The relationship of physical function to social integration after stroke.
Article Type: Report
Subject: Stroke patients (Care and treatment)
Stroke patients (Social aspects)
Interpersonal relations (Management)
Interpersonal relations (Health aspects)
Outcome and process assessment (Health Care) (Methods)
Authors: Baseman, Susan
Fisher, Kathleen
Ward, Louise
Bhattacharya, Anand
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
Topic: Event Code: 290 Public affairs; 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 238912114

Stroke is a leading cause of death and a serious long-term disability in this country. Much of the research on stroke rehabilitation has focused on physical/functional recovery as the predominant measure of outcome. There is a gap in knowledge of social issues and integration into societal, family, and community roles after stroke. A descriptive, correlational survey design was used to examine the relationships of functional status, depression, and overall stroke recovery to social integration in a convenience sample of ischemic stroke survivors. The survey response rate was 21.4%. Results showed that functional status, overall stroke recovery, and depression are highly significant predictors of social integration, explaining 62% of the variance (adjusted [R.sup.2]). Comorbid depression was negatively (-.74) and significantly (.01, two-tailed) correlated to social integration, such that higher levels of depression are associated with lower levels of social integration. Finally, employment status after stroke dropped from 48% to 4.2%, and poststroke employment status was correlated to social integration (significance = .03). Care for patients with chronic conditions like stroke should address all domains of the individual--physical, psychosocial, and environmental. Factors including depression and perceptions of overall stroke recovery are significant and should be addressed in the rehabilitation process to better promote social integration. Social integration is an important and understudied aspect of stroke recovery that warrants further research.


Stroke is the third leading cause of death in the United States, accounting for approximately 1 in every 15 deaths, and is a leading cause of disability (Duncan et al., 2005; Goldstein et al., 2006; Siebens, 2002; Thom et al., 2006). Each year, approximately 700,000 people experience a stroke (Goldstein et al., 2006), and the estimated direct and indirect cost for stroke in 2006 was $57.9 billion (Thom et al., 2006).

Stroke alters the individual's capacity for social role functioning, and survivors of stroke are often at risk for a loss of functional independence (Duncan et al., 2005; Glass & Maddox, 1992). Social role functioning is often adversely affected by stroke-related losses in physical, cognitive, and psychological functioning, including changes in affect,

mood, and behavior. Belanger, Bolduc, and Noel (1988) define social integration as follows: "Integration ... is concerned with three main aspects: to live in the most natural environment possible, to interact with a wide variety of people, and to take part in the usual activities of our society" (p. 253).

Much of the research and literature on stroke and stroke rehabilitation has focused on physical functional recovery as the predominant measure of outcome (Duncan et al., 2005; Forster & Young, 1996; Roth & Lovell, 2003). Integration with regard to family and social roles and community involvement is increasingly emphasized in poststroke rehabilitation guidelines, standards of care, and evidence-based reviews of stroke rehabilitation (Duncan et al., 2005; Siebens, 2002; Teasell, Foley, Bhogal, & Speechley, 2003; Wojner, 2000).


The purpose of this research was to explore the relationship among social integration, functional status, and level of depression in stroke survivors. In addition, this research was designed to assess whether the stroke survivors' degree of functional recovery, overall recovery from stroke, and presence of depression (independent variables) could predict their level of social integration (dependent variable). Depression was also assessed to determine if this comorbid condition common in stroke survivors impacts their social integration in any way.


1. Stroke survivors' social integration will have a positive correlation to their functional status.

2. Comorbid depression will be associated with decreased social integration, overall stroke recovery, or both in stroke survivors.

3. Functional status, depression, and overall stroke recovery are key factors that together influence social integration after stroke.

Review of the Literature

The concept of integration has received increased attention from healthcare providers in recent years (Whittemore, 2005). An important aspect of integration for this population is that of the effect of a chronic illness like stroke on the individual. This includes absorbing the reality of a diagnosis of a chronic condition into one's self-concept and the processes involved in assimilating this knowledge and then learning to live with the chronic disease and disability (Hernandez, 1995, 1996; Loeb, Penrod, Falkenstern, Gueldner, & Poon, 2003; Michael, 1996; Westra & Rodgers, 1991; Whittemore, 2005; Whittemore, Chase, Mandle, & Roy, 2002).

