Changes in the acute functional and cognitive disability states of severe hemorrhagic stroke patients.
Article Type: Report
Subject: Stroke patients (Care and treatment)
Stroke patients (Psychological aspects)
Aneurysms (Care and treatment)
Cognition disorders (Care and treatment)
Brain (Injuries)
Brain (Care and treatment)
Authors: Oh, HyunSoo
Seo, WhaSook
Pub Date: 10/01/2010
Publication: Name: Journal of Neuroscience Nursing Publisher: American Association of Neuroscience Nurses Audience: Professional Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 American Association of Neuroscience Nurses ISSN: 0888-0395
Issue: Date: Oct, 2010 Source Volume: 42 Source Issue: 5
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 238912115
Full Text: ABSTRACT

The purpose of this study was to characterize temporal patterns of functional and cognitive disability changes during the acute period in hemorrhagic stroke patients. The study subjects were 62 hemorrhagic stroke patients admitted to a surgical intensive care unit at a university hospital located in Incheon, South Korea. As outcome variables, functional disability, cognitive ability, and employment status were evaluated directly at 1, 3, and 6 months after admission. The results showed that significant improvements in functional and cognitive ability were observed between 1 and 6 months after admission. In terms of functional disability, subjects considered their overall functional ability (dependence on others) to be less recovered than the specific functional abilities (feeding, grooming, or toileting): 75% of the subjects stated that they were completely independent on others, whereas 92.9%, 83.9%, and 83.9% of subjects indicated that they were completely independent for feeding, grooming, and toileting at the 6-month assessments, respectively. In terms of cognitive ability, attention, communication, and memory recovery rates were found to be relatively good. However, the proportion of subjects that achieved complete problem solving and safety and social behavior recovery were lower than those that achieved attention, communication, and memory recovery. Our findings can provide the empirical evidences when neuroscience nurses use educational and supportive strategies for rehabilitation of hemorrhagic stroke patients.

**********

Hemorrhagic stroke can be subclassified as intracerebral or subarachnoid (Black & Hawks, 2006; Phipps, Sands, & Marek, 1999). In intracerebral hemorrhage (ICH), which accounts for 10% to 15% of all strokes, bleeding occurs directly into brain parenchyma in the absence of trauma or surgery, primarily by leakages from small intracerebral arteries damaged by chronic hypertension (Fewel, Thompson, & Hoff, 2003). Subarachnoid hemorrhage (SAH) accounts for approximately 1% to 7% of all strokes and mainly results from aneurysmal rupture, which can be the most devastating neurological catastrophes affecting relatively young adults (Vespa et al., 1997). The mortality rate for spontaneous ICH (sICH) has been reported to be 23.3% to 34.0% (Kim & Lee, 2005; Liu et al., 2006; O & Byun, 1991; Tanne et al., 2006), and 66% to 76.7% of those that survive have been reported to be disabled (Kim & Lee, 2005; O & Byun, 1991; Yamaguchi et al., 2006), whereas the mortality and disability rates for spontaneous SAIl (sSAH) are 40% to 50%, respectively (Bonita & Thomson, 1985; Bornstein, Weir, Petruk, & Disney, 1987; Yamaguchi et al., 2006).

The primary outcome measures of hemorrhagic stroke are fatality and functional handicap rates (Hop, Rinkel, Algra, & Gijn, 2001). However, it has been proposed that the outcome measures generally used should be varied because of the diverse natures of associated disabilities, that is, physical and emotional dysfunctions and impairments of memory, attention, communication, and problem-solving ability (Bonita & Thomson, 1985; Bornstein et al., 1987; Lim & Chun, 2000; Scheid, Walther, Guthke, Preul, & von Cramon, 2006). During critical periods, physical and cognitive dysfunctions tend to be overlooked. However, after passing the critical period, patients and families now start to realize that they are in serious distress associated with the physical and cognitive dysfunctions required for basic daily activities and the demands of the 24-hour patient supervision and monitoring (Rosenthal, Griffith, Kreutzer, & Pentland, 1999).

Numerous investigations have been conducted on mortality rates and prognostic indicators of mortality in hemorrhagic stroke patients (Bonita & Thomson, 1985; Bornstein et al., 1987; Kim & Lee, 2005; Liu et al., 2006; O & Byun, 1991; Tanne et al., 2006; Yamaguchi et al., 2006). As mortalities resulting from hemorrhagic stroke decline because of diagnostic and treatment improvements (Ukraintseva, Sloan, Arbeev, & Yashin, 2006), disabilities resulting from hemorrhagic stroke seem set to increase. Thus, there is a need for modalities that better predict disability type and degree after hemorrhagic stroke and that provide an improved basis for establishing detailed rehabilitation plans and family counseling.

It has been reported that cognitive and functional improvements occur rapidly between 3 and 9 months after hemorrhagic stroke and that these then tend to plateau at 9 months (Mocco et al., 2006; Samra et al., 2007). Under clinical care, most hemorrhagic stroke survivors experience marked recovery during the acute periods, but specifics concerning the types and degrees of disability and the nature of the acute recovery progress after hemorrhagic stroke have not been fully clarified. Therefore, the purpose of this study was to characterize temporal patterns of functional and cognitive disability changes during the acute period in hemorrhagic stroke patients.

