallis ANOVA test and the
Mann Whitney U test. Response to open-ended questions was done by content analysis. Overall,
the limitation found in data collection process is that the use of set questions used in previous
research decreased specificity of data according to the research question. It provided generalized
information and lacked details regarding specific rehabilitation needs. In addition, the sample
size was too small which reduced the reliability of the research. However, the strength of the data

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collection process is the selection right sample group as the cohort was representative of the
population of interest.
Results:
In the research study, 67% of participants had mile stroke and 33% had moderate/severe
stroke. The analysis of research data revealed that 52% perceived fulfillment of stroke
rehabilitation needs at 12 months and there were 13% who believed that stroke rehabilitation was
necessary. Furthermore, the comparative analysis of dyads revealed that people with mild stroke
were in the dyads who perceived rehabilitation needs were met. In those groups, no changes in
daily life activities were found. However, for dyads with unmet or discordant response, it was
found that they were more dependent on daily life activities. They also reported significant
changes in their daily life pattern. In relation to the dyad’s perspective on strategies used to
manage the change, it was found that people mainly used strategies like physical exercise,
partner aids, cycling to overcome the issue. The burden of care was also less for those groups
which reported that their rehabilitation needs were met (Ekstam et al., 2015). Hence, the study
gave the indication that rehabilitation perception differs based on stroke severity and major life
events. The outcome is consistent with the research study by Lynch et al. (2015). It gave
implication for practice change by suggesting inclusion of family caregivers in the rehabilitation
system.
While reporting about research finding, it is necessary for authors to discuss about
research findings. Limitation related to the work was given by the researcher and this gave
implications for future research. As proper comparison regarding dyad’s perception about

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rehabilitation need was not done, Ekstam et al. (2015) suggested exploring effects of using a
dyadic perspective throughout the rehabilitation process.
Part B:
Certain methodological limitations found in the work act as barriers in applying the
evidence to clinical practice. Although the study gave unique perceptive of using systemic
approach in rehabilitation process by utilizing dyad’s perspective, however the study cannot be
applied because lack of rich data on comparison between partners or dyads in the study. The
difference in perception has been found regarding severity, however difference in perception
related to rehabilitation needs for patients and caregiver has not been adequately covered. The
research has missing data which cannot be applied in clinical practice.
Conclusion:
The report gave a critical analysis of a research paper to understand how caregiver can
support family members in identifying activities of daily living following stroke. The critical
review of the research article by Ekstam et al. (2015) gave the indication that perception related
to rehabilitation needs differs based on severity of stroke. Hence, the study showed that care
giving burden and unmet need perception is high for dyads with unmet needs. The study gave the
implication that inclusion of caregiver in rehabilitation system is necessary to support them and
reduce care giving burden.

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Reference:
Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed
methods approaches. Sage publications.
Dworzynski, K., Ritchie, G., & Playford, E. D. (2015). Stroke rehabilitation: long-term
rehabilitation after stroke. Clinical Medicine, 15(5), 461-464.
Ekstam, L., Johansson, U., Guidetti, S., Eriksson, G., & Ytterberg, C. (2015). The combined
perceptions of people with stroke and their carers regarding rehabilitation needs 1 year
after stroke: a mixed methods study. BMJ open, 5(2), e006784.
Lynch, E. A., Luker, J. A., Cadilhac, D. A., & Hillier, S. L. (2015). Rehabilitation assessments
for patients with stroke in Australian hospitals do not always reflect the patients'
rehabilitation requirements. Archives of physical medicine and rehabilitation, 96(5), 782-
789.
Ullberg, T., Zia, E., Petersson, J., & Norrving, B. (2016). Perceived unmet rehabilitation needs 1
year after stroke: an observational study from the Swedish stroke register. Stroke, 47(2),
539-541.
Veerbeek, J. M., Kwakkel, G., van Wegen, E. E., Ket, J. C., & Heymans, M. W. (2011). Early
prediction of outcome of activities of daily living after stroke: a systematic
review. Stroke, 42(5), 1482-1488.
Wisdom, J., & Creswell, J. W. (2013). Mixed methods: integrating quantitative and qualitative
data collection and analysis while studying patient-centered medical home
models. Rockville: Agency for Healthcare Research and Quality.

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