Advertisement

First-stroke recovery process: The role of family social support

      Abstract

      Tsouna-Hadjis E, Vemmos KN, Zakopoulos N, Stamatelopoulos S. First-stroke recovery process: the role of family social support. Arch Phys Med Rehabil 2000;81:881-7. Objective: To determine the role of family social support in three stroke rehabilitation variables (functional status, depression, social status) during a 6-month recovery period. Design: Assessment of first-stroke patients' functional status, depression, and social status before discharge and at 1, 3, and 6 months after stroke onset, in comparison with the amount of family social support received. The family social support scale—compliance, instrumental, and emotional support—was employed in the first month. Setting: A university hospital and patients' residences. Patients: A consecutive sample of 43 first-stroke patients meeting the inclusion criteria. Main Outcome Measures: Changes of patients' rehabilitation variables over the 6-month period were tested by use of repeated multivariate analysis of variance measures. Results: Observers of functional, depression, and social status changes were blind to patient grouping according to levels of family support. These three variables were significantly affected by higher levels of support (p =.001, p =.001, p =.020, respectively), but a significant interaction was found only with regard to functional status adjusted for initial stroke severity (p =.019). Patients with moderate/severe stroke and high levels of social support attained a significantly better and progressively improving functional status than those with less support. Conclusions: High levels of family support—instrumental and emotional—are associated with progressive improvement of functional status, mainly in severely impaired patients, while the psychosocial status is also affected. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

      Keywords

      SOCIAL RELATIONS and support are being increasingly related to general well-being
      • Cobb S
      Social support as a moderator of life-stress.
      • Berkman LF
      • Syme SL
      Social networks, host resistance and mortality.
      and to illness course and rehabilitation.
      • Williams SE
      • Freer CA
      Aphasia: its effects on marital relationships.
      • Hyman MD
      Social isolation and performance in rehabilitation.
      In stroke patients, social support is believed to affect the quality of patient care and illness outcome, regarding patient's physical and psychosocial well-being.
      • Williams SE
      • Freer CA
      Aphasia: its effects on marital relationships.
      • Hyman MD
      Social isolation and performance in rehabilitation.
      • Evans RH
      • Bishop DS
      Psychosocial outcomes in stroke survivors.
      • Evans RL
      • Northwood LK
      Social support needs in adjustment to stroke.
      Functional deterioration, major depression, and social disintegration after stroke often interact to reduce life satisfaction.
      • Astrom M
      • Adolfsson R
      • Asplund K
      • Astrom T
      Life before and after stroke.
      Sometimes stroke patients with great physical or emotional impairment also undergo social deterioration and need the most intense social intervention.
      • Robinson RG
      • Bolduc PL
      • Kubos KL
      • Starr LB
      • Price TR
      Social functioning assessment in stroke patients.
      It has been noted, though, that the psychosocial status of stroke patients is not always in accordance with their functional status; sometimes a small physical disability may coexist with great difficulty in general adaptation.
      • Ebrahim S
      • Barer D
      • Nouri F
      Affective illness after stroke.
      • Lawrence L
      • Christie D
      Quality of life after stroke: three-year follow-up.
      • Ahlsio B
      • Britton M
      • Murray V
      • Theorell T
      Disablement and quality of life after stroke.
      While researchers attempt to define potentially more efficient patterns of providing rehabilitation care,
      • Alexander MP
      Stroke rehabilitation outcome.
      it is suggested that a proper plan for patient rehabilitation should aim at improving functional condition, depressive disorder, and social involvement.
      • Feigenson JS
      • McDowell FH
      • Meese P
      • McCarthy ML
      • Greenberg SD
      Factors influencing outcome and length of stay in a stroke rehabilitation unit. Part 1. Analysis of 248 unscreened patients—medical and functional prognostic indicators.
      Studies have compared the course of the illness at day hospitals and outpatient services with home care and have found great advantages in the latter.
      • Young JB
      • Forster A
      The Bradford community stroke trial: results at six months.
      • Johansson BB
      • Jadback G
      • Norrving B
      • Widner H
      • Wiklund I
      Evaluation of long-term functional status in first-ever stroke patients in a defined population.
      Evidence exists that family members, especially the patient's spouse, may offer important social support,
      • Evans RH
      • Bishop DS
      Psychosocial outcomes in stroke survivors.
      • Lehmann JF
      • DeLateur BJ
      • Fowler Jr, AS
      • Warren CG
      • Arnhold R
      • Schertzer G
      • et al.
      Stroke rehabilitation: outcome and prediction.
      • Shapiro J
      Family reactions and coping strategies in response to physically ill or handicapped child: a review.
      • Bishop DS
      • Epstein NB
      • Keitner GI
      • Miller IW
      • Srinivasan SV
      Stroke morale family functioning, health status and functional capacity.
      including instrumental help,
      • Pilisuk M
      • Parks SH
      The healing web: social networks and human survival.
      emotional encouragement, and compliance with therapeutic instructions,
      • Reiss D
      • Gonjalez S
      • Kramer N
      Family process, chronic illness and death on weakness of strong bonds.
      because patients themselves are usually dependent, disabled, or both. Similarly, a nonsupportive family context may be associated with nonadherence to treatment recommendations
      • Evans RH
      • Bishop DS
      Psychosocial outcomes in stroke survivors.
      • Evans RL
      • Bishop DS
      • Matlock AL
      • Stranahan S
      • Smith GC
      • Halar EM
      Family interaction and treatment adherence after stroke.
      and with a bad course of illness.
      • Evans RL
      • Bishop DS
      • Matlock AL
      • Stranahan S
      • Smith GC
      • Halar EM
      Family interaction and treatment adherence after stroke.
      • Strickland R
      • Altson J
      • Davidson J
      Negative influence of families on compliance.
      • Gresham GE
      • Phillips TF
      • Wolf PA
      Epidemiologic profile of long term disability: Framingham study.
      In this research, family support will be studied, conceptualized as the sum of instrumental exchanges, emotional encouragement, and compliance with treatment recommendations.
      The role of family support has recently been investigated in studies using longitudinal techniques and repeated observations.
      • Glass TA
      • Matchar DB
      • Belyea M
      • Feussner JR
      Impact of social support on outcome in first stroke.
      • Glass TA
      • Maddox GL
      The quality of social support: stroke recovery as psycho-social transition.
      Despite the evidence that satisfactory social support plays a role in recovery from stroke, three major gaps remain in the literature. First, outcome measures refer only to functional status and not to psychosocial status (depression, social interest), which may change independently of functional status. Second, although the effect of different quantity levels of family social support has been investigated, no study has examined which of the forms of family members' behavior have a profound effect on patients' rehabilitation process. Finally, the initial severity of the stroke and the functional status at discharge, which, along with age, are considered to be the most powerful predictors of stroke recovery, have rarely been tested
      • Glass TA
      • Matchar DB
      • Belyea M
      • Feussner JR
      Impact of social support on outcome in first stroke.
      against the factor of family social support.
      The purpose of this study is to examine the impact of the family social support on the rehabilitation process—defined as the functional, depression, and social status changes—of a sample of first-time stroke survivors. The study deals with all the above issues through a longitudinal and multiphasic patient assessment.