There are some variations among different literature sources regarding how to define acute stage in brain injury (Ding et al., 2008; Holm, Schonberger, Ingrid, & Caetano, 2009). This study defined an acute stage as starting at the onset of brain injury and lasting 6 months, including a transition period (sub-acute) between the acute and the chronic periods.

Research Questions

The specific research questions of this study are as follows: (1) What are the temporal patterns of functional changes during the first 6 months after hemorrhagic stroke? (2) What are the temporal patterns of cognitive changes during the first 6 months after hemorrhagic stroke?

Method

Design and Subjects

In this study, we adopted a nonexperimental prospective research design. The study subjects were 62 hemorrhagic stroke patients admitted to a surgical intensive care unit (ICU) at a university hospital located in Incheon, South Korea. Inclusion criteria were as follows: (1) hemorrhagic stroke patients admitted within 6 hours of onset, (2) patients with admission Glasgow Coma Scale (GCS) scores of <8 (severely brain damaged), (3) patients with age >18 years, and (4) patients with no previous physical or cognitive disabilities.

In this study, the GCS score was assessed to determine the severity of brain injury, which might affect functional and cognitive recovery. Study subjects were limited to patients with admission GCS scores of <8 on the basis of previous studies showing that the GCS score significantly reflected the severity and that total GCS scores of 8 or below indicated severe brain injury (Bahloul et al., 2004; Hukkelhoven et al., 2005; Mosenthal et al., 2004; Rovlias & Kotsou, 2004).

Data Collection

GCS scores and demographic and other general data were collected at the time of admission. Outcome variables, that is, functional disability and cognitive ability, were evaluated directly at 1, 3, and 6 months after admission to an ICU. For subjects discharged before the 6-month evaluation, the information required to assess outcome variables was obtained by telephone interviews. All data were collected by the first author.

Data collection was performed with permission from the institutional review board of research in the hospital. Informed consent for medical record reviews was obtained from patients or family members on behalf of the patients who were in an inadequate condition to make a decision. Because ICU patients are usually unconscious and their families are not allowed to visit patient except regular visiting hours, it was not often possible to get consent from patients or families. In this study, first getting consent to access the medical records was occasionally failed. Data without patient consent were not included in this study.

Separate informed consents for each 1-, 3-, and 6-month recovery data were also obtained. Although our subjects were incapable of giving informed consent at admission (GCS scores of <8), they often regained the ability to make informed decision. In such cases, informed consents were obtained directly from the patients at each follow-up. We provided the following information to patients and families when obtaining informed consent: purpose and process of this study in detail and confidentiality of all data.

Measurements

To evaluate functional disability, the Rappaport Disability Rating Scale (DRS) was used. Because the DRS has been reported to be highly reliable and valid tools to measure functional disability of moderate and severe brain injury patients in previous other studies (Fleming & Maas, 1994; Gouvier, Blanton, Laporte, & Nepomyceno, 1987; Rappaport, Hall, Hopkins, Belleza, & Cope, 1982; van Baalen et al., 2003), this scale was considered to be appropriate for measuring functional disability of severe hemorrhagic stroke patients in this study. The DRS is an eight-item self-rating scale that consists of four main areas, "arousability and awareness," "ability for self-care," "dependence on others," and "psychosocial adaptability" (Rappaport et al., 1982). However, only the factors ability for self-care and dependence on others were used in this study because these two were directly related to functional disability. This scale is so simple, specific, and easy to understand that it could be easily applied over the telephone. Higher scores represent higher levels of functional disability. It was found to have a Cronbach's [alpha] (internal consistency of reliability) of .93 in this study.

Cognitive ability was measured using the Functional Cognitive Index (FCI), which was designed to assess attention, communication, behavior/safety, behavior/social, problem solving, and memory. The FCI is a six-item, 6-point self-rating scale, that is, "coma and vegetative state," "severely disabled," "moderately disabled," "mildly disabled," "minimally disabled," and "almost normal." This scale has been acknowledged to be highly applicable in various clinical settings (Labi, Brentjens, Shaffer, Weiss, & Zielezny, 1998). The reliability coefficient (internal consistency of reliability) of this scale in this study was .98.

To measure functional and cognitive ability comprehensively, the employment status was also measured using the "psychosocial adaptability" subscale of DRS. Employment status was evaluated by asking the subjects to rate on a 4-point scale: "not restrictive" (can compete in the open market for a relatively wide range of job commensurate), "competitively sheltered" (can compete in a limited job market for a relatively narrow range of job), "not competitive, sheltered" (cannot compete successfully in job market), and "not employable" (completely unemployable) (Rappaport et al., 1982).

Data Analysis

Statistical analysis was performed using the Statistical Package for the Social Science for Windows (Version 12.0; SPSS Inc., Chicago, IL). Descriptive analysis was used to analyze general subject characteristics. Repeated measures ANOVA and Schaffe test were used to determine the significance of pattern changes in functional and cognitive disability. The Freedman test and the Wilcoxon sign test were used to determine the significance of pattern changes in each subareas of functional and cognitive disability.