Recovery of function to prestroke level of motor ability and independence in activities of daily living has long been the gold standard by which success in rehabilitation after stroke is measured. Duncan and Zorowitz, cochairs of the Veteran's Administration/ Department of Defense Clinical Practice Guidelines Working group, developed the stroke guideline that has subsequently been endorsed by the Stroke Council of the American Heart Association (Duncan et al., 2005). This guideline states that the primary goals for management of adult stroke rehabilitation care are to prevent complications, to minimize (functional) impairments, and to maximize function.

Roth et al. (1998) defined stroke rehabilitation as a "multidimensional process" that includes "facilitation of psychosocial coping and adaptation by the patient and family, promotion of community reintegration, and enhancing quality of life for stroke survivors" (pp. 333-334). The aims of stroke rehabilitation include helping the patient to achieve a level of functioning that allows them to make the same choices and to enjoy a lifestyle similar to that they had before stroke (Trigg & Wood, 2000).

There are several key factors and interventions associated with improved social integration after stroke. In an evidenced-based review of stroke rehabilitation, Teasell et al. (2003) found that social support, strong and functional families, and family education using an active educational-counseling approach had moderately strong to strong levels of evidence in the literature for improving integration after stroke. Other factors that were identified by consensus or anecdotally as having an impact on integration, but for which evidence was either equivocal or not found, included leisure therapy, vocational rehabilitation, treatment of sexual dysfunction/discussion of sexual issues, and guidelines and methods to identify driving ability (Agency for Health Care Policy and Research, 1995; Bhogal, Teasell, Foley, & Speechley, 2003; Teasell et al., 2003).

Belanger et al. (1988) conducted a study of social integration in stroke survivors. This study examined the relative importance of physical aftereffects, socioeconomic characteristics, and social and environmental factors on the degree of social integration subsequently achieved. The authors found that the presence of motor problems is the main factor in determining the living environment after stroke. Social factors are also strongly correlated with living at home after stroke, including the constant presence of someone else in the house, the availability of help from relatives or close friends, and younger age. They also noted a significant decrease of activities after stroke in all the areas defined earlier as associated with social integration. The seriousness of physical aftereffects accounts for most of this variance in social integration; however, they noted that all stroke patients studied, even those with minimal losses in physical autonomy, had a notable decrease in social integration (Belanger et al., 1988).

Secrest and Thomas (1999) conducted a qualitative study to investigate the quality of life as experienced by stroke survivors after rehabilitation. They found the stroke survivors' experience to be grounded in loss and effort. Their analysis revealed focal themes of independence--ability/dependence--disability, in control/out of control, and connection/ disconnection with others. They found that these common themes in quality of life after stroke "transcended the physical and physiological markers that healthcare providers use to categorize treatment regimens" (p. 244). They conclude that rehabilitation emphasizing adaptation to the nonfunctional may improve a person's physical abilities but may not lessen the sense of discontinuity of self after stroke.

Roth et al. (1998) studied the association between impairment and disability during stroke rehabilitation. Both disability and impairment were measured at rehabilitation admission and discharge, and they found that there were statistically significant associations between the measures. They concluded that reduced impairment level alone did not fully explain the reduced disability that occurred after rehabilitation and that even patients without substantial impairment reduction demonstrated disability reduction after rehabilitation.

Thorngren, Westling, and Norrving (1990) evaluated rehabilitation outcome, place of residence, and functional ability at three time intervals in the first year after stroke. They found that almost all patients (approximately 90%) were able to walk indoors and climb stairs. However, up to 20% of those living independently in their own homes did not go outdoors independently. These subjects had a decreased degree of socialization outside the home at all time intervals (3, 6, and 9 months after stroke) despite good physical recovery.

Depression is a comorbid condition that occurs frequently in stroke patients (Agrell & Dehlin, 1989; Carney & Freedland, 2002; Diller & Bishop, 1995; Gordon & Hibbard, 1997; May et al., 2002; Robinson & Szetela, 1981). Estimates of the incidence of depression in the poststroke population ranged from 14% to 40% (Diller & Bishop, 1995; Langhorne et al., 2000; May et al., 2002; Robinson, 1997; Roth & Lovell, 2003).