      Methods

      Subjects

      The sample of the study is part of a prospective stroke databank developed in the Department of Clinical Therapeutics of Athens University over a period of 5 years (1042 patients).
      • Vemmos KN
      • Georgilis K
      • Zis V
      • Gouliamos A
      • Toumanidis S
      • Barbaresou M
      • et al.
      The Athens Stroke Registry: final results of a three-year hospital based study [Abstract].
      All study subjects, suffering from an acute first stroke, were admitted to the hospital and were classified according to aetiopathogenic mechanisms of stroke. A brain computed tomography scan was obtained on admission and standard investigations were performed during hospitalization according to the study protocol. Inclusion criteria for our study were: (1) patients with an acute first stroke, (2) hospitalization within 48 hours of the onset of neurologic symptoms, (3) no preexisting stroke deficit, and (4) informed consent for the study from the patient or a family member. Patients with transient ischemic attacks, recurrent stroke, and subarachnoid hemorrhage were excluded. During a period of 3 months (15 February 1993 to 15 May 1993) among 70 patients admitted to the hospital, 50 (71%) were screened (nine patients died, four patients were admitted more than 48 hours from stroke onset, three patients had recurrent stroke, and four patients refused to participate in the study). As the study was carried out, four more died and three dropped out, so data were collected on 43 patients (24 men, 19 women; aged 40 to 83yrs). The procedures followed for patient recruitment were in accordance with the Helsinki Declaration of 1975, as revised in 1983.