Findings

Descriptive Statistics

Of the 62 subjects enrolled in this study, 26 (42%) were men and 36 (58%) were women. Subject age (mean [+ or -] SD) was 54.06 [+ or -] 12.05 years. Regarding diagnosis, 23 subjects (38.7%) had sICH and 38 subjects (61.3%) had aneurismal sSAH. The bleeding sites of 23 ICH subjects were thalamus (n = 8), cerebral hemisphere (n = 5), basal ganglia (n = 4), cerebellum (n = 2), and pons (n = 1). In terms of SAH, aneurysm locations were anterior communicating artery (n = 11), middle cerebral artery (n = 10), posterior communicating artery (n = 4), internal carotid artery (n = 2), and basilar artery (n = 1). The mean amount of bleeding was 12.0 [+ or -] 13.1 ml with a range from 1.4 to 54.0 ml (computed using data from 21 subjects' medical records).

After hemorrhagic stroke, intracranial hematoma was observed in 96.8% and a midline shift in 6.5%. Hypertensive subjects accounted for 48.4% (n = 30) of the study subjects and diabetes mellitus patients for 8.1% (n = 5). In terms of surgical modalities related to stroke, 26 (41.9%) had undergone surgery, for example, clipping (80.8%), extralesional or extraventricular drainage (11.5%), hematoma removal, or coiling (10.2%). The remaining 36 (58.1%) received only medical therapy. Mean patients' GCS score at the time of ICU admission was 4.37 [+ or -] 1.69 (range = 3-8). Routine bedside physical therapy with active range of motion exercise was provided to all acute brain injury patients one to two times a day for 10 to 20 minutes each time in the institution, in which data of this study were collected.

Progress in Functional Disability

Table 1 demonstrates that functional disability scores progressively decreased over the 6-month period after admission, signifying a significant progressive improvement in functional ability (p = .00; Table 1). In addition, post hoc analysis showed that these improvements in functional ability between 1 and 3 months and between 3 and 6 months were statistically significant (p = .00 and .02, respectively). However, improvements in functional ability were more prominent and rapid between 1 and 3 months after admission (Table 1).

Our analysis of subareas of functional ability showed that all significantly improved during the 6-month period after admission (p = .00), for example, self-feeding, grooming, toileting, and dependence on others. Furthermore, grooming and dependence on others were found to improve significantly between 1 and 3 months and between 3 and 6 months (Table 1). For self-feeding and toileting abilities, significant improvements were observed between 1 and 3 months. There were further improvements in self-feeding and toileting abilities between 3 and 6 months, but these were not statistically significant (Table 1).

As shown in Table 2, 66.1% of subjects were able to feed themselves independently at 1-month assessments, and this rate increased to 85.7% and 92.9% at 3- and 6-month assessments, respectively. At 6-month assessments, only 7.1% of subjects were found to be partially dependent, but no subject was totally dependent in terms of feeding. On the other hand, the proportion of subjects completely independent in terms of grooming ability were 48.2%, 75.0%, and 83.9% at 1-, 3-, and 6-month assessments, respectively. The proportion of subjects completely independent in terms of toileting were 51.8% at 1 month, and this increased to 78.6% and 83.9% at 3 and 6 months, respectively, which was similar to that observed for grooming ability.

In this study, the level of dependence on others was evaluated to assess an overall status of functional dependence for physical activities of daily living on others. Results showed that 53.6% of subjects were completely independent at 1 month, and this increased to 69.7% and 75.0% at 3- and 6-month assessments, respectively (Table 2). Thus, it appears that recovery in terms of dependence on others was poorer than recovery as determined by feeding, grooming, and toileting ability.

Progress in Cognitive Disability

The FCI is a 6-point self-rating scale, that is, coma and vegetative state, severely disabled, moderately disabled, mildly disabled, minimally disabled, and almost normal. The content and the relevance of each item of the FCI were pretested upon 20 brain injury patients in a recovery stage and their families. During pretesting, respondents consistently reported that it was difficult to distinguish between mildly disabled and minimally disabled. Therefore, these two were combined in this study.

Table 3 shows that cognitive ability scores increased throughout the 6-month period after admission, indicating a progressive improvement in cognitive ability (p = .00). Post hoc analysis showed that improvements in cognitive ability between 1 and 3 months and between 3 and 6 months were also statistically significant (p = .00).

An analysis of subareas of cognitive ability showed that all significantly improved over the 6-month postadmission period (p = .00), that is, attention, communication, memory, problem solving, safety behavior, and social behavior. Furthermore, improvements in these subareas between 1 and 3 months were all statistically significant (p = .00). Except attention and communication abilities, most subareas showed significant improvements between 3 and 6 months (Table 3).

In terms of attention ability, 73.2% of subjects were completely recovered at 1-month assessments, and this increased to 95.7% and 100.0% at 3- and 6-month assessments, respectively (Table 4). Attention ability was recovered almost near normal in all subjects at 6 months. The proportion of subjects that experienced complete communication recovery were 60.0%, 85.7%, and 87.8% at 1, 3, and 6 months, respectively. At 6-month assessments, 10.2% of subjects had mild and 2.0% had moderate communication impairments (Table 4).

