Hong Kong Physiotherapy Journal (2013) 31, 69e74

Available online at www.sciencedirect.com

journal homepage: www.hkpj-onl ine.com

RESEARCH REPORT

Community reintegration in strokesurvivors: Relationship with motor functionand depression

Adebimpe Obembe, PhD a,*, Boladale Mapayi, FWACPsych b,Olubusola Johnson, PhD a, Tolulope Agunbiade, BMR (PT) a,Anne Emechete, BSc (OT), MEd a,c

aDepartment of Medical Rehabilitation, Faculty of Basic Medical Sciences, College of Health Sciences,Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria

bDepartment of Mental Health, Faculty of Clinical Sciences, College of Health Sciences, ObafemiAwolowo University, Ile-Ife, Osun State, Nigeria

cOccupational Therapy Unit, Department of Medical Rehabilitation, Obafemi Awolowo UniversityTeaching Hospital, Ile-Ife, Osun State, Nigeria

KEYWORDScommunityreintegration;

motor function;post-strokedepression;

rehabilitation;stroke

* Corresponding author. DepartmentState, Nigeria.

E-mail addresses: bimpy248@yaho

1013-7025/$ - see front matter Copyrig

http://dx.doi.org/10.1016/j.hkpj.2013.04.00

Abstract Stroke survivors show a variety of physical and psychosocial problems, which canaffect their reintegration into the community. This study explored the association of commu-nity reintegration with motor function and post-stroke depression (PSD). Ninety community-dwelling stroke survivors with mean age of 58.3 � 7.8 years participated in this study. Partic-ipants were 56 men and 34 women attending the physiotherapy clinics of selected hospitals insouthwestern Nigeria. Motor function was assessed using the Motor Assessment Scale (MAS),PSD by the Hamilton Depression Scale, and community reintegration by the Reintegration toNormal Living Index (RNLI). The mean RNLI, MAS, and PSD scores were 57.3 � 23.5,34.9 � 10.9, and 9.4 � 4.8, respectively. RNLI scores were significantly associated with MAS(r Z 0.584, p Z 0.001) and PSD (r Z �0.373, p Z 0.006) scores. Multiple regression analysisshowed that age, depression, and motor function were associated with RNLI scores, which ac-counted for 41% of the variance. This study concluded that the higher the community reinte-gration, the higher the motor function, and the lower the PSD. Motor function and depressionare factors that influence community reintegration and should be properly assessed andadequately treated before stroke survivors return to the community.Copyright ª 2013, Hong Kong Physiotherapy Association Ltd. Published by Elsevier (Singapore)Pte Ltd. All rights reserved.

of Medical Rehabilitation, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun

o.com, aobembe@oauife.edu.ng (A. Obembe).

htª 2013, Hong Kong Physiotherapy Association Ltd. Published by Elsevier (Singapore) Pte Ltd. All rights reserved.

1

70 A. Obembe et al.

Introduction stroke survivors have residual neurological deficits that

Stroke is a leading cause of death and permanent disability[1]. Stroke survivors are often left with physical impair-ments that limit functional abilities [2]. A stroke can bedevastating to individuals and their family members,robbing them of their independence. Case fatality in Africaaverages about 35% but could be as low as 14.9% or as highas 77% when due to cerebral haemorrhage [3]. In Nigeria,stroke is a major cause of neurological admissions and itsincidence may be on the increase [4]. Case fatality ratesare as high as 45% [5].

Community reintegration is one of the most importantelements of stroke rehabilitation and likely the mostunderestimated area [6]. It has been defined as the ’re-organization of physical, psychological and social charac-teristics so that the individual can resume well-readjustedliving after incapacitating illness or trauma’ [7]. It is alsothe term used to refer to returning to the mainstream offamily and community life, engaging in normal roles andresponsibilities, actively contributing to one’s social groupsand the society as a whole [8]. Self-perceived participationin community activities represents an individual’s percep-tion of and satisfaction with his or her involvement in lifesituations. Many people with stroke have a low level ofsatisfaction with community reintegration after they aredischarged from the hospital and return to the community[9]. The effects of some stroke-related factors (e.g.,physical impairments and mental status) on satisfactionwith community reintegration have been examined in somestudies [10,11].