      Stroke severity and rehabilitation variables assessment

      Stroke severity was assessed by a physician on admission, by use of the Scandinavian stroke scale (SSS).
      • Scandinavian Stroke Study Group
      Multicenter trial of hemodilution in ischemic stroke: background and study protocol.
      This scale, which assesses neurologic impairments in the acute phase of stroke, provides a reliable instrument for stratification of stroke patients and has good interobserver agreement (r =.954).
      • Lindestrom E
      • Boysen G
      • Christiansen LW
      • Rogvi-Hansen B
      • Nielsen PW
      Reliability of Scandinavian neurological stroke scale.
      In clinical research it is described as a well-documented measure with simplicity and prognostic value.
      • Roden-Jullig A
      • Britton M
      • Gustafsson C
      • Fugl-Meyer A
      Validation of four scales for the acute stage of stroke.
      Scores range from 0 (very severe stroke) to 58. Rehabilitation variables—functional capacity, depression status, and social status—were assessed by three scales that were used by repeated measures over a 6-month period from stroke onset.
      Functional capacity was measured using the Barthel index of activities of daily living (ADL index),
      • Mahoney FI
      • Barthel DW
      Functional evaluation: the Barthel index.
      a highly valued instrument in stroke research with good validity and reliability.
      • Collins C
      • Wade S
      Horne V. The Barthel ADL index: a reliability study.
      Data from clinical studies have revealed that it is among the best-validated assessment instruments
      • Granger CV
      • Hamilton BB
      • Gresham GE
      The stroke rehabilitation outcome study: part I. General description.
      and the best-suited measures of physical disability.
      • Wood-Dauphinee SL
      • Williams IJ
      • Shapiro SH
      Examining outcome measures in a clinical study of stroke.
      The ADL items, scored on an ordinal scale, assess ability to perform essential activities such as toilet use and feeding. Index scores range from 0 (complete functional impairment) to 100 (complete functional independence).
      Depression status was assessed using the Zung scale.
      • Zung WWK
      A self-rating depression scale.
      This instrument has been usefully employed in large scale studies to document depressive symptoms and their clinical correlates at specific time points.
      • Wade DT
      • Legh-Smith J
      • Hewer RA
      Depressed mood after stroke.
      • Herrmann N
      • Black SE
      • Lawrence J
      • Szekely C
      • Szalai JP
      The Sunnbrook stroke study: a prospective study of depressive symptoms and functional outcome.
      The Zung scale has been shown to have a sensitivity of 97% and specificity of 63% for depressive disorder in a general medical clinic according to the Diagnostic and Statistical Manual of Mental Disorders, edition 3.
      • Zung WWK
      • Magruder-Habib K
      • Velez R
      • Alling W
      The comorbidity of anxiety and depression in general medical patients: a longitudinal study.
      (In this study, three of the 40 items referring to major physical stroke symptoms were omitted. This approach of removing items not relevant to the population under study may be expected to optimize the sensitivity of the scale). The Zung items scored on an ordinal scale, range from 1.00 (no depression) to 4.00 (high depression).
      Social status, ie, patients' mood and social involvement, was assessed by the Social scale. This scale was constructed from the three of the four subscales (A, B, and C) (21 items) of the General Health Questionnaire index.
      • Goldberg DP
      The detection of psychiatric illness by questionnaire.
      This index is a screening questionnaire aimed at detecting those unable to carry out (one's) normal “healthy” functions.
      • Goldberg DP
      The detection of psychiatric illness by questionnaire.
      It is a well-validated instrument with concurrent validity of.73, sensitivity of 88%, and specificity of 84.2%.
      • Goldberg DP
      • Hillier VF
      A scaled version of the general health questionnaire.
      When used with stroke patients, it has been found to be a valid and reliable measure of mood disorder
      • Robinson RG
      • Price TR
      Post-stroke depressive disorders: a follow-up study of 103 patients.
      and to compare well with other stroke variables.
      • Ebrahim S
      • Barer D
      • Nouri F
      Affective illness after stroke.
      Scores of the scale range from 0 (serious social dysfunction) to 100 (complete social involvement).
      Patients' rehabilitation variables were assessed in the hospital before discharge (only functional status, because interviews on depression and social status were not possible for many patients) and at 1, 3, and 6 months from stroke onset, at patients' residences. All assessments were carried out by a physician's assistant who was trained in using the ADL index, the Zung scale, and the Social scale through several sessions on real patients. The assistant completed the three scales
      • Astrom M
      • Adolfsson R
      • Asplund K
      • Astrom T
      Life before and after stroke.
      forms after the interview, because several biases may be introduced by patients or proxies who complete questionnaires by themselves. When patients were unable to cooperate, a proxy replied. The interviewer was blind to other patients variables, such as initial stroke severity and family support received.

      Social support subvariables

      The family social support scale

      The level of family social support was assessed using a questionnaire given by an experienced health visitor at the patient's residence, 1 month from stroke onset. We developed a construct of family support to meet two essential requirements not found in the literature.
      Assessment of the quantity of social support was based on data from observation and inspection along with patient's (or proxy's) answers. The advantages of observational family assessment are elaborated by researchers.
      • Bishop D
      • Evans R
      Family functioning assessment techniques in stroke.
      In the Family Social Support (FSS) scale, each item has two equivalent parts: (1) a behaviorally specific question addressed to the patient, and (2) a question to be answered by the interviewer after inspecting the patient's residence and/or of proxy's attitude and behavior. Each item is scored on a Likert-type 3-point scale in which possible responses are explicitly stated. Both parts are filled out by the interviewer, the sum being the final item score. (For example, “Do they help you to keep yourself clean?” with answers “Always,” “Sometimes,” or “Rarely,” then inspect how clean the patient is, reporting “Very clean,” “Not so clean,” or “Unclean.”)
      Consideration of family social support is the sum of three separate subscales reflecting three dimensions of social support: (A) compliance with therapeutic instructions, (B) instrumental support, and (C) emotional support. This conceptualization is based on the idea that a supportive family should adhere to treatment recommendations
      • Evans RH
      • Bishop DS
      Psychosocial outcomes in stroke survivors.
      • Evans RL
      • Bishop DS
      • Matlock AL
      • Stranahan S
      • Smith GC
      • Halar EM
      Family interaction and treatment adherence after stroke.
      and should offer instrumental support and emotional encouragement.
      • Bishop DS
      • Epstein NB
      • Keitner GI
      • Miller IW
      • Srinivasan SV
      Stroke morale family functioning, health status and functional capacity.
      • Reiss D
      • Gonjalez S
      • Kramer N
      Family process, chronic illness and death on weakness of strong bonds.
      Subscale A, compliance with therapeutic instructions, has been constructed and employed in a previous study.
      • Sideris DA
      • Tsouna-Hadjis P
      • Toumanidis ST
      • Vardas PE
      • Moulopoulos SD
      Attitudinal educational objectives at therapeutic consultation.
      The patient and his proxies are asked to show the medication that is being taken and to answer questions regarding the patient's physiotherapy schedule and life style adaptations. This information is then compared with the original therapeutic instructions and the degree of compliance is estimated. Scores range from 0 to 100 (100 = full compliance).
      Subscale B, instrumental support, was developed on the basis of stroke patients treatment instructions
      • American Heart Association
      Family guide to stroke treatment, recovery and prevention.
      in collaboration with a PhD nurse and a physical therapist, both specialized in stroke rehabilitation. It elicits information about practical treatment of the patient (feeding, bathing, etc), as well as about major or minor modifications to the living facility in an attempt to help the patient and make him/her more independent. Scores range from 0 to 100 (100 = satisfactory instrumental support).
      Subscale C, emotional support, was developed to assess involvement of family members with the patient, ie, how many hours they spent with him, how much interest they showed in her, how patient they have been with him, and how much they motivated and encouraged her. Scores range from 0 to 100 (100 = satisfactory emotional support).
      The three subscales provide a mean, which is the index of family social support. The FSS scale has been tested with a number of first-stroke patients and items were modified accordingly. We worked with each subscale and selected those items that taken together produced a subscale with a high reliability. Test-retest reliability is.85 and split-half reliability is.82. Items yield significant correlations with total scores (Cronbach's alphas ranged between.72 and.89), an indication of internal consistency. To test validity, a discriminant analysis was performed on the FSS scores (assessed blindly) of two groups of stroke patients (home-treated and nursing home–treated). According to relevant evidence (unpublished data), the two groups were expected to yield different amounts of family support (high and low FSS scores, respectively). Results were as expected (60% of the former group and 83% of the latter were correctly predicted).