The proportion of subjects that achieved complete memory recovery at 1 month after admission were 50.0%, which was lower than the proportion that achieved complete attention and communication recovery. However, the proportion that achieved complete memory recovery increased rapidly to 81.6% and 93.9% at 3- and 6-month assessments, respectively. At 6 months after admission, only 6.1% of subjects had a mild memory deficit, and no subject had a moderate or severe memory deficit (Table 4).

Recovery rates for problem-solving ability and safety and social behavior were lower than attention, communication, and memory recovery. In terms of problem-solving ability, 51.0%, 69.8%, and 75.7% of subjects had completely recovered at 1, 3, and 6 months after admission (Table 4), and safety and social behavior recovery were found to show almost identical patterns of recovery.

Employment Status

Employment status represents a comprehensive return of physical and cognitive functions. It was found that employment status was improved significantly over the 6-month period after admission (p = .00; Table 3). Furthermore, improvements between 1 and 3 months and between 3 and 6 months were also statistically significant (p = .00). At 1 month after admission, only 16.1% of subjects were ready to return to work without any restriction, and this increased to 37.5% and 62.5% at 3 and 6 months, respectively (Table 4).

Discussion

This study was conducted to analyze functional and cognitive disability patterns over time in patients with a GCS score of <8 at admission after hemorrhagic stroke. The results obtained show that significant functional ability improvements occur over the 6-month postadmission period and that these improvements are most prominent between 1 and 3 months after admission. In particular, self-feeding and toileting abilities improved rapidly and significantly between 1 and 3 months after admission, and maximum recovery status was reached at 3 months; further improvements in self-feeding and toileting abilities between 3 and 6 months were not statistically significant. However, grooming and dependence on others consistently and significantly improved even after 3 months.

In this study, the functional ability that improved most remarkably was self-feeding, that is, 92.9% of subjects were able to feed themselves independently at 6-month assessments. Grooming and toileting abilities also showed significant improvement. However, dependence on others recovery was relatively poorer, that is, approximately 25% of subjects were partially "dependent on others," whereas only 7.1% to 12.5% of subjects were found to be partially dependent for feeding, grooming, or toileting. On the basis of this finding, it can be inferred that subjects regarded their overall functional ability to be impaired although they achieved a higher level of independence with major daily living activities, such as, feeding, grooming, and toileting.

Tanne et al. (2006) reported that 57% of ICH patients were initially assessed as severe or moderate and that 15% of these had a mild handicap at time of discharge. In this previous study, the proportion of patients found to have severe/moderate functional disability were higher than that in this study, although subjects enrolled in this study had a lower mean GCS score at admission. Such inconsistencies between studies in terms of recovery rates may be due to subject age and outcome measurement time differences. In terms of age, the mean subject age in this study was 54 years, whereas in the study of Tanne et al., it was 71 years. Studies have consistently reported that age is inversely correlated with recovery from brain injury (Kelly et al., 2003; Navarrete-Navarro et al., 2003; Saloheimo, Lapp, Juvela, & Hillbom, 2007). During our review of the literature, outcome measurement timing was found to be quite different in this study and in the study of Tanne et al. In this study, measurements were taken at 6 months after admission, whereas Tanne et al. took measurement at the time of discharge, which was only a mean 8 days after admission. Recently, Cooper, Jauch, and Flasherty (2007) found that only 10% to 20% of sICH patients achieved near complete recovery. However, this study contained a higher proportion of patients with a severe functional disability than this study.

Studies vary considerably in functional recovery status after aneurysmal SAH, that is, some have reported mild (Tomberg et al., 2001) or moderate recovery (Mocco et al., 2006), whereas others reported little (Hellawell & Pentland, 2001). As compared with these studies, our subjects showed relatively good functional recoveries and disability rates after sSAH. However, further studies are required to define the variables that affect functional recovery after sSAH.

Hemorrhagic stroke patients may experience diverse cognitive disabilities, involving impairments of attention, orientation, communication, memory, problem solving, and judgment (Guise, Feyz, LeBlanc, Richard, & Lamoureux, 2005; Mavaddat, Sahakian, Hutchinson, & Kirkpatrick, 1999; Scheid et al., 2006; Vitaz, Jenks, Rague, & Schield, 2003). In this study, cognitive abilities were found to improve significantly between 1 and 6 months after admission. However, although all subareas of cognitive ability examined improved significantly over 6 months, the proportion that achieved complete problem solving and safety and social behavior recovery at 6 months after admission was lower than those that achieved complete attention, communication, and memory recovery. In addition, memory ability progress was poorer and slower than attention and communication progress.

In this study, approximately 25% of subjects were somewhat disabled in terms of problem solving and safety and social behavior at 6 months after admission. Impediments in problem solving and safety and social behavior appear to be associated with executive dysfunction, which can cause difficulties in motivating, planning, and performing task functions (American Association of Neuroscience Nurses, 2001), indicating a requirement for close observation and monitoring because of dependency. Furthermore, because many hemorrhagic stroke patients exhibit negative neurobehavioral changes, despite achieving relatively good physical recoveries, patients and their families experience substantial psychological distress (Buchanan, Elias, & Goplen, 2000). For this reason, patients and families tend to view problem solving and safety and social behavior dysfunctions more negatively than healthcare givers.

Employment status can be taken to represent comprehensive recovery in terms of physical and cognitive function, and the results of this study show that only 62.5% of subjects were ready to return to work without any restriction at 6 months after admission. Thus, apparently, a gap exists between the ability to perform ordinary daily activities and the ability to perform productive task, requiring more complicated mental processes.

