Mental Health and

Occupational Balance in Stroke

Improving the Mental Health of Stroke Survivors

Sam Talisman, OTD, OTR

Washington University School of Medicine
Program in Occupational Therapy
Goals for Today
•  Understand the impact of mental health on stroke
survivors’ engagement and performance in daily
occupations.
•  Identify mental health challenges people with physical disabilities may
face.
•  Relate mental health issues to problems with occupational
performance.

•  Appraise interventions designed to improve the mental

health of stroke survivors.

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INTRODUCTION

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What do we know about mental health?

•  How do we define it?

•  What does it look like?

•  What do we do if it’s good? If it’s bad?

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Language Surrounding Mental Health
•  World Health Organization
•  “Mental health is defined as a state of well-being in which every
individual realizes his or her own potential, can cope with the normal
stresses of life, can work productively and fruitfully, and is able to
make a contribution to her or his community.” (WHO, 2014)

•  OTPF: body functions ! mental functions (AOTA, 2014)

•  Other professions

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Division of Mental and Physical

•  Health: “a state of complete physical, mental, and social

well-being and not merely the absence of disease or
infirmity” (WHO, 1948)

•  Clinical divisions- “mental health settings”

•  Professional divisions

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Health v. Illness

Unhealthier Healthier

Illness No Illness

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Post-Stroke Mental Health

Disorders:

•  Depression (Morrison, Pollard, Johnston, & MacWalter, 2005; Chen, Tsai, Chung, Chen, Wu, &
Chen, 2015)

•  Anxiety (Hackett, Köhler, O’Brien, & Mead, 2014; Ferro, Caeiro, & Santos, 2009; Campbell Burton et
al., 2013)

•  Others

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Post-Stroke Mental Health

Sub-threshold of a disorder- examples:

•  Emotional Lability (Hackett, Köhler, O’Brien, & Mead, 2014)

•  Lowered Self-Esteem (Vickery, Evans, Lee, Sepehri, & Jabeen, 2009)

•  Loss of Sense of Self (DeJean, Giacomini, Vanstone, & Brundisini, 2013)

•  Apathy (Hackett, Köhler, O’Brien, & Mead, 2014)

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Pathology

•  Psychological
•  Stroke is a stressful life event
•  Fear of the unknown

•  Neurological
•  Reorganized brain
•  Washington Post: “After a stroke, her decades of severe depression
vanished” (March 11, 2018)

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Cycle of Stroke and Mental Health

Stroke

Decreased
MH Issues
Health

Decreased
Function

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Cycle of Stroke and Mental Health
Stroke

Decreased
Occupational
MH Issues
Health Issues

Decreased
Function

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MENTAL HEALTH EFFECTS

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Occupational Issues
Mental health issues decrease occupational engagement after
a stroke.

Why?
•  Functional impairment (Gillen, 2011)

•  Decreased motivation (Hackett, Köhler, O’Brien, & Mead 2014; Frost, Weingarden, Zeilig,
Nota, & Rand, 2015)

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Occupational Issues
•  ADLs/IADLs (Coenen et al., 2016)

•  Work (Matuska & Barrett, 2016)

•  Caregiving (Coenen et al., 2016)

•  Social Participation (Woodman, Riazi, Pereira, & Jones, 2014)

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Cognitive

Stress acts as a cognitive load. (Stawski, Sliwinski, & Smyth, 2006)

This can cause a cycle between mental health and

occupational performance.

Changes in cognition can go unnoticed and unreported. (Knopman

et al., 2009)

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Cognitive
•  Processing speed

•  Language

•  Visuospatial ability

•  Memory (Campbell, Marriott, Nahmias, & MacQueen, 2004)

•  Attention

•  Executive functioning (Park et al., 2015; Royall, Palmer, Chiodo, & Polk, 2004; Muir et
al., 2015)

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Physiological

The brain and the body influence each other.

Stress: mental ! physical (Truelsen, Nielsen, Boysen, & Grønbæk, 2003)

Pain: mental ! physical (Kross, Berman, Mischel, Smith, & Wager, 2011)

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Physiological

•  Sleep (Nakase, Tobisawa, Sasaki, & Suzuki, 2016)

•  Appetite

•  Fitness (Lerdal & Gay, 2013; Tang et al., 2010)

•  Sexual functioning (Balon, 2007; Kennedy & Rizvi, 2009; Hattjar, 2012)

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Motor
Lower post-stroke participation in therapy and occupations
means less motor recovery.

