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Evaluation of the Journal article titled: Health-related quality of life in persons with long-term pain after a stroke.
The title indicates the content of the research article however, it would have been more informative if it had included that the study was a quantitative and qualitative measurement of the health-related quality of life (HRQoL) of the subjects included.
The abstract clearly indicates why and how the research was carried out. It is a good concise summary of the research article; however, it does appear to contradict itself. In the background, the authors state that they are not aware of any other published studies on this subject. In the conclusion, they state that the patients in this study have a lower HRQoL due to their long term pain when compared to previous studies. This discrepancy is not made clear until the article is read in its entirety.
The literature review identifies studies that show that quality of life (QoL) is decreased in stroke survivors. Dowswell et al. (2000) demonstrated that in their study group the effects of stroke were serious and mostly negative.
Different types of pain have been reported in patients that have suffered from strokes such as neurogenic and nociceptive pain as well as headaches (Price, 2003, Bowsher, 2001). A study by one of the authors has found that all three types of pain were found in patients two years after the stroke (Widar, et al., 2002). It has also been shown that chronic pain, caused by various illnesses does affect well being and quality of life (Benbow et al., 1999).
The literature review gives a definition of QoL and discusses how that it different to HRQoL and why it is important to study HRQoL in terms of chronic illnesses. The literature indicates the need for the proposed research, because none of the studies detailed in the review link chronic pain in stroke survivors with HRQoL.
The aim of the research was to ask stroke survivors to describe their HRQoL with regards to their chronic pain symptoms and then to compare that with different types of pain, age, gender and household status using the Medical Outcomes Study 36-itemShort-Form Health Survey (SF-36) and Hospital Anxiety and Depression (HAD) scale. The aim of the research was clearly identified in the article.
The research method used was both qualitative and quantitative. As HRQoL has been described as the impact of health on a person's ability to lead a fulfilling life the authors have claimed it is important for patients to be able to describe their experiences in their own words; hence the use of the qualitative interview. The quantitative questionnaires were used to enable comparison of HRQoL between different demographic data and types of pain.
Patients were approached if they had suffered an acute stroke two years prior to the study and had cerebral infarcts or haemorrhages identified by clinical examination and computerised tomography.
Patients were included if they had chronic pain that had lasted longer than six months. Patients were excluded if they were unable to hold a conversation or had other pain conditions that were not related to the stroke. Three hundred and fifty six patients were contacted by letter, of these 43 participated in the study. The research method used was appropriate for the sample size as a longitudinal study could not have been used to collect the data as the sample size was too small.
The data was collected in the form of an interview which asked the question How would you describe your quality of life, especially in relation to your pain? The interviewer asked extra questions to ascertain that the patient was describing the pain and the interview was recorded and transcribed which makes the interview process reliable.
The interview was followed by completion of the quantitative SF-36 and HAD Scale questionnaires. SF-36 is widely used to measure HRQoL after stroke and consists of eight assessment scales. These include physical functioning,physical role functioning, bodily pain, general health, vitality, social functioning, emotional role functioning and mental health (Dorman et al., 1999). However, a study by Hobart et al. (2002) questions the validity of using SF-36 in stroke patients as the social functioning and general health scales were found not to be reliable indicators for HRQoL.
The HAD Scale consists of fourteen assessment scales. Each scale is rated from 0-3 where 0 is no distress and 3 is maximum distress. The HAD Scale has been reported to be a valid indicator of anxiety and depression in stroke survivors (Johnston et al., 2000)
Both written and oral information was given to patients in which it was made clear that participation in the study was voluntary and that patient confidentiality would be maintained. Patients completed written informed consent forms and the study was approved by an ethical research committee. This is in accordance with the guidelines issued by the UK Department of Health (2001).
The approach used to analyse the qualitative data was latent content analysis. The recorded interviews were listened to and the transcribed interviews were read repeatedly. Statements were identified that were related to HRQoL and were grouped with statements from other participants that had similar meaning. The analysis was scrutinised by other staff members to ensure reliability.
The data from SF-26 was transformed into a scale from 0 to 100, using the standard scoring algorithms, where lower scores indicate lower HRQoL and higher scores indicate higher HRQoL. Both the scores from the SF-26 and the HAD Scale were analysed using non-parametric statistics, the Kruskal-Wallis test and the Mann-Whitney U-test.
The findings from the qualitative interview have been discussed in detail in the research paper and the authors have identified the factors that patients perceive to be important in maintaining HRQoL, which are similar to the scales used in SF-26. The exception is economic security which the authors suggest may also be important.
The authors looked at the data generated from SF-26 and HAD Scale and discussed that in relation to HRQoL when compared with different types of pain, age, gender and household status. Their findings were:
No significant difference of HRQoL between the different types of pain
HRQoL decreased in the older age group
Lower HRQoL was found mostly in men than in women
Lower HRQoL was found in those living with a partner
Utilising the findings
One of the recommendations that arose from the research article was that better social support can increase or maintain HRQoL of stroke survivors with long term pain. A qualitative study by Pound et al. (1999) described how stroke survivors developed social strategies in which to deal with their illness by relying on family support and it has been reported that social support can lead to faster recovery after stroke (Pound et al., 1999). The authors conclude that clinicians and formal carers should be more willing to complement the routines and systems developed between the patient and informal caregiver.