Physical impairment has immense impact on communityreintegration of stroke patients and emotional alterationsare very frequent after stroke [12]. In the study by Carteret al [10], two factors that contributed most to impairmentof community reintegration were depression and physicaldisability. Moreover, home rehabilitation intervention hasbeen shown to induce motor and functional gains, whichtranslate into a greater degree of higher-level function andsatisfaction with community reintegration [13].

Mood disorder may be a specific complication of stroke,and failure to recognize and treat the disorder may be animportant unmet need of survivors of stroke [14]. Depres-sion manifests itself as a combination of feelings ofsadness, loneliness, irritability, worthlessness, hopeless-ness, agitation, and guilt accompanied by an array ofphysical symptoms [15]. It is the most common mentalhealth condition after stroke [16] and has been linked toworse functional outcome, slower recovery, and lowerquality of life [17]. Depression affects 25e40% of patientswithin the 1st year after a stroke [18] and is most evidentwithin the first 2 years post stroke [19]. Studies in Nigeriahave reported 9.2e38.8% prevalence of depression amongstroke survivors [20e22]. Some studies have suggested thatstroke and depression often occur together [23e25].Depression also has potentially long-lasting impact onfunctioning among stroke survivors [26].

Motor impairment is a frequent complication afterstroke. The ability of patients to live independently afterstroke depends largely on the reduction of motor impair-ment and the recovery of motor function [27]. Two-thirds of

persistently impair function [28]. Impairment of motorfunction often involves paralysis or paresis of the muscleson the side of the body contralateral to the side of thelesion. In the stroke survivor population, 50% have somelevel of hemiparesis, 30% are unable to walk without someassistance and 20% are dependent in activities of dailyliving. The result of this disability is a significant impact onindependence, quality of life, and lost productivity [29].

Stroke rehabilitation is a complex field that covers awide continuum of care from the acute phase of stroke tocommunity reintegration [19]. However, community rein-tegration, being an important aspect of stroke rehabilita-tion, has received relatively less attention from cliniciansand researchers. A previous Nigerian study [30] assessedthe community reintegration and walking ability of strokesurvivors, but the mental health condition of the partici-pants were not taken into consideration. This study there-fore aimed to determine the association of communityreintegration with motor function and post-stroke depres-sion (PSD).

Methods

Data were collected from stroke patients seen at the out-patient physiotherapy departments of 4 university teach-ing hospitals in southwestern Nigeria. The stroke survivorswere enrolled from Obafemi Awolowo University TeachingHospital Ile-Ife and Ilesa units, Ladoke Akintola Universityof Technology Teaching Hospital Osogbo, University Col-lege Hospital Ibadan, and Lagos University Teaching Hos-pital. The participants in this study were 90 communitydwelling stroke survivors between 40 and 65 years of age(mean age: 58.3 � 7.8 years). Inclusion criteria included adiagnosis of stroke by a neurologist, the first episode ofunilateral stroke with hemiparesis, and a stroke durationof 6 months or more. Moreover, the patients included inthe study had been diagnosed as having depression by apsychiatrist using the internationally acceptable methods.Patients were excluded if they had history of any otherneurological pathology, dementia, and serious musculo-skeletal conditions affecting the lower limbs. Moreover,patients who scored 2 or less on the Functional AmbulationCategories (FAC) classification [31] or who were depen-dent on a walker for ambulation were excluded from thestudy.

Ethical clearance was sought and obtained from theEthics and Research Committee of the Obafemi AwolowoTeaching Hospitals Complex, Ile-Ife. Informed consent of allthe participants was duly obtained. The participants whomet the inclusion criteria were selected and informed ofthe research protocol. All experiments were conducted inaccordance with the Declaration of Helsinki.

The Reintegration to Normal Living Index (RNLI) wasused to assess community reintegration. The scale wasdeveloped by Wood-Dauphnee and Williams [7] to measurepatients’ perceptions of their own capabilities. It is an 11-item scale that covers areas such as participation in rec-reational and social activities, movement within the com-munity, and how comfortable the individual is in his/herrole in the family and with other relationships. The items

Table 1 Characteristics of participants

Characteristics

Age (y), n (%)�50 28 (31.1)51e60 28 (31.1)�61 34 (37.8)

Sex, n (%)Male 56 (62.2)Female 34 (37.8)

Dominant side, n (%)Right 84 (93.3)Left 6 (6.7)

Side of paresis, n (%)Right 48 (53.3)Left 42 (46.7)

Types of stroke, n (%)Ischaemic 74 (82.2)Haemorrhagic 16 (17.8)

RNLI score, mean � SD 57.3 � 23.5MAS score, mean � SD 34.9 � 10.9HDS score, mean � SD 15.4 � 4.8

HDS Z Hamilton Depression Scale; MAS Z Motor AssessmentScale; RNLI Z Reintegration to Normal Living Index.