Why lower?

•  Functional impairment (Gillen, 2011)

•  Decreased motivation (Subramanian, Lourenço, Chilingaryan, Sveistrup, & Levin, 2013;

Kramer, Johnson, Bernhardt, & Cumming, 2016)

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Motor

•  Sensory feedback (Subramanian, Chilingaryan, Sveistrup, & Levin, 2015)

•  UE function

•  LE function
•  The role of self-efficacy: self-fulfilling prophecy (Schmid et al., 2012)
•  Fear of falling cycle (Delbaere, Crombez, Vanderstraeten, Willems, & Cambier, 2004)

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Spiritual

Spirituality ties directly to a person’s self-expression and

engagement in their life. (Eakmann, 2016)

Positive spirituality can improve mental health and

occupational functioning. (Pargament, Koenig, Tarakeshwar, & Hahn, 2004; Giaquinto,
Spiridigliozzi, & Caracciolo, 2007)

Negative spirituality can have the opposite effect. (McConnell,

Pargament, Ellison, & Flannelly, 2006; Abu-Raiya, Pargament, & Exline, 2015; Fitchett et al., 2004)

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Spiritual
Factors to overcome:

•  Limited occupational engagement

•  Limited relationships (Puchalski et al., 2009)

•  Poor coping and spiritual struggles (McConnell, Pargament, Ellison, & Flannelly,
2006)

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Social Support

More disability + MH issues = lower social support (Kamenov et al.,

2016)

Depression limits the benefits others typically gain from any

social support available.

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Social Support

•  Actual v. perceived support (Northcott, Moss, Harrison, & Hilari, 2016)

•  Caregiver burden (Han & Haley, 1999; Jönsson, Lindgren, Hallström, Norrving, & Lindgren,
2005)

•  Social participation (Northcott, Moss, Harrison, & Hilari, 2016; Northcott & Hilari, 2011)

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Technology

Well-prescribed AT can improve mental health. (Scherer & Glueckauf,

2005)

Poorly prescribed AT can damage mental health. (Scherer & Glueckauf,

2005)

Proper prescription must consider a person’s self-image and

related concerns. (Pape, Kim, & Weiner, 2002)

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Physical Environment
•  Discharge location influences motivation (Holmqvist & von Koch, 2001;
Åstrand et al., 2016; Vanroy et al., 2016)

•  Green space (Van den Berg, Maas, Verheij, & Groenewegen, 2010)

•  Noise (Snögren & Sunnerhagen, 2009)

•  Pollution (Wilker et al., 2013)

•  Physical and structural barriers (Zhang, Yan, You, Li, & Gao, 2016; Zhang, Sui,
Yan, You, Li, & Gao, 2017)

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Mental Health Cycles
•  MH issues contribute to:
•  Lower occupational performance and engagement
•  Cognitive deficits
•  Physiological dysfunction
•  Motor problems
•  Spiritual struggles
•  Decreased social support
•  Resistance to technology
•  Poor physical environment

…Which then lead to further MH issues.

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Cycle of Stroke and Mental Health-
Revisited
Stroke

Decreased
Occupational
MH Issues
Health Issues

Decreased
Function

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Mental Health and Occupational Balance

•  Mental health as a cycle

•  MH as a change agent

•  MH as balance

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 PEOP: Enabling Everyday Living
THE NARRATIVE PERSON OCCUPATION ENVIRONMENT
The past, current and future " Cognition • Cultural Environment
perceptions, choices, interests,
•  Activities.Tasks,Roles
" Psychological • Classifications • Social Support
goals and needs that are unique " Physiological • Social Determinants and
to the Person, Organization or " Sensory/Perceptual Social Capital
Population " Motor • Health Education and Public Policy
" Spirituality/Meaning • Physical and Natural Environment
Personal Narrative • Assistive Technology
Perceptions and Meaning
Choices and
Responsibilities
Attitudes and Motivations
Needs and Goals