This would be easier to achieve within a specialised stroke unit, where formal care givers are able to be more flexible in their time, than on an acute nursing ward.
One way in which to achieve better quality of care is to provide information and training to informal caregivers. Smith et al. (2004) found that carers received minimal training and found that there was a lack of information in how to best provide care to the patient. Informal carers of patients with chronic back pain also reported the same (Miller and Timson, 2004).
A study by Wiles et al. (1998) discussed the implementation of a computer database to provide personalised information to give to carers and stroke survivors to help improve the consistency of information disseminated. In theory this sounds like a good suggestion to tackle the problem, although a scan of the literature has found no further information on this topic.
The authors of this study recommend that awareness of the QoL of the caregiver is important for them to be able to offer the best care and support. Kalra et al. (2004) found that training informal carers improved QoL in both stroke survivors and carers. Caregivers were trained in basic nursing tasks three to five times for 30-45 minute sessions. This is something that could be implemented into the clinical setting and has the advantage of reducing the costs of stroke care.
The importance of educating patients has been highlighted in a study by Oliver (1994) in which the author recognises that a chronically ill patient is more likely to have fewer complications if their health provider identifies and provides the information/education required.
The research paper commented that mood disorders could potentially negatively impact HRQoL, possibly because of dependency on others. It is thought that current nursing interventions may do too much for stroke survivors, which may lead to patients relying on the compensatory actions of nurses, thereby hampering the patients' recovery (Booth et al., 2005). It is important that patients receive education on how to monitor their own health which could help the transition to life after a stroke and promote patient independence.
Specialised stroke units have been found to be effective in limiting morbidity and mortality from the disease, due to the multidisciplinary approach to patient care, although the psychological needs of patients are not always addressed (Warner, 2000). This is one area of care that should be examined further.
References
Benbow S J, Cossins L, MacFarlane I A, 1999. Painful diabetic neuropathy. Diabetic Medicine, 16, 632-644.
Booth J, Hillier V F., Waters K R. & Davidson, I, 2005. Effects of a stroke rehabilitation education programme for nurses. Journal of Advanced Nursing 49, 465-473.
Bowsher D 2001. Stroke and central poststroke pain in an elderly population. Journal of Pain. 2, 258-61.
Department of Health, 2001. Government arrangements for NHS research ethics committees (GAfREC). Retrieved 5th July 2005 from http://www.dh.gov.uk/PublicationsAndStatistics/PublicationsPolicyAndGuidance/ PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4005727&chk=CNcpyR
Dorman PJ, Dennis M, Sandercock P, 1999. How do scores on the EuroQol relate to scores on the SF-36 after stroke? Stroke. 30, 2146-2151
Dowswell G, Lawler J, Dowswell T, Young J, Forster A & Hearn J, 2000. Investigating recovery from stroke: a qualitative study. Journal of Clinical Nursing 9, 507-515.
Hobart J C, Williams L S, Moran K and Thompson A J, 2001. Quality of Life Measurement After Stroke: Uses and Abuses of the SF-36 Stroke, 33, 1348 - 1356.
Johnston M, Pollard B, Hennessey P, 2000, Construct validation of the hospital anxiety and depression scale with clinical populations. Journal of Psychosomatic Research. 48, 579-84.
Kalra L, et al. 2004, Training informal caregivers of patients with stroke improved patient and caregiver quality of life and reduced costs. BMJ 328, 1099-1101
Miller J, Timson D, 2004, Exploring the experiences of partners who live with a chronic low back pain sufferer. Health and Social Care in the Community, 12, 34-42,
Oliver G, 1994. Helping those with chronic or life threatening illness. In Webb P (ed), Health Promotion and Patient Education. London, Chapman and Hall.
Pound P Gompertz P & Ebrahim S,1999. Social and practical strategies described by people living at home with stroke. Health & Social Care in the Community 7, 120-128.
Price C I M, (2003) Treatment of shoulder and upper limb pain after stroke: an obstacle course for evidence-based practice. Reviews in Clinical Gerontology. 13, 321-33
Smith L N, Lawrence M, Kerr S M, Langhorne P & Lees K R, 2004. Informal carers' experience of caring for stroke survivors. Journal of Advanced Nursing 46, 235-244
Warner R, 2001. The effectiveness of nursing in stroke units. Nursing Standard. 14, 32-35
Widar M & Ahlström G, 2002. Disability after a stroke and the influence of long-term pain on everyday life. Scandinavian Journal of Caring Sciences 16, 302-310
Wiles R, Pain H, Buckland S & McLellan L, 1998. Providing appropriate information to patients and carers following a stroke. Journal of Advanced Nursing 28, 794-801.
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