      Data analysis

      For the statistical analysis, repeated measures multivariate analysis of variance (MANOVA) on SPSS
      a. SPSS Inc. 444 North Michigan Ave, Chicago, IL 60611.
      was used, to examine the determinants of change in three outcome variables—functional status, depression, and social status—over a 6-month period. We studied the effect of different quantities of social support (independent variable) on the shape of patients' status trajectories, using prospectively gathered assessments (time) and controlling for stroke severity. Stroke severity was considered as a patient characteristic and was used as a covariate. Our design coupled serial measurement of outcome at standard measurement intervals. The hypothesis tested was that after controlling for time since stroke and stroke severity, patients receiving higher levels of social support have a significantly better and progressively improving functional and also depression and social status than patients with lower levels of support.
      For statistical reasons, we grouped the support (FSS) variable. Our intention was to form three groups corresponding to three levels of support, and for this reason we divided patients at the 70th and 40th percentiles. High support (70 to 100) was received by 67% of the patients, medium support (40 to 69) was received by 24%, and low support (0 to 39) by 9%. The latter percentage is low, compared with that of other research data (17.4%),
      • Glass TA
      • Matchar DB
      • Belyea M
      • Feussner JR
      Impact of social support on outcome in first stroke.
      where support was also grouped. This constriction of our data led us to our final decision to form two groups for two levels of support: the high support group (70 to 100) and the medium/low support group (0 to 69).
      Because the FSS variable has three subscales, we tested the effect of each of them separately on the patients rehabilitation variables, by use of ANOVA. Reliability coefficients of the three subscales were satisfactory (.82 to.89).
      FSS data collection at 1 month was repeated later, at 3 months, with the same interviewer. Changes over time were nonsignificant and a high correlation across time was obtained (r =.588, p =.001).

      Results

      Patient characteristics

      Twenty-four (56%) patients were men. This percentage is not statistically different compared with 613 (59%) men of our 5-year stroke registry. The mean age of patients was 70.7 years. The etiology of stroke in our sample was atherosclerosis in 10 patients, cardioembolism in 16, lacunar stroke in 9, infarction of undetermined cause in 11, and intracerebral hemorrhage in 4.
      Patients' demographic and clinical characteristics in total and according to level of social support are presented in table 1.
      Tabled 1Table 1: Descriptive statistics of patients by levels of social support
      Level of Social Support
      VariableTotal (n = 43)Low/Medium (n = 14)High (n = 29)
      Demographic variables
       Age (yrs) (mean±SD)70.7±10.074.2±6.269.1±11.2
       Sex (% female)44.071.031.0
       Marital status (% unmarried)13.914.313.8
      Stroke severity (SSS), (mean±SD)34.2±18.427.6±19.137.2±17.5
      Stroke unit/general medical ward23/208/615/14
      Days of hospitalization (mean±SD)13.8±5.3615.1±5.513.3±5.4
      Discharge (not home) (%)9.020.03.4
      Hypertension (%)605762
      Diabetes melitus (%)232124
      Coronary artery disease (%)262128
      Atrial fibrillation (%)373638
      Abbreviations: SSS, Scandinavian stroke scale (0 to 58).
      Ten of 14 patients with medium/low support were women. Mean SSS was 34.2; 22 patients had a mild stroke (score 41 to 58) and 21 patients had a moderate/severe stroke (score 0 to 40). The high support group and the medium/low support group were equivalent with respect to age and stroke severity. Among 29 patients with high support, 22 had a mild stroke, and among 14 patients with medium/low support 8 had a moderate/severe stroke. After discharge the majority of patients (91%) returned home, where, in most cases, a wife (in 20 cases), sister, or children living in the home or nearby took care of them. Four patients (9%) were taken to nursing homes.
      In 75% of the cases, the patient was the primary source of data in the four follow-up rehabilitation status interviews and in the social support assessments. Complementary information was gathered from proxies, wherever this was possible. Total FSS scores ranged from 27 to 95.