PERFORMANC
Organizational Person Environment

PARTICIPATION
Narrative
Mission and History
Focus and Priorities

BEING
WELL-
Stakeholders and Values
Needs and Goals

Population/

E
Community Narrative
Environments and Occupation
Behaviors
Demographics and
Disparities Incidence and
Prevalence
Needs and Goals
The performance of occupation (doing) enables the participation (engagement) in every day life
that contributes to a sense of well-being (satisfaction)
Model of Mental Health and Occupational
Balance in Stroke (MHOBS)

Individual

Mental
Health

Occupation

Intrinsic Extrinsic

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Out of Balance

Individual

Mental
Health

Occupation

Intrinsic Extrinsic
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NOT LIMITED TO STROKE
•  Cancer (Vanderwerker, Laff, Kadan-Lottick, McColl, & Prigerson, 2005)

•  TBI (Andelic, Sigurdardottir, Schanke, Sandvik, Sveen, & Roe, 2010)

•  SCI (Migliorini, Tonge, & Taleporos, 2009)

•  Heart attack (Schleifer & Macari-Hinson, 1989)

•  More!

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ASSESSMENTS

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Measures
•  Activity Card Sort (ACS)
•  Canadian Occupational Performance Measure (COPM)
•  Executive Function Performance Test (EFPT)
•  Hospital Anxiety and Depression Scale (HADS)
•  Patient Health Questionnaire (PHQ-9)
•  Medical Outcomes Study Short Form 36 (SF-36)
•  Spirituality Index of Well-Being (SIWB)
•  Quality of Life in Neurological Disorders
Measurement System (Neuro-QoL)
•  World Health Organization’s Quality of Life-BREF
(WHOQOL-BREF)
•  Craig Hospital Inventory of Environmental Factors (CHIEF)

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Hospital Anxiety and Depression Scale
(HADS)
•  Two 7-question subscales
•  Anxiety
•  Depression

•  4-point Likert scale

•  Absence < - - > extreme presence of symptoms

•  Validated beyond hospital settings

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Patient Health Questionnaire (PHQ-9)
•  9-question screen
•  Symptoms of depression

•  4-point Likert scale

•  Not at all < - - > nearly every day

•  Breaks scores into:

•  Mild (5)
•  Moderate (10)
•  Moderately severe (15)
•  Severe (20)

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Neurological Quality of Life (Neuro-QOL)
•  Multiple long-form and short-form questionnaires

•  5-point Likert scale

•  Domains:
•  Physical
•  Mental
•  Social

•  Specifically for people with neurological conditions

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World Health Organization’s Quality of Life-
BREF (WHOQOL-BREF)
•  26-question assessment

•  5-point Likert scale

•  Measures quality of life:

•  Physical health
•  Psychological health
•  Social relationships
•  Environment

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INTERVENTIONS

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Mental Health Considerations

Stay occupation-focused! Identify goals and barriers to

meaningful occupations.

Screen for disorders and mental health changes to determine

need.

Consider how mental health is related to other issues that

may arise or are already there.

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Mental Health Considerations
•  Think about recovery potential based on effort

•  Facilitate competency and give feedback (Eakmann, 2016)

•  Improve autonomy

•  Encourage belonging and social support

•  Advocacy- individual and community

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Conclusions

Mental health isn’t a separate issue- it’s related to everything.

Staying occupation-based will improve mental health along

with other outcomes.

We all have simple tools to use to address mental health in

every day practice. Now, let’s use them!

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Acknowledgements
•  Dr. Carolyn M. Baum, PhD, OTR, FAOTA

•  Lauren Milton, OTD, OTR/L

•  Patricia Nellis, OTD, OTR/L

•  Washington University OTD Class of 2017

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References
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life in stroke? Archives of Physical Medicine and Rehabilitation, 91(10), 1511-1515.

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of community-dwelling stroke survivors. Disability and Rehabilitation, 36(24), 2031-2043.
•  World Health Organization (2014, August). Mental health: A state of well-being. Retrieved from
http://www.who.int/features/factfiles/mental_health/en/
•  Zhang, L., Sui, M., Yan, T., You, L., Li, K., & Gao, Y. (2017). A study in persons later after stroke of the relationships between social participation,
environmental factors and depression. Clinical Rehabilitation, 31(3), 394-402.
•  Zhang, L., Yan, T., You, L., & Li, K. (2015). Barriers to activity and participation for stroke survivors in rural China. Archives of Physical Medicine
and Rehabilitation, 96(7), 1222-1228.