71

are essentially declarative statements (e.g., I move aroundmy living quarters as I feel necessary), including thefollowing domains: indoor, community, and distancemobility; self-care; daily activity (work and school); rec-reational and social activities; family role(s); personal re-lationships; presentation of self to others; and generalcoping skills. Each item was rated with a 4-point ordinalscale (1e4) with higher scores indicating a higher level ofsatisfaction. The scores for each item were summed andthen normalised to 100, with a score of 100 indicating thatthe participants were fully satisfied, scores of 60 through 99indicating mild-to-moderate restrictions in self-perceivedcommunity reintegration, and scores less than 60 indi-cating severe restrictions in self-perceived communityreintegration [9].

Motor function was assessed using the Motor AssessmentScale (MAS) [32]. This is a criterion-based scale assessingeight areas of functional motor activity with each itemscored on a 7-point ordinal scale (ranging from 0 Z nomotor function, to 6 Z optimal task performance or per-formance completed within the set time frame) [33]. Thehigher the score, the higher functioning the patient is onthe affected side.

The Hamilton Depression Scale (HDS) was used to assessdepression. It is a 21-item questionnaire that rates theseverity of symptoms observed in depression, such asdepressed mood, insomnia, agitation, anxiety and weightloss. It was originally published by Max Hamilton in 1960 tomeasure severity of depression in previously diagnoseddepressed patients [34], but was reviewed and evaluated in1966, 1967, 1969, and 1980. Although the HDS form lists 21items, the scoring is based on the first 17. It generally takes15e20 minutes to complete the interview and score the re-sults. Eight items were scored on a 5-point scale (0Z absent,1Zmild, 2Zmoderate, 3Z severe, 4Z very severe). Ninewere scored from 0e2 (0Z absent, 1Zmild, 2Z definite).The scores of the 17 items were summed to yield the totalscore, with a higher score indicating more severe depression(0e7Znormal, 8e13Zmilddepression, 14e18Zmoderatedepression, 19e22 Z severe depression, and �23 Z verysevere depression). The scale has been used and validated inNigeria [35,36].

Participants’ clinical and socio-demographic character-istics were summarised using descriptive statistics of mean,standard deviations, frequencies, and percentages. Infer-ential statistics using the Mann-Whitney U test was used tocompare the RNLI scores between groups (sex, stroke type,side of paresis). The Pearson Correlation Product MomentCorrelation Coefficient (r) was used to determine the as-sociation of community reintegration with age, strokeduration, motor function, and PSD. Multiple regressionanalysis was then used to predict community reintegration.Before the hierarchical multiple regression analysis wasperformed, the independent variables were examined formulticollinearity by means of Pearson’s correlation. Inmultiple regression analysis, only the factors that weresignificant in the bivariate correlation analysis wereentered into the prediction model (i.e., age, depression,and motor function). Level of significance was set atp < 0.05. All statistical procedures were performed withthe Statistical Package for Social Sciences (SPSS) 16.0 (SPSSInc., Chicago, IL, USA).

Results

The participants were 56 (62.2%) men and 34 (37.8%)women. The stroke duration ranged from 1 to 5 years(mean: 2.2 � 1.2 years). Seventy-four (82.2%) stroke sur-vivors had a diagnosis of hemiparesis after ischaemicstroke, and 16 (17.8%) had haemorrhagic stroke. Thecharacteristics of the 90 stroke survivors with respect toage, sex, stroke type, side of paresis, and dominant sidebefore stroke are presented in Table 1.