      Social support levels and rehabilitation variable changes

      Patients' consecutive rehabilitation scores correlated highly during follow-up assessments. Descriptive statistics for the three rehabilitation variables (functional status, depression, and social status) are presented in table 2, cross-classified by the level of family social support. The difference in mean functional status scores at discharge between low/medium and high support patients is not significant (t = 1.61) Mean functional status scores of patients with high social support have changed from 58 to 89 within the 6-month period. Change of this size (31% improvement) does not appear in any of the other two rehabilitation variables.
      Table 2Mean values of health variables by levels of social support
      Levels of Social Support
      Total (n = 43)Low/Medium (n = 14)High (n = 29)
      Functional status (ADL) (0-100)
       Discharge51.9038.2058.40
       1st month65.5043.2076.20
       3rd month72.9044.6086.60
       6th month74.5045.4089.10
      Psychological status (Zung) (4.0-1.0)
       1st month2.002.701.80
       3rd month1.842.311.65
       6th month2.252.562.14
      Social status (Social) (0-100)
       1st month46.8024.2057.70
       3rd month57.7029.1071.50
       6th month53.9036.2062.10
      Abbreviation: ADL, activities of daily living.
      Table 3 presents multivariate results of repeated measures MANOVA for the functional (ADL), the depression (Zung), and the social (Social) variable.
      Table 3Multivariate results for time effect and time by support effect on functional status, psychological status, and social status
      Approximate FSignificant F
      Functional status
       Time (adjusted for severity)9.32.000
       Social support3.73.019
      Psychological status
       Time (adjusted for severity)9.55.001
       Social support.95.399
      Social status
       Time (adjusted for severity)4.39.020
       Support1.15.329

      Functional status change

      Multivariate tests for functional status and time are highly significant (p = 0.001) and suggest that functional status, while adjusted for stroke severity, improves significantly with time within the 6-month period. (In repeated measures designs after transformation of variables, time is built into the specification of the dependent variable, one of which, in the present study, is functional status. Consequently, the effect of any other variable cannot be divorced from time. Moreover, in repeated measures designs the between- subjects effects are adjusted for the covariate, which in the present study is stroke severity.) The interaction of functional status with support and time (adjusted for severity) is also significant (p =.019), indicating that patients who receive more family social support, improve more over time with respect to functional status and according to stroke severity. (The test for the support effect is based on the constant [ADL in time] adjusted for the covariate [severity].) The univariate effect of time agrees with the above and is also highly significant (p =.001), indicating that the functional status improves with time since onset.

      Depression status changes

      Multivariate tests for depression status and time (table 3) are also significant (p =.001), suggesting that this variable (when adjusted for stroke severity) changes with time. This change, however, is not as continuous an improvement as that of functional status (table 2). The interaction of depression status with support and time (adjusted for severity) is not significant, which implies that the amount of social support does not affect the depression status of patients with different stroke severity levels over the 6-month period. The univariate effect of support on depression status is significant (p =.002), which suggests that patients who receive a high level of support (regardless of stroke severity) have a different depression status from patients who receive a low level of support.

      Social status change

      Multivariate results for patients' social status (table 3) indicate that this variable changes significantly over time (p =.020). Its interaction with support and time (adjusted for severity), however, is not significant. On the other hand, the univariate effect of support on patients' social status (regardless of severity) is significant (p =.001) and indicates that, overall, patients receiving high support have a significantly better social status.
      The crucial role of stroke severity is manifested by the univariate results; the average scores of the four functional status measurements differ according to stroke severity (p =.021) and the same is true for the three depression status average scores (p =.001) and for the three social status average scores (p =.002). (To test the robustness of the cut point used to differentiate high from low/medium support groups, data were also analyzed using ordinary least-squares regression, with stroke severity and support as continuous variables. Results were analogous to the above. For simplicity, only MANOVA is presented here.) Further interpretation of the above effects will be possible by visual inspection of average curves.

      Graphic analysis

      Figure 1 illustrates the trajectories of recovery from stroke, showing changes in functional, depression, and social status over time for each level of support.
      Figure thumbnail gr1
      Fig. 1Changes in the mean levels of the (A) functional, (B) depression, and (C) social status of patients with mild or moderate/severe stroke, receiving high support or low/medium support, during the 6-month recovery period: --□--, mild stroke with low/medium support; —□—, moderate/severe stroke with low/medium support; --○--, mild stroke with high support; —○—, moderate/severe stroke with high support.
      Here, the stroke severity (SSS) scores are split into two groups: mild (scores 41 to 58) and moderate/severe scores (0 to 40). Figure 1A shows that in patients with mild stroke, mean functional status scores are high regardless of the quantity of support and have already plateaued within the first month. The high support curves slope upward, and the slope and height of the moderate/severe stroke and high support curve are quite noticeable, indicating continuous functional status improvement up to the sixth month. Findings suggest that the functional benefits of social support are not equal among those with less and more severe strokes and, therefore, that more severely impaired patients may require higher support. Further, among patients with moderate/severe stroke, those with high support have relatively better functional status scores at discharge than those with medium/low support; the difference, though, is not statistically significant (t = 1.95, NS). Mean levels of depression status (fig 1B) decline after the third-month measurement in both mild and moderate/severe stroke groups. Overall, major differences in depression status were not found between groups; patients receiving high support had only a slightly better depression status at the follow-up assessment than patients receiving medium/low support. This finding was also evidenced by the support effect finding of univariate statistics (p =.020) mentioned earlier. Regarding the social status of the patients (fig 1C), high support axes are well above the medium/low support ones with the same stroke severity. A decline after the third month, however, is obvious in these high support axes. Moreover, the social status of patients with mild stroke and medium/low support is not as high as their functional status.
      Overall, the impact of social support on depression and social status already becomes apparent by the first month, but is more dramatic and lasting (fig 1, table 2) with regard to functional status.