Washington University School of Medicine

Program in Occupational Therapy
Interventions for Stroke Survivors
with Depressive Disorders

Brian Chen, OT/S

Washington University School of Medicine
Program in Occupational Therapy
Overview
1.  Therapeutic Exercise Program (Lai et al., 2006)
2.  Dense Cranial Electroacupuncture Stimulation (Man et al., 2014)
3.  Brief Psychosocial Behavioral Intervention (Mitchell et al., 2009)
4.  Upper Extremity Aerobic Exercise (Topcuoglu, Ordu Gokkaya, Halil, &
Karakuş, 2015)

5.  Motivational Interviewing (Watkins et al., 2007)(Watkins et al., 2011)

6.  Transitional Care Program (Wong & Yeung, 2017)

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Program in Occupational Therapy
Therapeutic Exercise Program (Lai et al., 2006)

•  Progressive exercise program targeting strength, balance,

endurance, and upper extremity function to encourage
more use of the affected extremities
•  Dosage: 90 minute session, 3 times/week, for 12 to 14
weeks (total 36 sessions)
•  Supervised by physical therapist or occupational therapist
•  Includes structured protocols for exercise tasks, criteria for
progression, and guidelines for reintroducing therapy after
intercurrent illness

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Program in Occupational Therapy
 GDS, SIS Emotion, and MOS 36 SF Emotions scores at baseline, postintervention, and follow-up after Exercise
versus UC (Lai et al., 2006)

GDS SIS Emotion MOS 36 SF Emotions

Exercise Usual Care Exercise Usual Care Exercise Usual Care

n=44 n=49 n=44 n=49 n=44 n=49

Baseline
3.4 ± 2.8 3.8 ± 2.7 81 ± 14.3 80 ± 14.6 84 ± 30.9 80 ± 35.9

n=44 n=49 n=44 n=49 n=44 n=49

Postintervention (3
month)
2.5 ± 2.5** 4.4 ± 3.4 83.0 ± 12.1* 76.5 ±16.2 93.0 ± 22.5* 77.5 ± 37.9

n=40 n=40 n=40 n=40 n=40 n=40

Follow Up (9 Month)
2.0 ± 1.8 3.4 ± 3.2 81.1 ± 14.1 80.1 ± 16.8 95.8 ± 13.5 85.8 ± 31.9

*p < 0.05; **p < 0.01

GDS = Geriatric Depression Scale; SIS = Stroke Impact Scale; MOS = Medical Outcomes Study 36 Item Short
Form

Washington University School of Medicine

Program in Occupational Therapy
Therapeutic Exercise Program (Lai et al., 2006)

•  Depressive symptoms do not appear to limit gains in

impairments or functional limitations attributable to
exercise
•  Exercise improved depressive symptoms and quality of life
mostly in those with greater initial depressive symptoms

Washington University School of Medicine

Program in Occupational Therapy
Dense Cranial Electroacupuncture
Stimulation (Man et al., 2014)

•  Electrical Stimulation is delivered on a group of acupoints

on the forehead (6), which are innervated by the
trigeminal sensory pathway
•  Acupuncture intervention was conducted for 3 sessions per
week over 4 consecutive weeks while subjects were being
medicated with SSRIs.
•  Both Intervention and Control groups were given SSRIs
and Body Acupuncture
•  Control groups were given sham cranial acupuncture (n-CEA) in which
needles were adhered to the skin rather than inserted.
•  All subjects (in both groups) received rehabilitation therapy
(1-2 sessions/week) when they entered the study and
were allowed to continue during the study

Washington University School of Medicine

Program in Occupational Therapy
 Changes in HAMD-17 score from baseline in PSD Subjects (Man et al., 2014)

DCEAS n-CEA
n=23 n=20
Week 1
-1.9 ± 2.3** -0.1 ± 1.9
n=23 n=20
Week 2
-6.8 ± 2.3 -6.5 ± 1.9
n=23 n=20
Post Intervention (week 4)
-11.6 ± 2.3 -11.2 ± 1.9
**p < 0.01
DCEAS = Dense Cranial Electroacupuncture Stimulation; HAMD-17 = 17-item Hamilton
Rating Scale for Depression; n-CEA = Non-invasive Cranial Electroacupuncture