The mean RNLI score was 57.3 � 23.5 (range: 39e90).Eighteen (20%) participants were severely restricted (RNLIscore < 60) and 72 (80%) participants were mildly tomoderately restricted (RNLI score Z 60e99) in communityreintegration. The mean PSD was 15.4 � 4.8 (range 2e38).None of the participants had severe PSD (HDSscore Z 23e50). Only four male participants in the agecategory of 50 years and below had moderate PSD (HDSscore Z 14e18), while majority of the participants (96%)had mild PSD (HDS score Z 8e13). The mean MAS score was34.9 � 10.9 (range: 18e42).

Table 2 shows the result of the correlation analysis be-tween RNLI scores, MAS scores and PSD; and the Mann-Whitney U test comparing RNLI scores according to sex,stroke type, and side of paresis. Community reintegrationhad a significant correlation with age (r Z e0.221,pZ 0.036), motor function (rZ 0.584, pZ 0.001), and PSD(r Z e0.373, p Z 0.006). There were no significant dif-ferences in RNLI scores between male and female strokesurvivors (p Z 0.335), ischaemic and haemorrhagic strokesurvivors (p Z 0.885), and between stroke survivors withright-sided hemiparesis and those with left-sided hemi-paresis (p Z 0.073).

Table 2 Correlation analysis and comparison of RNLIscores according to sex, stroke type and side of paresis

Correlationwith RNLIscores (r)

Comparisonof RNLIscores (z)a

p

Age �0.221 0.036*Stroke duration �0.174 0.101Motor function 0.584 0.001*Depression �0.373 0.006*Sex (men vs.women)

�0.972 0.335

Stroke type(ischaemic vs.haemorrhagic)

�0.147 0.885

Side of paresis(left vs. right)

1.816 0.073

*Statistically significant (p < 0.05).RNLI Z Reintegration to Normal Living Indexa Derived from Mann-Whitney U test.

72 A. Obembe et al.

Age, motor function, and depression were then enteredinto the multiple regression model. The results showed thatage (p Z 0.016), motor function (p Z 0.000), and depres-sion (p Z 0.008) were significant predictors of communityreintegration. The final regression model predicted 41% ofthe variance in the RNLI scores (F3,86 Z 19.904, p < 0.001).Moreover, among the independent variables, motor func-tion had the greatest effect on community reintegration(standardised regression coefficient Z 0.457) (Table 3).

Discussion

Community reintegration, being the final stage of rehabil-itation, is very important. The concept of reintegrating toone’s previous roles and relationships with family, co-workers, and the community, if considered at all, hasbeen presumed to be hinged on physical and functionalrecovery in stroke survivors.

Satisfaction with community reintegrationamong stroke survivors

In this study, none of the stroke survivors was fully satisfiedwith their community reintegration. The mean RNLI scoreof the stroke survivors in this present study is lower thanthat of the findings in previous studies [9,12,30]. There maybe some reasons for the differences in the results. First, the

Table 3 Regression analysis to predict community reintegration

Unstandardisedcoefficient (B)

Standacoeffic

Age �0.658 �0.217Depression �1.256 �0.255Motor function 0.988 0.457

Final regression model (R2 Z 0.410, F3,86 Z 19.904, p < 0.001).

study environment was different. Second, the previousstudies involved stroke survivors with onset of 1 year ormore, whereas our sample consisted of some patients whohad a post-stroke duration of 6 months to 1 year. Similar toprevious studies [9,30], this study showed that men wereless satisfied with their reintegration to normal living thanwomen, although the difference did not quite reach sta-tistical significance, probably owing to reduced statisticalpower related to the small sample size.

Age is independently associated withcommunity reintegration

Age was also found to be a significant predictor of the RNLIscores. The association is a negative one, indicating thatolder participants had lower level of satisfaction withcommunity reintegration. None of the participants in theage category of �50 years was restricted in reintegration tonormal living, but the age category �60 years, despitebeing able to walk unassisted, had the most number ofstroke survivors restricted in their community reintegra-tion. This is in agreement with the findings in the study byMurtezani et al [12], who reported that regardless of theunassisted walking, older chronic stroke patients were notsatisfied with their level of social reintegration. The olderpatients may have less self-perceived reintegration tonormal living because most of them have decreased socialparticipation. In contrast, other studies [9,12] have found apositive association between age and community reinte-gration. The reason for the discrepancy in results is un-certain. It was postulated that the younger stroke survivorsmay be more educated and have higher expectation of theirrecovery and community reintegration than their oldercounterparts [9].