      Social support subvariables and rehabilitation variables

      To determine the degree to which the three family support subvariables (compliance, instrumental support, and emotional support) affected patients' rehabilitation variables, we performed ANOVA tests with patients of high and medium/low support. F values and levels of significance of these comparisons are given in table 4. The amount of compliance with therapeutic instructions was found to have no significant effect on patients' functional, depression, and social status scores. Instrumental support of high quantity significantly affected patients' functional and social status throughout the 6-month period, while its effect on depression was limited. Last, emotional support in large amounts significantly affected the psychosocial health variables at the first- and third-month measurement and the functional variable at the third- and sixth-month measurements. Probably, the functional and social status of high support patients improves until the sixth month, mainly as a result of high instrumental and emotional support. The depression status improves at first through third month, mainly as a result of high emotional support.
      Table 4Analysis of variance tests of functional psychological and social status by high and medium/low support*
      Significance of F
      SubvariablesFunctional StatusPsychological StatusSocial Status
      Compliance with therapeutic instructions
       1st monthNSNSNS
       3rd monthNSNSNS
       6th monthNSNSNS
      Instrumental support
       1st monthp =.008p =.036p =.002
       3rd monthp =.010NSp =.001
       6th monthp =.004NSp =.040
      Emotional support
       1st monthNSp =.004p =.035
       3rd monthp =.022p =.013p =.010
       6th monthp =.023NSNS
      * At each support subvariable, patients are grouped as high support (score 70-100) or medium/low support (score 0-69) subjects. NS, not significant.

      Discussion

      The longitudinal method applied in this study revealed that the quantity of family social support received by the 43 first-stroke patients was found to significantly predict changes in their functional status as well as in their social and depression status within the first 6 months after the stroke. Among more severely impaired patients, a high level of support was found to be predictive of a great amount of progressive functional improvement. Functional recovery in these patients showed the steepest curves (fig 1), even after the third month, although it did not reach the level shown by the mild stroke patients, who also sustained their improvement over a longer period. Depression and social status recovery were not found to have a significant interaction with family support and stroke severity. However, the trajectories of change in moderate/severe stroke and higher support were more or less similar to those of mild stroke and lower support (fig 1). Lower scores and a lower rate of improvement were found for depression and social status than for functional status, revealing a more rigid and less predictable character. A certain decline noticed in these latter variables between 3 and 6 months, particularly in the high support groups, indicates that psychosocial rehabilitation does not eventually follow functional rehabilitation. The reason is possibly related to patients' disappointment that the process was not as complete as expected. Further investigation on this issue is required, because researchers
      • Robinson RG
      • Bolduc PL
      • Kubos KL
      • Starr LB
      • Price TR
      Social functioning assessment in stroke patients.
      • Feibel JH
      • Springer CJ
      Depression and failure to resume social activity after stroke.
      have found a significant correlation between depression and failure to resume social activity after stroke. Besides, it might be argued that because depression is affected by family support, it may at the same time have in itself a profound effect on the family. In studies where social support is not taken into account, a worse recovery picture
      • Astrom M
      • Asplund K
      • Astrom T
      Psychosocial function and life satisfaction after stroke.
      with increased depression
      • Espmark S
      Stroke before 50: follow up study of vocational and physiological adjustment.
      is observed in the majority of patients. Our findings stress the benefits of social support even in more severely impaired patients. The data also indicate that functional recovery alone should not be considered as the evidence of patient well-being.
      The importance of family environment and social support for stroke disease, which has been stressed also by other authors,
      • Evans RH
      • Bishop DS
      Psychosocial outcomes in stroke survivors.
      • King RB
      Quality of life after stroke.
      is extensively illustrated in this study, which was carried out in the Athenian urban milieu; FSS scores did not change over time. Two-thirds of the patients received high levels of social support at home, although families in general have been reported to have limited initial knowledge about the special characteristics of the illness
      • Williams SE
      • Freer CA
      Aphasia: its effects on marital relationships.
      and community rehabilitation services are rare. Only 9% of the patients received low levels of support. In fact, these patients were mostly those taken to nursing homes. Nursing homes are considered inefficient, and, for this reason, most Athenian families keep their patients at home, intending to offer appropriate amounts of support. Also, because in our sample most patients were recovering at home, the small percentage of low support seems reasonable. Most of the patients were married and a number of them lived with their spouse and/or children, while three patients moved to their children's home after the incidence. Caregivers were women in most cases (20 wives) and by tradition after milieu, women are more supportive than men. This may be the reason why the majority of patients receiving medium/low support were also women.
      The present data also provide evidence about specific dimensions of social support. It was observed that the contribution of the three support subvariables to the beneficial effect of high social support is not equivalent. Compliance with therapeutic instructions, which is known to affect positively the course of a number of illnesses,
      • Granger CV
      • Hamilton BB
      • Gresham GE
      The stroke rehabilitation outcome study: part I. General description.
      did not significantly affect the recovery process. On the other hand, instrumental support in high quantity was found to have a positive impact on functional status as well as on social status. Finally, high levels of emotional support from family members also had a profound effect on patients' rehabilitation variables (table 4).