Washington University School of Medicine

Program in Occupational Therapy
Dense Cranial Acupuncture Stimulation (Man et al.,
2014)

•  Subjects of n-CEA group had better treatment outcomes

than DCEAS group on movement disability associated with
daily self-caring activity
•  Although the needle did not pierce through the skin, similar electrical
stimulation was applied
•  Superficial electrical stimulation appeared to be more beneficial in
improving limbic paralysis
•  Effects similar to Transcutaneous Electrical Nerve Stimulation (TENS),
which excites mechanoreceptors and myelinated nerve fibers
•  Suggests greater improvement of DCEAS on PSD was
unlikely due to improvement of movement ability

•  Although this study demonstrated antidepressant efficacy

of acupuncture therapy, the underlying mechanisms are
not yet well delineated
Washington University School of Medicine
Program in Occupational Therapy
Brief Psychosocial Behavioral Intervention
(Mitchell et al., 2009)

•  Rationale: without behavioral change, there would be no

long lasting change from the initial mood elevation seen
with antidepressants
•  Intervention adapted from the “Seattle Protocols,” shown
to reduce disability associated with depression in
Alzheimer’s Disease
•  Taught participants to view depressive symptoms as observable and
modifiable behaviors that are initiated and maintained by person-
environment interactions
•  Taught specific problem solving approaches and solutions to
behavioral challenges were individualized to each person

•  Both Intervention and usual care groups continued their

antidepressant medications, adjusted by their usual care
provider as needed
Washington University School of Medicine
Program in Occupational Therapy
 Mean Change in HRSD Over Time and % in remission (HRSD ≤ 9) (Mitchell et al., 2009)

Mean Change in HRSD % in remission (HRSD ≤ 9)

PBI UC PBI UC

n=45 n=53 n=45 n=53

Post Intervention (Week 9)
-9.8 ± 4.9** -3.6 ± 5.6 47** 19

n=46 n=50 n=46 n=50

Follow Up (Week 21)
-8.3 ± 6.8 -6.0 ± 6.5 46* 22

n=44 n=48 n=44 n=48

Follow Up (12 Month)
-9.2 ± 5.7* -6.2 ± 6.4 48* 27

n=34 n=33 n=34 n=33

Follow Up (24 Month)
-11.3 ± 6.5 -9.3 ± 4.7 65 46

** p < 0.001; *p < 0.05

HRSD = Hamilton Rating Scale for Depression; PBI = Psychosocial Behavioral Intervention; UC = Usual Care

Washington University School of Medicine

Program in Occupational Therapy
Brief Psychosocial Behavioral Intervention
(Mitchell et al., 2009)

•  A brief psychosocial-behavioral intervention adjunctive to

antidepressant therapy is highly effective in reducing
depression and achieving remission in the short term with
the effect sustained for up to 2 years
•  Participants in the usual care control group also reduced
their depression over the first year, but did so more slowly
and with a lesser degree of remission

Washington University School of Medicine

Program in Occupational Therapy
Upper Extremity Aerobic Exercise (Topcuoglu, Ordu Gokkaya,
Halil, & Karakuş, 2015)

•  Arm crank ergometry (5 W/min) 5 days a week, 30

minutes a day, for a period of 4 weeks.

•  Complex Regional Pain Syndrome (CPRS) Type 1

physiotherapy program:
•  TENS (shoulder-hand region encompassing the painful region; 100
Hz, 20 min/day), Cold pack (20 min/day), retrograde massage, and
contrast baths
•  Stroke Rehabilitation physiotherapy program
•  therapeutic exercises, neurophysiological exercises, postural
exercises, balance and coordination exercises, and exercises of
activities of daily living

Washington University School of Medicine

Program in Occupational Therapy
Upper Extremity Aerobic Exercise (Topcuoglu, Ordu Gokkaya,
Halil, & Karakuş, 2015)

•  There was a statistically significant difference between the

treatment groups and UEAE were less depressed when
compared to the ST group (p = 0.005)

Washington University School of Medicine

Program in Occupational Therapy
Motivational Interviewing (Watkins et al., 2007) (Watkins et al., 2011)