Conclusions

In this study, significant improvements in functional and cognitive ability were observed between 1 and 6 months after admission. In terms of functional disability, subjects regarded disabilities associated with overall function (dependence on others) to be less improved than the specific functions (feeding, grooming, and toileting). Moreover, in terms of cognitive ability, attention, communication, and memory recovery rates were found to be relatively good. However, the proportion of patients that achieved complete problem solving and safety and social behavior recovery were lower than those that achieved attention, communication, and memory recovery. Such differences in recovery rate might be related to, in part, the levels of complexity of different types of cognitive ability; that is, problem solving and safety and social behavior were less recovered because they were probably more complicated cognitive abilities that required more comprehensive mental processes than attention or memory does.

There have been various rehabilitation programs designed to cover training for specific types of cognitive ability (such as attention, communication, and memory) or more comprehensive types of cognitive ability (such as problem solving and safety and social behavior). Future research in this area needs to focus on determining which kind of cognitive rehabilitation program, specific or comprehensive, works better for the acute stage of hemorrhagic stroke patients.

It is expected that this result can be meaningful information to neuroscience nurses for a better understanding on the temporal patterns of functional and cognitive disability changes during the acute period in hemorrhagic stroke patients. In addition, our findings can provide the empirical evidences when neuroscience nurses use educational and supportive strategies for rehabilitation of hemorrhagic stroke patients.

The results of this study are limited in terms of their general applicability because of the small sample size. In addition, this study provides information regarding functional and cognitive recovery only within the first 6 months after hemorrhagic stroke. Therefore, further long-term follow-up studies with a large sample will be needed to determine overall functional and cognitive recovery status after hemorrhagic stroke.

DOI: 10.1097/JNN.0b013e3181ecaf81

Acknowledgments

This work was supported by an Inha University research grant.

References

American Association of Neuroscience Nurses. (2001). AANN's neuroscience nursing. Human responses to neurologic dysfunction (2nd ed.). Philadelphia: W.B. Saunders Company. Bahloul, M., Chelly, H., Ben Hamida, M., Ben Hamida, C., Ksibi, H., Kallel, H., et al. (2004). Prognosis of traumatic head injury in South Tunisia: A multivariate analysis of 437 cases. Journal of Trauma, 57(2), 255 261.

Black, J., & Hawks, J. (2006). Medical surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: Elsevier Saunders.

Bonita, R., & Thomson, S. (1985). Subarachnoid hemorrhage: Epidemiology, diagnosis, management, and outcome. Stroke, 16, 591 594.

Bornstein, R. A., Weir, B. K., Petruk, K. C., & Disney, L. B. (1987). Neuropsychological function in patients after subarachnoid hemorrhage. Neurosurgery, 21, 651-654.

Buchanan, K. M., Elias, L. J., & Goplen, G. B. (2000). Differing perspectives on outcome after subarachnoid hemorrhage: The patient, the relative, the neurosurgeon. Neurosurgery, 46, 831 838.

Cooper, D., Jauch, E., & Flasherty, M. (2007). Critical pathways for the management of stroke and intracerebral hemorrhage: A survey of US hospitals. Critical Pathways in Cardiology, 6(1), 18-23.

Ding, K., de la Plata, C. M., Wang, J. Y., Mumphrey, M, Moore, C., Harper, C., et al. (2008). Cerebral atrophy after traumatic with mater injury: Correlation with acute neuroimaging and outcome. Journal of Neurotrauma, 25(12), 1433 1440.

Fewel, M. E., Thompson, B. G. Jr., & Hoff, J. T. (2003). Spontaneous intracerebral hemorrhage: A review. Neurosurgical Focus, 15(4), El.

Fleming, J. M., & Maas, F. (1994). Prognosis of rehabilitation outcome in head injury using the Disability Rating Scale. Archives of Physical Medicine and Rehabilitation, 75, 133-143.

Gouvier, W. D., Blanton, E D., Laporte, K. K., & Nepomyceno, C. (1987). Reliability and validity of the Disability Rating Scale and the levels of Cognitive Functioning Scale in monitoring recovery from severe head injury. Arehives of Physical Medicine and Rehabilitation, 68, 2, 94-97.

Guise, E., Feyz, M., LeBlanc, J., Richard, S., & Lamoureux, J. (2005). Overview of traumatic brain injury patients at a tertiary trauma centre. Canadian Journal of" Neurological Sciences, 32, 186-193.

Hellawell, D. J., & Pentland, B. (2001). Relatives' reports of long term problems following traumatic brain injury or subarachnoid hemorrhage. Disability and Rehabilitation, 23(7), 300 305.

Holm, S., Sch6nberger, M., Ingrid, P., & Caetano, C. (2009). Patients and relatives' experience of difficulties following severe traumatic injury: The sub-acute stage. Neuropsychological Rehabilitation, 19(3), 444-460.

Hop, J., Rinkel, G., Algra, A., & Gijn, J. (2001). Changes in functional outcome and quality of life in patients and caregivers after aneurismal subarachnoid hemorrhage. Journal of Neurosurgery, 95, 957-963.