      Study limitations

      The small sample size in this study calls for cautious interpretations. Consecutive and systematic measurements were intended to balance this shortcoming. The FSS was constructed for a direct and objective assessment of social support and an attempt to overcome any weakness of this instrument was made by reliability and validity tests and reassessment of all patients in the third month by the same interviewer. Yet, ratings by the same interviewer may imply bias, which could affect some variables.
      Recruitment of all patients by the same facility is another shortcoming of the study.
      Given the correlational nature of the study design, cause and effect relationships between support and stroke severity cannot be clearly distinguished, and therefore this is one more study limitation.
      It has been recommended by a consensus conference on stroke research that follow-up assessment be performed from the time of stroke onset.
      • Gresham G
      Methodological issues in stroke outcome research.
      All follow-up assessments in our study were performed at 1, 3, and 6 months from disease onset, but, before those, the first assessment of functional status was performed before discharge, the day of which varied.
      Premorbid measures of family social support were not available. It is thus impossible to know whether support before stroke differs from support after stroke. It is also not possible to assess whether more social support is a function of either stroke severity or recovery progress. Any such assessment, though, would not minimize the noteworthy association of social support with functional capacity and other rehabilitation variables.
      In this study, ordinal level scores were treated as if they were equal interval and this places a great deal of trust in the robustness of the multivariate statistics.
      Patients who received high support had a slightly less severe stroke, a younger age, and a relatively better ADL score at discharge—a tendency noticed also in other studies
      • Alexander MP
      Stroke rehabilitation outcome.
      —and the majority were men. A possible correlation between gender and support was revealed in this study. This correlation, however, which is crucial though not surprising, requires more extensive consideration. If, for instance, caregivers were men in most cases, would scores of social support have been much lower? Further investigation is needed to clarify which patient subgroups tend to be at a disadvantage regarding family care, and how this can be avoided.
      In conclusion, the amount of family social support can, to a considerable extent, predict patient well-being better than features of the illness believed to be powerful, such as severity. The present evidence stresses the healing effect of a supportive family environment and the particular importance of instrumental and emotional support, illustrating at the same time how vulnerable stroke patients are to depression. Further research is needed to define factors that improve patients' psychosocial well-being, thus contributing to a holistic stroke recovery. Finally, it is suggested that stroke rehabilitation programs should aim at high levels of family support through education and other forms of assistance. Such procedures will help families to maintain and strengthen their supportive dynamics.

      Acknowledgements

      We thank Dr. Lia Tselika-Garfe, Department of Health Science, Athens, for helpful feedback and suggestions, and Ms. Sofia Argyropoulou, Ms. Kallioppi Vakrakou, and Ms. Despina Savvidou, for contacting the patients and carrying out the interviews.