•  Four 30 to 60 minute sessions

•  Therapists elicit patients’ personal, realistic goals for

recovery and perceived barriers to attaining these.
•  By working with patients’ dilemmas and ambivalence, and
through supporting and reinforcing optimism and self-
efficacy, therapists enabled patients to identify their own
solutions

•  All patients received usual medical, nursing, and therapy

input, including inpatient care and discharge planning
through multidisciplinary team meetings and a stroke
review clinic appointment at 1, 3, and 6 months post
stroke
Washington University School of Medicine
Program in Occupational Therapy
 Effects of Early Motivational Interviewing on mood (Watkins et al., 2007; 2011)

Not often feeling sad or depressed

Normal mood (GHQ-28 < 5)
(Yale)
n (%)
n (%)

MI UC MI UC

n=195 n=197 n=197 n=200

Baseline
72 (36.9%) 74 (37.6%) 114 (57.9%) 108 (54.0%)

n=172 n=167 n=172 n=167

3 month poststroke
94 (54.7%)* 70 (41.9%) 91 (52.9%)* 71 (42.5%)

n=162 n=155 n=164 n=156

12 month poststroke
88 (54%)* 66 (42.6%) 74 (45.1%) 69 (44.2%)
*p < 0.05
GHQ-28 = Global Health Questionnaire; MI = Motivational Interviewing; UC = Usual Care

Washington University School of Medicine

Program in Occupational Therapy
Motivational Interviewing (Watkins et al., 2007) (Watkins et al., 2011)

•  There was a protective effect of MI on death (p=0.03) at

12 months, suggesting that improving mood could increase
survival post-stroke
•  None of the therapists who participate in this study were
clinical psychologists (although they did receive regular
clinical psychologist supervision) suggesting that MI could
be learned by other healthcare professionals.

Washington University School of Medicine

Program in Occupational Therapy
Transitional Care Program (Wong & Yeung, 2017)

•  Both intervention and control groups received a routine

hospital based physical training programme

•  3 Key Components
1.  The Holistic Care Interventions Component
2.  The Transitional Care Track
3.  The Holistic Care Managers

Washington University School of Medicine

Program in Occupational Therapy
Transitional Care Program (Wong & Yeung, 2017)

•  The Holistic Care Interventions Component

•  Structured using the Omaha System – an assessment-intervention-
evaluation framework
•  Assessment Framework with 4 domains: Environmental,
Psychosocial, Physiological, and health related behaviors
•  Intervention Scheme: surveillance, health teaching and
counselling, treatment and procedures, and case management
•  Stroke Specific Domains: management and prevention of stroke
recurrence, symptoms assessment and management, enhancing
physical function: self-care abilities and exercise, healthy behavior:
adherence to medication and diet, building resilience: connection with
self, family, social life and a Higher Being, and emotion management

Washington University School of Medicine

Program in Occupational Therapy
Transitional Care Program (Wong & Yeung, 2017)

•  The Transitional Care Track

•  Pre-discharge – entrance family meeting
•  Week 1 – home visit on day 2-4, telephone follow-up on day 7
•  Week 2 – home visit on day 2-4, telephone follow-up on day 7
•  Week 3 – home visit on day 2-4, telephone follow-up on day 7
•  Week 4 – home visit on day 2-4, exit family meeting

Washington University School of Medicine

Program in Occupational Therapy
Transitional Care Program (Wong & Yeung, 2017)

•  The Holistic Care Managers (HCM)

•  Recruited nurses who had relevant experience in stroke care and in
the community setting; supported by multidisciplinary team
•  3 day training workshop on the Omaha system, transitional care,
home visits, telephone follow-up and the holistic care intervention
protocols
•  Workshops included theoretical input and training cases

•  OT scope of practice

Washington University School of Medicine

Program in Occupational Therapy
 SF-36-HK and WHOQoL-SRPB-HK scores at baseline, 4 weeks, and 8 weeks (Wong and Yeung, 2017)