The impact of depression on stroke outcomes is generally thought to be significant, but the relationship of depression to social integration specifically is unclear. Comorbid depression is thought to contribute to fatigue and reduced effort in rehabilitation, factors that could impede both physical and social recovery from stroke (Agrell & Dehlin, 1989; Belanger et al., 1988; Bhogal et al., 2003; Carney & Freedland, 2002; Duncan et al., 2000; Gillen, Tennen, Eberhardt, McKee, Genert-Dott, & Affleck, 2001; Shinar et al., 986). Depression, social isolation, poor or absent family support, and caregiver stress and depression have been associated with poor functional outcomes and decreased quality of life for stroke survivors (Bhogal et al., 2003; Carney & Freedland, 2002; Coleman, Mahoney, & Parry, 2005; Duncan et al., 2002; Duncan et al., 2005; Forster & Young, 1996; Gillen et al., 2001; Glass & Maddox, 1992; McColl, Davies, Carlson, Johnston, & Minnes, 2001; Secrest & Thomas, 1999; Teasell et al., 2003).

Clearly, stroke is a disabling chronic condition that places the individual at risk for loss of functional independence and alters capacity for social role functioning. Stroke rehabilitation currently emphasizes recovery of function in terms of motor ability and independence in activities of daily living. The goal of this research was to evaluate the relative importance of social integration as compared with functional status after stroke to the stroke survivor.


Sample and Setting

A 96-bed rehabilitation facility with accreditation from the Commission on Accreditation of Rehabilitation Facilities was the site for this study. This facility offers both inpatient and outpatient stroke rehabilitation programs and serves approximately 300 inpatients each year.

After institutional review board approvals, three surveys and a letter explaining the study were mailed to ischemic stroke patients from a list using the eRehabData[R], an inpatient rehabilitation outcomes system of the American Medical Rehabilitation Providers Association (2008). An honest broker from the study site created the list, and no one connected to the study had knowledge of or access to individually identifying information of any participant.

Inclusion and exclusion criteria (Table 1) were used to filter the data (using relevant queries and International Classification of Disease, Ninth Revision codes), which was then synchronized with address data to develop the final mailing list of eligible participants. A total of 310 stroke survivors were approached to return the completed surveys using the stamped, self-addressed envelope. A $5.00 incentive gift card was enclosed in each survey mailing.


Demographic Questionnaire

The demographic questionnaire included questions on age, gender, ethnicity, marital status, prestroke and poststroke employment status, living arrangement, elapsed time since stroke, use of depression medication, and education level. A visual analog scale was used to assess subjects' overall perception of their total stroke recovery in a single question not specifically linked to either social or functional descriptors.

Subjective Index of Physical and Social Outcome

The Subjective Index of Physical and Social Outcome (SIPSO) is an instrument intended to measure a patient's subjective assessment of their social integration after a stroke (Trigg & Wood, 2000). The 10-item instrument consists of two subscales: functioning/mobility and social/emotional functioning (Trigg & Wood, 2000). Each item is scored on a range of 0 to 4, with a total of 20 points possible on each of the two subscales or 40 points on the total instrument score. Higher scores correlate to greater perceived integration; lower scores indicate poorer integration (Trigg & Wood, 2000).

Construct validity was established by calculating correlation between SIPSO and four other measures, and the correlation coefficients ranged between .67 and .80, with a significance of p < .01 for all measures (Trigg & Wood, 2000). Internal consistency was evaluated with item-to-total correlations (all were found to be greater than .6) and with principal components analysis (used to form the two subscales; Trigg & Wood, 2000). The Cronbach's alpha for the SIPSO was calculated at .92 for the overall scale, .94 for the first subscale, and .85 for the second subscale (Trigg & Wood, 2000). All scores indicate good internal consistency/reliability of the tool and subscales (Trigg & Wood, 2000).

Test-retest reliability was assessed using 31 pairs of questionnaires with an interval of one month between administrations (Trigg & Wood, 2000). Kappa values were reported to range from .4 to .7, and 95% of the difference between scores data points fell within [+ or -] 2 SEM (Trigg & Wood, 2000).