      References

        • Cobb S
        Social support as a moderator of life-stress.
        Psychosom Med. 1976; 38: 300-314
        • Berkman LF
        • Syme SL
        Social networks, host resistance and mortality.
        Am J Epidemiol. 1979; 109: 186-204
        • Williams SE
        • Freer CA
        Aphasia: its effects on marital relationships.
        Arch Phys Med Rehabil. 1986; 67: 250-252
        • Hyman MD
        Social isolation and performance in rehabilitation.
        J Chronic Dis. 1972; 25: 85-97
        • Evans RH
        • Bishop DS
        Psychosocial outcomes in stroke survivors.
        Stroke. 1990; 21: II-48-II-49
        • Evans RL
        • Northwood LK
        Social support needs in adjustment to stroke.
        Arch Phys Med Rehabil. 1983; 64: 61-64
        • Astrom M
        • Adolfsson R
        • Asplund K
        • Astrom T
        Life before and after stroke.
        Cerebrovasc Dis. 1992; 2: 28-34
        • Robinson RG
        • Bolduc PL
        • Kubos KL
        • Starr LB
        • Price TR
        Social functioning assessment in stroke patients.
        Arch Phys Med Rehabil. 1985; 66: 496-500
        • Ebrahim S
        • Barer D
        • Nouri F
        Affective illness after stroke.
        Br J Psychiatry. 1987; 151: 52-56
        • Lawrence L
        • Christie D
        Quality of life after stroke: three-year follow-up.
        Age Aging. 1979; 8: 164-172
        • Ahlsio B
        • Britton M
        • Murray V
        • Theorell T
        Disablement and quality of life after stroke.
        Stroke. 1984; 15: 886-890
        • Alexander MP
        Stroke rehabilitation outcome.
        Stroke. 1994; 25: 128-134
        • Feigenson JS
        • McDowell FH
        • Meese P
        • McCarthy ML
        • Greenberg SD
        Factors influencing outcome and length of stay in a stroke rehabilitation unit. Part 1. Analysis of 248 unscreened patients—medical and functional prognostic indicators.
        Stroke. 1977; 8: 651-656
        • Young JB
        • Forster A
        The Bradford community stroke trial: results at six months.
        Br Med J. 1993; 304: 1085-1089
        • Johansson BB
        • Jadback G
        • Norrving B
        • Widner H
        • Wiklund I
        Evaluation of long-term functional status in first-ever stroke patients in a defined population.
        Scand J Rehabil Med Suppl. 1992; 26: 105-114
        • Lehmann JF
        • DeLateur BJ
        • Fowler Jr, AS
        • Warren CG
        • Arnhold R
        • Schertzer G
        • et al.
        Stroke rehabilitation: outcome and prediction.
        Arch Phys Med Rehabil. 1975; 56: 383-389
        • Shapiro J
        Family reactions and coping strategies in response to physically ill or handicapped child: a review.
        Soc Sci Med. 1983; 17: 913-931
        • Bishop DS
        • Epstein NB
        • Keitner GI
        • Miller IW
        • Srinivasan SV
        Stroke morale family functioning, health status and functional capacity.
        Arch Phys Med Rehabil. 1986; 67: 84-87
        • Pilisuk M
        • Parks SH
        The healing web: social networks and human survival.
        University Press of New England, Hanover (NH)1986
        • Reiss D
        • Gonjalez S
        • Kramer N
        Family process, chronic illness and death on weakness of strong bonds.
        Arch Gen Psychiatry. 1986; 43: 795-804
        • Evans RL
        • Bishop DS
        • Matlock AL
        • Stranahan S
        • Smith GC
        • Halar EM
        Family interaction and treatment adherence after stroke.
        Arch Phys Med Rehabil. 1987; 68: 513-517
        • Strickland R
        • Altson J
        • Davidson J
        Negative influence of families on compliance.
        Hosp Community Psychiatry. 1981; 32: 349-350
        • Gresham GE
        • Phillips TF
        • Wolf PA
        Epidemiologic profile of long term disability: Framingham study.
        Arch Phys Med Rehabil. 1979; 60: 487-491
        • Glass TA
        • Matchar DB
        • Belyea M
        • Feussner JR
        Impact of social support on outcome in first stroke.
        Stroke. 1993; 24: 64-70
        • Glass TA
        • Maddox GL
        The quality of social support: stroke recovery as psycho-social transition.
        Soc Sci Med. 1992; 34: 1249-1261
        • Vemmos KN
        • Georgilis K
        • Zis V
        • Gouliamos A
        • Toumanidis S
        • Barbaresou M
        • et al.
        The Athens Stroke Registry: final results of a three-year hospital based study [Abstract].
        Cerebrovasc Dis. 1996; 6: 65
        • Scandinavian Stroke Study Group
        Multicenter trial of hemodilution in ischemic stroke: background and study protocol.
        Stroke. 1985; 16: 885-890
        • Lindestrom E
        • Boysen G
        • Christiansen LW
        • Rogvi-Hansen B
        • Nielsen PW
        Reliability of Scandinavian neurological stroke scale.
        Cerebrovasc Dis. 1991; 1: 103-107
        • Roden-Jullig A
        • Britton M
        • Gustafsson C
        • Fugl-Meyer A
        Validation of four scales for the acute stage of stroke.
        J Intern Med. 1994; 236: 125-136
        • Mahoney FI
        • Barthel DW
        Functional evaluation: the Barthel index.
        Md State Med J. 1965; 14: 61-63
        • Collins C
        • Wade S
        Horne V. The Barthel ADL index: a reliability study.
        Int Disabil Studies. 1988; 10: 61-63
        • Granger CV
        • Hamilton BB
        • Gresham GE
        The stroke rehabilitation outcome study: part I. General description.
        Arch Phys Med Rehabil. 1988; 69: 506-509
        • Wood-Dauphinee SL
        • Williams IJ
        • Shapiro SH
        Examining outcome measures in a clinical study of stroke.
        Stroke. 1990; 21: 731-739
        • Zung WWK
        A self-rating depression scale.
        Arch Gen Psychiatry. 1965; 12: 63-70
        • Wade DT
        • Legh-Smith J
        • Hewer RA
        Depressed mood after stroke.
        Br J Psychiatry. 1987; 151: 200-205
        • Herrmann N
        • Black SE
        • Lawrence J
        • Szekely C
        • Szalai JP
        The Sunnbrook stroke study: a prospective study of depressive symptoms and functional outcome.
        Stroke. 1998; 9: 618-624
        • Zung WWK
        • Magruder-Habib K
        • Velez R
        • Alling W
        The comorbidity of anxiety and depression in general medical patients: a longitudinal study.
        J Clin Psychiatry. 1990; 51: 77-80
        • Goldberg DP
        The detection of psychiatric illness by questionnaire.
        Oxford University Press, Oxford1972
        • Goldberg DP
        • Hillier VF
        A scaled version of the general health questionnaire.
        Psychol Med. 1979; 9: 139-145
        • Robinson RG
        • Price TR
        Post-stroke depressive disorders: a follow-up study of 103 patients.
        Stroke. 1982; 13: 635-641
        • Ebrahim S
        • Barer D
        • Nouri F
        Affective illness after stroke.
        Br J Psychiatry. 1987; 151: 52-56
        • Bishop D
        • Evans R
        Family functioning assessment techniques in stroke.
        Stroke. 1990; 21 Suppl II: II-50-II-51
        • Sideris DA
        • Tsouna-Hadjis P
        • Toumanidis ST
        • Vardas PE
        • Moulopoulos SD
        Attitudinal educational objectives at therapeutic consultation.
        Med Educ. 1986; 20: 307-313
        • American Heart Association
        Family guide to stroke treatment, recovery and prevention.
        Times Books, New York1994
        • Feibel JH
        • Springer CJ
        Depression and failure to resume social activity after stroke.
        Arch Phys Med Rehabil. 1982; 63: 276-278
        • Astrom M
        • Asplund K
        • Astrom T
        Psychosocial function and life satisfaction after stroke.
        Stroke. 1992; 23: 527-531
        • Espmark S
        Stroke before 50: follow up study of vocational and physiological adjustment.
        Scand J Rehabil Med. 1973; : 1-107
        • King RB
        Quality of life after stroke.
        Stroke. 1996; 27: 1467-1472
        • Gresham G
        Methodological issues in stroke outcome research.
        Stroke. 1990; 21: II-1-II-2