SF-36-HK MCS WHOQOL-SRPB-HK CES-D-HK Total CES-D-HK Mood

HBPTP
TCP HBPTP TCP
TCP HBPTP TCP HBPTP mean
mean (10th mean (10th mean (10th
mean (SD) mean (SD) mean (SD) mean (SD) (10th and
and 90th) and 90th) and 90th)
90th)

n=54 n=54
n=54 n=54 n=54 n=54 n=54 n=54
4 Weeks
49.9 1
49.2 (1.1) 12.5 (3.1)** 9.8 (2.5) 2 (0-5)** 4 (1.5-8) 2.8 (1-5)
(1.0)** (0-3.5)**
n=54
n=54 n=54 n=54 n=54 n=54 n=54 n=54
8 Weeks
49.9
49.4 (1.4) 12.1 (2.9)** 9.8 (2.7) 2 (0-4)** 4 (0-7) 1 (0-3)** 3 (0-5)
(1.0)**
*p < 0.05; ** p < 0.01
SF-36-HK = Short Form Health Survey-36, Hong Kong version; WHOQOL-SRPB-HK = World Health Organization - Quality of
Life - Spirituality, Religion and Personal Beliefs, Hong Kong Version; CES-D-HK = Center for Epidemiological Studies
Depression Scale, Hong Kong Version; TCP = Transitional Care Programme; HBPTP: Hospital Based Physical Training Program

Washington University School of Medicine

Program in Occupational Therapy
References
•  Lai, S. M., Studenski, S., Richards, L., Perera, S., Reker, D., Rigler, S., & Duncan, P. W. (2006). Therapeutic exercise and depressive symptoms
after stroke. Journal of the American Geriatrics Society, 54(2), 240-247. doi:https://dx.doi.org/10.1111/j.1532-5415.2006.00573.x
•  Man, S. C., Hung, B. H., Ng, R. M., Yu, X. C., Cheung, H., Fung, M. P., . . . Zhang, Z. J. (2014). A pilot controlled trial of a combination of dense
cranial electroacupuncture stimulation and body acupuncture for post-stroke depression. BMC Complementary & Alternative Medicine, 14, 255.
doi:https://dx.doi.org/10.1186/1472-6882-14-255
•  Mitchell, P., Veith, R., Becker, K., Buzaitis, A., Cain, K., Fruin, M., . . . Teri, L. (2009). Brief psychosocial-behavioral intervention with antidepressant
reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial. Stroke; a
journal of cerebral circulation, 40(9), 3073-3078. Retrieved from http://onlinelibrary.wiley.com/o/cochrane/clcentral/articles/144/CN-00720144/
frame.html; http://stroke.ahajournals.org/content/strokeaha/40/9/3073.full.pdf doi:10.1161/STROKEAHA.109.549808
•  Topcuoglu, A., Ordu Gokkaya, N. K., Halil, U., & Karakuş, D. (2015). The effect of upper-extremity aerobic exercise on complex regional pain
syndrome type I: A randomized controlled study on subacute stroke. Topics in stroke rehabilitation, 22(4), 253-261. doi:10.1179/1074935714Z.
0000000025
•  Watkins, C. L., Auton, M. F., Deans, C. F., Dickinson, H. A., Jack, C. I., Lightbody, C. E., . . . Leathley, M. J. (2007). Motivational interviewing early
after acute stroke: a randomized, controlled trial. Stroke, 38(3), 1004-1009. doi:https://dx.doi.org/10.1161/01.STR.0000258114.28006.d7
•  Watkins, C. L., Wathan, J. V., Leathley, M. J., Auton, M. F., Deans, C. F., Dickinson, H. A., . . . Lightbody, C. E. (2011). The 12-month effects of
early motivational interviewing after acute stroke: a randomized controlled trial. Stroke, 42(7), 1956-1961. doi:https://dx.doi.org/10.1161/
STROKEAHA.110.602227
•  Wong, F., & Yeung, S. (2017). Effects of a 4-week transitional care programme for discharged stroke survivors in Hong Kong: a randomised
controlled trial. Health & social care in the community, 23(6), 619-631. Retrieved from http://onlinelibrary.wiley.com/o/cochrane/clcentral/articles/
060/CN-01265060/frame.html; http://onlinelibrary.wiley.com/doi/10.1111/hsc.12177/abstract; http://onlinelibrary.wiley.com/store/10.1111/hsc.
12177/asset/hsc12177.pdf?v=1&t=j6z5p5sg&s=78c0344f6064d9351a2becfa293c919a66996362 doi:10.1111/hsc.12177

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Program in Occupational Therapy