Hukkelhoven, C. W., Steyerberg, E. W., Habbema, J. D., Farace, E., Marmarou, A., Murray, G. D., et al. (2005). Prediction outcome after traumatic brain injury: Development and validation of a prognostic score based on admission characteristics. Journal of Neurotrauma, 22(10), 1025-1039.

Kelly, P. J., Furie, K. L., Shafqat, S., Rallis, N., Chang, Y., & Stein, J. (2003). Functional recovery following rehabilitation after hemorrhagic and ischemic stroke. Archives of Physical Medicine and Rehabilitation, 84(7), 968 972.

Kim, H., & Lee, S. W. (2005). Prediction of 30-day mortality and functional outcome of patients with intracerebral hemorrhage in emergency department. Journal of the Korean Society of Emergency Medicine, 16(2), 229 237.

Labi, M. L. C., Brentjens, M., Shaffer, K., Weiss, C., & Zielezny, M. A. (1998). Functional Cognitive Index: A new instrument to assess cognitive disability after traumatic brain injury. Journal of Neurologic Rehabilitaion, 12, 45 52.

Lim, S. S., & Chun, M. H. (2000). Characteristics of language disorder in patients with traumatic brain injury. Journal of Korean Academy of Rehabilitation Medicine, 24(3), 381-387.

Liu, X., Xu, G., Wu, W., Zhang, R., Yin, Q., & Zhu, W. (2006). Subtypes and one-year survival of first-ever stroke in Chinese patients: The Nanjing stroke registry. Cerebrovascular Diseases, 22(2 3), 130-136.

Mavaddat, N., Sahakian, B. J., Hutchinson, E J., & Kirkpatrick, E J. (1999). Cognition following subarachnoid hemorrhage from anterior communicating artery aneurysm: Relation to timing of surgery. Journal of Neurosurgery, 91(3), 402-407.

Mocco, J., Ransom, E. R., Komotar, R. J., Sergot, E B., Ostapkovich, N., Schmidt, J. M., et al. (2006). Long-term domain-specific improvement following poor grade aneurysmal subarachnoid hemorrhage. Journal of Neurology, 253(10), 1278-1284.

Mosenthal, A. C., Livingston, D. H., Lavery, R. F., Knudson, M. M., Lee, S., Morabito, D., et al. (2004). The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. Journal of Trauma, 56(5), 1042 1048.

Navarrete-Navarro, E, Rivera-Fernandez, R., Lopez-Mutuberria, M. T., Galindo, I., Murillo, F., Dominguez, J., et al. (2003). Outcome prediction in terms of functional disability and mortality at 1 year among ICU-admitted severe stroke patients: A prospective epidemiological study in the south of the European Union (Evascan Project, Andalusia, Spain). Intensive Care Medicine, 29, 1237-1244.

O, K.Y., & Byun, Y.J. (1991). 103 cases of young adults with stroke: The causes and prognosis. Journal of Korean Neurosurgical Society, 9(4), 405-412.

Phipps, W., Sands, J., & Marek, J. (1999). Medical-surgical nursing: Concepts and clinical practice (6th ed.). St. Louis: C.V. Mosby.

Rappaport, M., Hall, K. M., Hopkins, K., Belleza, T., & Cope, D. N. (1982). Disability Rating Scale for severe head trauma: Coma to community. Archives of Physical Medicine and Rehabilitation, 63, 118 123.

Rosenthal, M., Griffith, E., Kreutzer, J., & Pentland, B. (1999). Rehabilitation of the adult and child with traumatic brain injury (3rd ed.). Philadelphia: F.A. Davis.

Rovlias, A., & Kotsou, S. (2004). Classification and regression tree for prediction of outcome after severe head injury using simple clinical and laboratory variables. Journal of Neurotrauma, 21(7), 886-893.

Saloheimo, P., Lapp, T. M., Juvela, S., & Hillbom, M. (2007). The impact of functional status at three months on long-term survival after spontaneous intracerebral hemorrhage. Stroke, 37(2), 487-491.

Samra, S. K., Giordani, B., Caveney, A. F., Clarke, W. R., Scott, P. A., Anderson, S., et al. (2007). Recovery of cognitive function after surgery for aneurysmal subarachnoid hemorrhage. Stroke, 38, 1864-1872.

Scheid, R., Walther, K., Guthke, T., Preul, C., & von Cramon, D. Y. (2006). Cognitive sequel of diffuse axonal injury. Archives of Neurology, 63, 418-424.

Tanne, D., Goldbourt, U., Koton, S.S., Grossman, E., Koren-Morag, N., Green, M.S., et al. (2006). A national survey of acute cerebrovascular disease in Israel: Burden, management, outcome and adherence to guidelines. Israel Medical Association Journal, 8, 3-7.

Tomberg, T., Orasson, A., Linnamagi, U., Toomela, A., Pulver, A., & Asser, T. (2001). Coping strategies in patients following subarachnoid hemorrhage. Acta Neurologica Scandinavica, 104(3), 148-155.

Ukraintseva, S., Sloan, F., Arbeev, K., & Yashin, A. (2006). Increasing rates of dementia at time of declining mortality from stroke. Stroke, 37, 1155-1159.

van Baalen, B., Odding, E., Maas, A. I. R., Ribber, G. M., Bergen, M. P., & Stam, H. J. (2003). Traumatic brain injury: Classification and initial severity and determination of functional outcome. Disability and Rehabilitation, 25(1) 9-18.

