Self-awareness, cognition and function in post-stroke recovery

Self-awareness, cognition and function in post-stroke recovery

Toni Heinemann, Senior Occupational Therapist

Toni Heinemann presented at the 29th National Conference and Exhibition on stroke rehabilitation, and the role of Occupational Therapy in post-stroke recovery.

Self-awareness is such a crucial part of a stroke survivor’s rehabilitation journey. It is the cornerstone for beginning to understand what has happened to them, and how it impacts their world and occupations. Occupational therapists play a pivotal role in the recovery of many stroke survivors, so this small pilot study was a collaboration between two hospitals: Osborne Park Hospital (rehabilitation hospital) and Sir Charles Gardiner Hospital (an acute tertiary hospital in Perth, Western Australia).

The primary aim was to examine the relationship between self-awareness and functional outcomes for patients in the first three months post stroke. The secondary aim included determining the feasibility of the Patient Competency Rating Scale (PCRS) as a measure of selfawareness in acute and sub-acute care. Self-awareness deficits following neurological injury have been well-recognised by clinicians and researchers (1-4). Self-awareness can be defined as a highly integrated brain function, encompassing the ability to perceive oneself in relatively objective terms while maintaining a sense of subjectivity.(1,8) The term “awareness deficits” is utilised to refer to a lack of recognition of changes to an individual’s self and abilities following brain injury.(6) It is believed that awareness of deficits is critical in influencing patient

Self-awareness deficits following neurological injury have been well-recognised by clinicians and researchers

outcomes related to rehabilitation and long-term functioning post brain injury (2, 5-8). Stroke survivors won’t engage in rehabilitation if they don’t see or believe they have any difficulties, and it doesn’t impact their occupations or safety. There are minimal studies that have explored screening of selfawareness in the acute stages (one week) post stroke as an indicator of functional outcomes. There is also limited data to define the impact of self-awareness on therapy outcomes in acute care and on transition to rehabilitation in patients 65 years of age and older.

This prospective observational pilot study recruited 27 stroke survivors and assessed self-awareness, cognition and function at three time points (acute, four weeks and 12 weeks). The assessments undertaken included the PCRS, Montreal Cognitive Assessment (MoCA) and motor component of Functional Independence Measure (mFIM)–the PCRS being a measure of self-awareness, the MoCA a measure of cognition and the mFIM a measure of dependence in daily functioning.

Results showed that MoCA and mFIM scores demonstrated statistically significant improvements in function and cognition in the first three months post stroke. The PCRS did not significantly change, however clinical improvements in awareness from one month to three months post stroke were noted. The PCRS also got worse from acute care to one month after stroke. These results recognised that self-awareness can change frequently for stroke survivors in their rehabilitation journey. There was a moderate significant correlation from acute to one month post stroke between the MoCA and PCRS.

From this small study we can see impaired cognition is associated with poor selfawareness which impacted on short-term functional rehabilitation gains. Assessment of self-awareness utilising the PCRS was feasible and provided clinical insights into how patients progressed. Ongoing assessment of self-awareness would be recommended to identify stroke survivors at risk of poor motor and functional gains in hospital rehabilitation, which impacts the time spent in hospital, discharge destination and follow-up support needs.

The implications for occupational therapists in stroke rehabilitation and potential directions for further research into the future include recognising:

• Impaired self-awareness is a cognitive deficit that requires identification post stroke to support patient rehabilitation outcomes. • The Patient Competency Rating Scale can identify older adults with selfawareness deficits for intervention at multiple intervals throughout the acute to rehabilitation hospital journey. • Poor self-awareness may still be present at three months post stroke but is likely most impaired at one month, a crucial time for engagement in sub-acute rehabilitation.

Final thanks to the Charlies Foundation for Research–which supported me as a clinician through a small research grant–and all the stroke survivors and their families for their participation in this research. Dr Kristie Harper, Judith Talbot and Angela Jacques also contributed to the research. About the author Toni Heinemann is a Senior Occupational Therapist who works in stroke rehabilitation at Osborne Park Hospital in Perth. Toni has worked across multiple tertiary and secondary hospitals as a clinician across Perth and also completed her masters of public health. She is passionate about the crucial role Occupational Therapy plays in many of the hidden symptoms of stroke – (cognition, fatigue, perception) and how to provide evidence based care for stroke survivors returning to their valued important occupations in rehabilitation.

References can be viewed by scanning the QR code