Center for Epidemiologic Studies Depression Scale

The Center for Epidemiologic Studies Depression Scale (CES-D) was developed for use in studies of depressive symptomatology in the general population (Radloff, 1977). Each item on the 10-item short form is scored 0 to 3, and Items 5 and 8 are reverse coded as compared with the other items. The higher the total score, the more likely the subject is to be depressed. The possible scores ranged from 0 to 30, and scores greater than 10 are considered to be depressed (Stanford Patient Education Research Center, 2008). Original psychometric testing found the tool to have high internal consistency and adequate test--retest reliability and construct validity in terms of correlations to other self-report measures and to clinical ratings of depression (Radloff, 1977).

Data Analysis

All data were entered, stored electronically, and analyzed using the Statistical Package for the Social Sciences for Windows (Version 16; SPSS Inc., Chicago, IL). Frequency statistics were used to describe demographic data (Table 2). After testing of assumptions of normal distribution and regression analysis, a simultaneous linear multiple regression (LMR) analysis was conducted to investigate the best linear combination of functional status, depression, and overall perception of stroke recovery in predicting social integration after stroke. The level of significance for all tests were set at alpha = .05.


Return responses were received over an 8-week period via return mail. Breakdown of responses received was as follows: 39 were returned from the post office marked as undeliverable because of a variety of factors, including no such address, addressee does not reside at that address, no forwarding address, forwarding address order expired, and so forth. Seven responses were returned either by family members or by the post office designating that the addressee was deceased. Two surveys were returned unanswered. One was returned unanswered, and the addressee gave the reason as not having had a stroke. Forty-eight completed surveys were returned and contained usable data. if one considers the 39 surveys that were never delivered, the actual number of surveys sent was effectively reduced to 271. Of these, total respondents were 58, including the participants (48), those who declined (2), those who were deceased (7), or those who were excluded (1), which resulted in a final response rate of 21.4%.

The final total number of participants was 48, with 27 men (56%) and 21 women (44%). Approximately equal number of respondents reported taking medication for depression (n = 23, or 48%) compared with those who did not (n = 24, or 50%). Most of the respondents were between 45 and 75 years old (77.1%), Caucasian (58.3%), mostly married (56.2%) or divorced (27%), and living with spouse (60%) or family (19%) at the time of their response. The percentage of those participants who reported having been employed before their stroke is almost 48%, and this drops to only 4.2% employed after stroke. The percentage of retirees increased from 33.3% before stroke to 41.7% after stroke. The number of participants who were unemployed increased from 4.2% before stroke to 29.2% after stroke as well. The number of participants identifying themselves as homemakers remained the same before and after stroke.

Internal consistency reliability (Cronbach's alpha) for the overall SIPSO scale and the CES-D depression scale was tested. The overall SIPSO scale showed good/excellent reliability (Cronbach's alpha = .92), which is identical to the reliability reported by Trigg and Wood (2000) in their initial report on the instrument. Internal consistency reliability for the CES-D short-form depression scale was also good (Cronbach's alpha = .78).

To assess how stroke survivors' social integration correlates to their functional status, Spearman Rho correlations were performed (see Table 3). These results demonstrated a significant relationship (p < .01) of moderate strength (rho = .64) between social integration and overall functional status after stroke.

Social integration was moderately and negatively correlated (rho = -.74) to depression (Table 3). Similarly, overall stroke recovery was negatively and moderately (-.49) associated with depression. Both relationships were significant (p < .01). An increase in depression was associated with decreased social integration and perceived stroke recovery in this sample.

Results from the assumption testing revealed that the dependent variable was normally distributed and the assumptions for LMR were met. Tests upheld the assumption of no multicollinearity among the predictors (Table 4). Result of the LMR analysis (Table 5) indicated that the combination of functional status, overall stroke recovery, and depression significantly predicted social integration in this sample (p < .001). This combination of factors was able to explain 62% of the variance in social integration scores in the sample. However, only functional status and depression significantly contributed to the prediction equation.