Vespa, P. M., Nuwer, M. R., Juhasz, C., Alexander, M., Nenov, V., Martin, N., et al. (1997). Early detection of vasospasm after acute subarachnoid hemorrhage using continuous EEG ICU monitoring. Electroencephalography and Clinical Neurophysiology, 103(6), 607-615.

Vitaz, T. W., Jenks, J., Rague, G. H., & Schield, C. B. (2003). Outcome following moderate traumatic brain injury. Surgical Neurology., 60, 285-291.

Yamaguchi, M., Sakurai, H., Shimizu, M., Tsushio, Y., Nakagawa, N., Masui, T., et al. (2006). Analysis of complications and prognosis for different types of stroke patients registered between 1993 and 2000 in Aichi Prefecture. Nippon Koshu Eisei Zasshi, 53(1), 20 28.

HyunSoo Oh, PhD RN, is a professor at the Department of Nursing, College of Medicine, Inha University, Incheon, Republic of Korea.

Questions or comments about this article may be directed to WhaSook Seo, PhD, at wschang@inha.ac.kr. She is a professor at the Department of Nursing, College of Medicine, Inha University, Incheon, Republic of Korea.
TABLE 1. Functional Disability at 1, 3, and 6 Months After Admission
and Analysis in the Subareas of Functional Ability (N = 62)

                       Descriptive   RM-ANOVA (a)   Post Hoc
                       Statistics                   Comparisons

Variable               Mean   SD     F (b)   p      Pairs   p

1-month functional     4.04   4.21                  A x B   0.00
  disability (A) (c)
3-month functional     1.95   2.92   27.81   0.00   A x C   0.00
  disability (B)
6-month functional     1.34   2.42                  B x C   0.02
  disability (C)

                            Descriptive   Friedman Test
                            Statistics

Variable                    Mean   SD     [chi square]    p

1-month feeding (A) (d)     0.55   0.93
3-month feeding (B)         0.16   0.42   28.67           .00
6-month feeding (C)         0.07   0.26
1-month grooming (A) (d)    0.73   0.88
3-month grooming (B)        0.32   0.64   31.92           .00
6-month grooming (C)        0.20   0.48
1-month toileting (A) (d)   0.88   1.13
3-month toileting (B)       0.32   0.74   34.51           .00
6-month toileting (C)       0.25   0.67
1-month dependence on       1.88   1.60
  others (A) (e)
3-month dependence on       1.14   1.37   56.15           .00
  others (B)
6-month dependence on       0.82   1.24
  others (C)

                            Wilcoxon Sign Test

Variable                    Pairs   Z       p

1-month feeding (A) (d)     A x B   -3.70   .00
3-month feeding (B)         B x C   -3.80   .00
6-month feeding (C)         A x C   -1.89   .06
1-month grooming (A) (d)    A x B   -3.72   .00
3-month grooming (B)        B x C   -4.23   .00
6-month grooming (C)        A x C   -2.11   .04
1-month toileting (A) (d)   A x B   -3.95   .00
3-month toileting (B)       B x C   -4.10   .00
6-month toileting (C)       A x C   -1.08   .28
1-month dependence on       A x B   -4.91   .00
  others (A) (e)
3-month dependence on       B x C   -4.94   .00
  others (B)
6-month dependence on       A x C   -3.25   .00
  others (C)

(a) Repeated measures ANOVA. (b) Greenhouse-Geisser. (c) One-month
functional disability, higher score means higher level of functional
disability. (d) Higher score means higher level of disability.
(e) Dependence on others, and higher score means higher level of
dependency.

TABLE 2. Frequencies of Level of Impairment in the Subareas of
Functional Ability (N = 62)

                      Level of Impairment (%)

                      Completely    Partial
Variable              Independent   Independent

1-month feeding       66.1          21.4
3-month feeding       85.7          12.5
6-month feeding       92.9          7.1
1-month grooming      48.2          37.5
3-month grooming      75.0          19.6
6-month grooming      83.9          12.5
1-month toileting     51.8          268
3-month toileting     78.6          16.1
6-month toileting     83.9          10.7

                      Frequency of Level of
                      Impairment (%)

                                    Mildly
Variable              Independent   Dependent

1-month dependence    53.6          10.7
  on others
3-month dependence    69.7          14.3
  on others
6-month dependence    75.0          12.5
  on others

                      Level of Impairment (%)

                      Minimal
Variable              Independent   No Response

1-month feeding       3.6           8.9
3-month feeding       1.8           0.0
6-month feeding       0.0           0.0
1-month grooming      7.1           7.1
3-month grooming      7.1           1.8
6-month grooming      3.6           0.0
1-month toileting     3.6           17.9
3-month toileting     0.0           5.4
6-month toileting     1.8           3.6

                      Frequency of Level of
                      Impairment (%)

                      Moderately    Totally
Variable              Dependent     Dependent

1-month dependence    26.8          8.9
  on others
3-month dependence    10.7          5.3
  on others
6-month dependence    10.7          1.8
  on others