Depression is independently associated withcommunity reintegration

Our results showed that depression is independently asso-ciated with RNLI scores. The higher the level of depression,the lower the level of satisfaction with community reinte-gration. Previous studies have also identified depression[9,10,37] as a determinant of satisfaction with communityreintegration in stroke survivors. Stroke severity or physicaldisability and functional impairment have been associatedwith depression [38,39]. Post-stroke depression has beenreported to slow down the process of rehabilitation,exerting a negative influence on all aspects of the processof recovery [38,40], and remission has been associated with

rdisedient (b)

95% CI p

�1.192 e �0.125 0.016�2.183 e �0.329 0.0080.590e1.387 <0.001

73

recovery in activities of daily living [41]. Patients withstronger reintegration to normal living have been found tohave better outcomes in anxiety, depression, daily activityand quality of life [12]. These reasons may be used toexplain the relationship found between community rein-tegration and PSD in this study. Taken together, the resultssuggest that relieving symptoms of depression may beessential in enhancing community reintegration amongstroke survivors but will require further investigations.

Since PSD can be treated, it should be assessed for andmanaged in stroke survivors before they return to thecommunity. Clinicians should work with the patient andcaregivers to avoid negative effects, promote problemsolving, and facilitate reintegration of the patients intovalued family and social roles [42]. Physiotherapists andoccupational therapists should work with clinical psychol-ogists to minimise the effects of depression in patients whoare diagnosed with the condition during rehabilitation. Allprofessionals in the care of patients with stroke should beaware of the possibilities of depression and trained to lookout for it and refer appropriately.

Motor function is independently associatedwith community reintegration

The results of our study showed a positive associationbetween community reintegration and motor function.The ultimate goal for many stroke survivors is to achieve alevel of functional independence that enables them toreturn to their homes and reintegrate into community lifeas much as possible [43]. Recovery of function to pre-stroke level of motor ability and independence in activ-ities of daily living has long been the gold standard bywhich success in rehabilitation after stroke is measured[44]. In a study conducted by Belanger et al [45] on socialintegration in stroke survivors, the determining factorsrelating to social integration are motor functions and au-tonomy, personal perception of health conditions, prox-imity of children and relatives, relatively low age, regularpresence of another person in the home, and proximity offriends. The authors found that the presence of motorproblems is the main factor in determining the livingenvironment after stroke.

The results of our study showed that motor function is anindependent predictor of the RNLI scores. These findingsare consistent with those of a previous study of strokesurvivors, which showed an association between socialintegration and motor function [42]. These findings high-light the potential importance of improving motor functionin enhancing community reintegration.

Research on stroke rehabilitation has focused on phys-ical/functional recovery as the predominant measure ofoutcome [42,46]. There is a gap in knowledge of social is-sues and integration into societal, family, and communityroles after stroke [43], despite that assessment of com-munity reintegration has been emphasised in stroke reha-bilitation reviews and guidelines [42,47,48]. While a lot ofstudies have examined the effect of different exerciseprograms to improve motor function [49e51], communityreintegration is not often used as an outcome. Sinceimprovement in motor function is directly associated with

community reintegration, community reintegration shouldbe assessed alongside motor function in community-dwelling stroke survivors with neuromuscular deficits dur-ing rehabilitation.

Limitations of the study and future directions

As the stroke survivors in the present study were able toambulate independently, the findings of this study may notbe generalised to stroke survivors who cannot ambulateindependently. Another limitation of this study was relatedto sampling bias as the participants were recruitedconsecutively as they became available based on the studycriteria (e.g., convenience sampling). The participants mayhave very different characteristics compared with otherstroke survivors who did not take part in this study.Furthermore, this was a hospital-based study. Authorstherefore recommend that further studies address theproblem of external validity. Community reintegration aspart of stroke recovery has been understudied in Nigeria.Further research is necessary to explore other factors thatmay affect community reintegration in Nigerian strokesurvivors with varying degrees of recovery.

Conclusion

In summary, this study found a significant association ofcommunity reintegration with motor function and PSD.Motor function and depression should be properly assessedand adequately treated before stroke survivors return tothe community to promote successful reintegration.

Acknowledgements

The authors thank the stroke survivors who took part in thisstudy and the physiotherapists in the selected hospitals fortheir assistance.

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