One-way analyses of variance were performed to assess whether social integration varied with sociodemographic characteristics, with the assumption that variables such as living arrangement, marital status, employment status, age, education level, or other demographic factors may need to be controlled in the regression analysis if they had a confounding effect on social integration after stroke. The results showed no significance differences between each of the demographic variables for social integration status after stroke, with the exception of poststroke employment status, for which F = 2.9 and significance was .03.


The purpose for conducting this research was to gather information on an aspect of stroke recovery that had been largely overlooked in the literature--social integration. The concept of reintegrating into one's previous roles and relationships with family, coworkers, and the community, if considered at all, has been presumed to parallel physical and functional recovery in stroke survivors. Stroke rehabilitation guidelines and evidence-based standards of care reflect the importance of social and family roles and community involvement in recovery after stroke. However, little research has been conducted to better describe and understand this issue from the perspective of the stroke survivor.

The principal assumption of this study was supported. The results showed that social integration is significantly correlated to functional status, depression, and overall stroke recovery and that the level of social integration was predicted by these covariates in this sample of stroke survivors. These results support the concept that care for patients with chronic conditions like stroke should address all domains of the individual--physical, psychosocial, and environmental--and that care directed at a single domain (such as physical functioning) may be too limited to deal effectively and comprehensively with such patients (Siebens, 2002).

The results also showed that the presence of comorbid depression was negatively and significantly correlated to social integration, such that higher levels of depression are associated with lower levels of social integration. Depression was also negatively and significantly correlated to overall stroke recovery in the stroke survivors who participated in this study.

Like the results reported by Secrest and Thomas (1999), this study shows support for the concept that patients' perceptions of their recovery and life after stroke are based on issues and themes well beyond the purely physical and physiological markers that are commonly used to define treatment. A sense of continuity (integration) with their previous image of themselves and their life before the stroke are important factors that should be considered in the stroke rehabilitation process (Secrest & Thomas, 1999).

Roth et al. (1998) similarly found that functional impairment alone cannot explain the level of disability in stroke rehabilitation. Consistent with the current results, they suggested that rehabilitation services that address psychosocial coping and adaptation and promotion of community reintegration, in addition to treatment of medical issues and restoration of functional independence, are needed to minimize disability after stroke.

The findings of Thorngren et al. (1990) of the decreased socialization in 20% of stroke survivors who had sufficient functional recovery to walk and climb stairs independently are similar to the current findings that functional status alone cannot completely predict socialization after stroke. Patient's perceptions of their overall stroke recovery and mood (depression) must also be considered and are significant factors in social integration after stroke.

The current findings that employment status dropped from 48% employed before stroke to 4.2% employed after stroke and that poststroke employment correlates significantly to social integration are similar to that of Teasell et al. (2003), who reported that less than half of stroke survivors previously employed return to work after stroke. They recommend, and the current findings support, that previously employed stroke survivors, when appropriate, should be evaluated for their potential to return to work.


There were some limitations to this study that must be considered when evaluating the results. The most significant limitations are the small sample size and the low response rate to the survey. These limitations, along with the fact that a convenience sample drawn from a single site was used, significantly limit interpretation of the results. An additional limitation of the sampling technique was that patients who received rehabilitation services either at another facility or at another level of care (subacute, skilled nursing, home care, or outpatient services) were also not represented. A population of stroke survivors with relatively more or less physical/functional impairment who yet could have varying degrees of social, vocational, or cognitive deficits may have been excluded by not receiving rehabilitation.

An additional limitation would be that among this sample, time since stroke varied from 6 months to 2 years or more. It would seem that social integration may be time dependent to some degree, and this additional factor was not addressed in the current study. This is a variable that should be addressed in future research on this subject.

Significance to Nursing Practice

Although the results of this study cannot be generalized for the reasons mentioned, they do provide some insight into the issue of social integration after stroke. These findings will resonate with nurses who care for the chronically ill and who understand that integration with regard to social roles and relationships and community involvement is a multidimensional, multidomain issue that is not necessarily achieved by recovery of physical function alone. These findings can be immediately translated to bedside clinical nursing care by supporting assessment of other factors, including socialization and depression, in patients receiving stroke rehabilitation. By implementing specific interventions to promote social integration and to decrease depression, functional and social outcomes may improve after stroke. The goal of this study was to better describe this issue, with the intent that understanding will lead to ways for providers to better assist stroke survivors to achieve social integration in their recovery.