TABLE 3. Cognitive Disability at 1, 3, and 6 Months After Admission
and Analysis n on the Subareas of Cognitive Ability (N = 62)

                                Descriptive
                                Statistics     RM-ANOVA (a)

Variable                        Mean    SD     F (b)   p

1-month cognitive ability (A)   23.22   8.08
3-month cognitive ability (B)   26.90   5.14   21.00   0.00
6-month cognitive ability (C)   28.02   3.65

                                Post Hoc Comparisons

Variable                        Pairs   p

1-month cognitive ability (A)   A x B   0.00
3-month cognitive ability (B)   A x C   0.00
6-month cognitive ability (C)   B x C   0.00

                                Descriptive
                                Statistics     Friedman Test

Variable                        Mean    SD     [chi square]   p

1-month attention (A)           5.20    1.28
3-month attention (B)           5.84    0.58   26.98          0.00
6-month attention (C)           6.00    0.40
1-month communication (A)       5.11    1.28
3-month communication (B)       5.77    0.67   25.33          0.00
6-month communication (C)       5.83    0.56
1-month memory (A)              4.85    1.38
3-month memory (B)              5.65    0.79   38.88          0.00
6-month memory (C)              5.94    0.25
1-month problem solving (A)     4.44    1.76
3-month problem solving (B)     5.17    1.36   28.20          0.00
6-month problem solving (C)     5.42    1.09
1-month safety behavior (A)     4.46    1.75
3-month safety behavior (B)     5.19    1.34   28.10          0.00
6-month safety behavior (C)     5.43    1.08
1-month social behavior (A)     4.10    1.80
3-month social behavior (B)     5.15    1.33   28.00          0.00
6-month social behavior (C)     5.41    1.07
1-month employment state (A)    1.77    1.11
3-month employment state (B)    1.20    1.17   52.28          0.00
6-month employment state (C)    1.82    1.15

                                Wilcoxon Sign Test

Variable                        Pairs   Z       p

1-month attention (A)           A x B    3.19   0.00
3-month attention (B)           A x C    3.54   0.00
6-month attention (C)           B x C    1.86   0.06
1-month communication (A)       A x B    3.35   0.00
3-month communication (B)       A x C    3.44   0.00
6-month communication (C)       B x C    1.13   0.26
1-month memory (A)              A x B    3.88   0.00
3-month memory (B)              A x C    4.35   0.00
6-month memory (C)              B x C    2.55   0.01
1-month problem solving (A)     A x B    3.34   0.00
3-month problem solving (B)     A x C    3.86   0.00
6-month problem solving (C)     B x C    2.45   0.01
1-month safety behavior (A)     A x B    3.32   0.00
3-month safety behavior (B)     A x C    3.82   0.00
6-month safety behavior (C)     B x C    2.43   0.01
1-month social behavior (A)     A x B    3.31   0.00
3-month social behavior (B)     A x C    3.80   0.00
6-month social behavior (C)     B x C    2.40   0.01
1-month employment state (A)    A x B   -4.44   0.00
3-month employment state (B)    A x C   -5.31   0.00
6-month employment state (C)    B x C   -3.91   0.00

(a) Repeated Measure ANOVA. (b) Greenhouse-Geisser.

TABLE 4. Frequencies of Level of Impairment in the Subarea of
Cognitive Ability (N = 62)

                           Level of Impairment (%)

Variable                   No Response   Severe   Moderate

1-month attention          0              7.3      2.4
3-month attention          0              0        0
6-month attention          0              0        0
1-month communication      0              2.2      8.9
3-month communication      0              0        2.1
6-month communication      0              0        2.0
1-month memory             2.1            6.3      6.2
3-month memory             0              0        2.1
6-month memory             0              0        0
1-month problem solving    4.3           11.3     10.0
3-month problem solving    0              4.2      5.0
6-month problem solving    0              4.1      0
1-month safety behavior    4.3           11.0     10.3
3-month safety behavior    0              6.2      4.2
6-month safety behavior    0              4.1      0
1-month social behavior    4.3           15.3      6.1
3-month social behavior    0             10.2      0
6-month social behavior    0              4.0      0

                           Level of Impairment (%)

Variable                   Mild   Normal

1-month attention          17.1    73.2
3-month attention           4.3    95.7
6-month attention           0     100
1-month communication      28.9    60.0
3-month communication      12.2    85.7
6-month communication      10.2    87.8
1-month memory             35.4    50.0
3-month memory             16.3    81.6
6-month memory              6.1    93.9
1-month problem solving    23.4    51.0
3-month problem solving    21.0    69.8
6-month problem solving    20.2    75.7
1-month safety behavior    23.4    51.0
3-month safety behavior    20.4    69.6
6-month safety behavior    20.4    75.6
1-month social behavior    23.3    51.0
3-month social behavior    20.2    69.6
6-month social behavior    20.4    75.6

                           Not               Competitive
Variable                   Restrictive (%)   Sheltered (%)

1-month employment state   16.1              25.0
3-month employment state   37.5              25.0
6-month employment state   62.5               5.4

                           Not               Not
Variable                   Competitive (%)   Employable (%)

1-month employment state   26.8              32.2
3-month employment state   19.6              17.9
6-month employment state   19.6              12.5
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.