Recommendations for Future Research

The results of this study, although preliminary and limited by the factors mentioned earlier, still show support for the concept that social integration is an important and understudied aspect of stroke recovery that warrants further research. This research should be replicated with a larger sample from other facilities and settings to determine if the results are similar or if other factors related to population or setting might have significance in understanding this issue. The findings of this study regarding employment status after stroke also bear further investigation. Given the individual and societal cost of loss of employment due to stroke, research to better understand this issue and to find effective vocational rehabilitation strategies and programs should be a research priority for nurses, for other healthcare providers, and for governmental agencies as well.

DOI: 10.1097/JNN.0b013e3181ecafea


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Questions or comments about this article may be directed to Susan Baseman, DrNP APRN, at She is the vice-president of Patient Quality and Disease Management at Cooper University Hospital, Camden, NJ.

Kathleen Fisher, PhD CRNP, is an associate professor at the College of Nursing and Health Professions, Drexel University, Philadelphia, PA.

Louise Ward, PhD MSN, is a clinical assistant professor at the College of Nursing and Health Professions, Drexel University, Philadelphia, PA.

Anand Bhattacharya, MHS, is with the College of Medicine, Drexel University, Philadelphia, PA.
TABLE 1. Inclusion and Exclusion Criteria

Inclusion                  Exclusion

Ischemic stroke 6 months   Ischemic stroke less than 6 months before
before enrollment          enrollment

Ages 45-85 years           Younger than 45 years or older than 85

English speaking           Severe expressive and/or receptive aphasia
                           such that it prevents ability to
                           understand/respond to study instruments

Able to understand and     Hemorrhagic stroke survivors
respond to verbal and/or
written instructions and
survey instruments

TABLE 2. Demographic Data Frequency Distributions

Age          45-55 years      56-65 years   66-75 years

Frequency    10               13            14
%            20.8             27.1          29.2

Status       Married          Single        Widowed/Divorced

Frequency    27                6            13
%            56.2             12.5          27.1

Ethnicity    Caucasian        American      Other

Frequency    28               18            1
             58.3             37.5          2.1

Lives with   Spouse/Partner   Alone         Facility

Frequency    29                7            2
             60.4             14.6          4.2

                              High School
Education    No High School   Diploma       Some College

Frequency    12               16            10
             25               33.3          20.8

Time Since
Stroke       6-9 months       9-12 months   12-18 months

Frequency    2                12            4
%            4.2              25            8.3

Employment   Employed         Retired       Homemaker

Frequency    23               16            4
%            47.9             33.3          8.3

Employment   Employed         Retired       Homemaker

Frequency    2                20            4
%            4.2              41.7          8.3

Age          76-85 years      >85 years    Missing

Frequency     6                4            1
%            12.5              8.3          2.1

Status       Missing

Frequency    2
%            4.2

Ethnicity    Missing

Frequency    1

Lives with   Child/Family     Missing

Frequency     9                1
             18.8              2.1

Education    College Degree   Degree       Missing

Frequency     6                2            2
             12.5              4.2          4.2

Time Since
Stroke       18-24 months     >24 months

Frequency     8               22
%            16.7             45.8

Employment   Unemployed       Other

Frequency    2                 3
%            4.2               6.2

Employment   Unemployed       Other

Frequency    14                8
%            29.2             16.7

TABLE 3. Spearman Rho Correlation
Spearman Rho         Social         Functional    Stroke
Correlations         Integration    Status        Recovery

Depression           -.74           -.33          -.49

Significance          .01            .026          .001

Social integration                   .64           .58

Significance                         .000          .00

Functional score                                   .75

Significance                                       .000

TABLE 4. Collinearity and Beta

Variable         Beta     Significance    Tolerance

Depression       -.45     .001            .82

Overall stroke   -.19     .78             .41

Functional       .38      .001            .45

TABLE 5. Linear Regression Model
Summary of Social Integration


Model   R       [R.sup.2]    [R.sup.2]    SEE

        .81     .649         .624         2.96

Note. Predictors: recovery, depression, and functional score.
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