Sleep after Stroke: Participant, Caregiver, and Clinician Materials for the Stroke Management Training and Inpatient Rehabilitation Discharge Education (STRIDE) Study

Background

During my second clinical experience I had the opportunity of working on the Brain Injury Team in the acute inpatient rehabilitation setting at Carolinas Rehabilitation in Charlotte, NC. I worked primarily with stroke survivors and their families and loved every aspect of working with the population from therapy to the extensive caregiver education. Upon returning to UNC after my clinical, I learned about the opportunity to work with Dr. Cassidy on the Stroke Management Training and Inpatient Rehabilitation Discharge Education (STRIDE) study and jumped on the opportunity. The aim of the study is to encourage individual engagement and accountability for physical wellbeing post-stroke after discharge from inpatient rehabilitation through physical activity monitoring, peer correspondence and completion of education modules that promote whole body wellness in a variety of areas. As a member of the team in the fall, I assisted with participant intake and recruitment, participant correspondence, and data collection. As part of the study, participants have an assigned weekly module designed to help them stay engaged in their health and wellness after experiencing a lifechanging health event like a stroke in addition to access to additional modules that cover a wide variety of topics from safety, nutrition, and social support to secondary conditions and basic stroke knowledge. My work in the fall and conversations with one specific participant inspired me to add to the library of modules and create an additional module for clinicians around the topic of sleep after stroke.

Statement of Need

The research for this module was inspired by conversations with a STRIDE study participant who discussed their concerns about significant changes in their sleep since returning home from inpatient rehabilitation.

Symptoms of sleep disorder are common after stroke and me be present in up to 92% of stroke survivors.¹ Untreated sleep disorders after stroke can contribute to recurrent stroke and impair stroke rehabilitation efficiency.² Less than 10% of stroke survivors are offered formal sleep testing and an estimated 2% complete such testing in the 3-month post-stroke period.³

The reasons for the low rate of screening are at least partly related to the lack of awareness about the prevalence of sleep disorders among stroke providers, patients, and their caregivers.⁴ The high prevalence of sleep disorder among the stroke population, the detrimental effects that sleep disorders may have after stroke, and the lack of stroke patients that receive treatment for symptoms of sleep disorder demonstrates an educational need for providers, patients and caregivers regarding sleep after stroke.

Purpose

The purpose of this capstone is to provide a review of current literature regarding common sleep changes after stroke, detail how those sleep changes affect stroke outcomes, and outline the best treatment methods for common sleep disorders after stroke. The patient and caregiver module was created for post-stroke participants and caregivers of the STRIDE research study to provide concise and applicable educational materials and empower participants to identify and seek treatment for sleep disorders to improve health and lifestyle outcomes post-stroke. The clinician module was created to improve awareness of sleep changes after stroke and educate clinicians to begin to screen and treat these changes to improve stroke outcomes.

Products

The patient and caregiver module will be added to a bank of modules that STRIDE participants and caregivers have access to as part of the study. Participants will receive a copy of the module, a voiceover recording of the module, and a summary handout for reference.

The clinician module is intended to be shared with healthcare providers that treat stroke patients similar to an in-service or continuing education module.

Sleep and Stroke Patient and Caregiver Products

https://youtu.be/SC-ycHSSCyE

Sleep and Stroke – Patient and Caregiver Module

Sleep and Stroke Handout

Sleep and Stroke Clinician Products 

https://youtu.be/LIKAtZ4XkeU

Sleep and Stroke – Clinician Module

Evaluation Component

During the capstone process, I shared and discussed my ideas and progress with my advisor Dr. Jessica Cassidy where we met over multiple zoom meetings to discuss changes and progress. My committee members reviewed and gave feedback on my products, and I presented to Dr. Cassidy’s lab group and received feedback and made changes accordingly.

Each educational module for the STRIDE study is complete with a short self-assessment that involves a quick 3-5 questions for participants to test their knowledge and ensure that they understand the key concepts from the modules. I created a short 3 question survey to assess patient knowledge after completing the Sleep and Stroke module. The assessments are in the form of a Qualtrics survey, but for the data collection purposes for the study I have included then in the form of a PDF for review.

Qualtrics Quiz Questions- Sleep and Stroke

Self-Assessment:

When I began as a member of the STRIDE team in the fall of 2021, I knew I wanted to contribute to the study as part of my capstone but I was unsure where that would lead. I toyed with a few different ideas during my research in the fall; I was interested in how yoga and tai chi impacted quality of life after stroke, but found that the research has been done primarily in a population of patients who were almost all independent with activities of daily living. The research I found wasn’t as inclusive and expansive as the STRIDE study and I didn’t think that it would be applicable for enough STRIDE patient participants. It was after a mid-week checkup and conversation with a study participant when I shifted my focus to sleep after stroke, something that I learned impacts almost every person who has had a stroke.

During the research process I struggled to make sure my patient materials where inclusive for all, engaging, and incorporated language that made sense to everyone. I found it much easier to create a module for clinicians where I could use “clinical” language and not have to be as specific or particular with my language. I learned quite a bit about how to create an effective video presentation using visuals, special effects, and diagrams for all different types of learners. I learned just how important it is to consider a patient’s sleep when they are recovering from a stroke. This is something that I will include in my evaluation, assessment, and continued treatment with my future patients. I will not be afraid to advocate for my patients to their doctors and the rest of their healthcare team if pharmacological treatment or if sleep testing is indicated and I will introduce my patients to self-management strategies where they are appropriate.

In all honesty, there are a couple of different things that I wish I had been able to accomplish with this project that I was unable to incorporate. I had intended to meet with researchers in UNC’s neurodiagnostic and sleep science department to discuss current research going on at UNC and resources that may be helpful for patients post-stroke, but was never able to find a time that worked with my schedule and the researcher’s. I was able to share my project with Dr. Cassidy’s lab, but I would love to find a way to incorporate the clinician module some other way in either the clinic or classroom with DPT students.

Despite these short comings, I am proud of the work I did and the current evidence that I found. I’m excited to have created resources about a topic that impacts almost every stroke patient and their caregiver. I hope that the resource for clinicians encourages providers to screen for sleep disorder and treat them effectively for improved patient outcomes.

Acknowledgements:

To Dr. Jessica Cassidy, PT, DPT, PhD for serving as my Capstone advisor and the fearless leader of the STRIDE research team. Your vision for this research project has changed many lives and is continuing to improve patient and caregiver engagement, experience, empowerment, and education as stroke survivors discharge from inpatient rehabilitation. Thank you for your constant guidance, inspiration, willingness to meet, edit, and bring me on your team!

To Ryan Fitzgerald, BS, BA, for assisting me with the management of study participants no matter how difficult or complicated the situation. Your mentorship throughout the duration of my STRIDE study involvement has been invaluable.

To Maureen Marquie, SPT, for checking in with me throughout the Capstone, guiding me with data calculations with participant research in the fall semester, and being a helping hand every step of the way. I’m glad we experienced this together.

To the Cassidy Plasticity Lab, for giving me feedback, support, and inspiration throughout the duration of this project.

To Dr. Kim Carver, PT, DPT, NCS for sharing your love and expertise for the stroke population and inpatient rehabilitation setting as my clinical instructor. You inspired me to pursue joining this research team and I’m so grateful for your support. Thank you being member of my Capstone Committee and providing feedback for the products of this project.

To Dr. Laura Martin, PT, DPT for serving as a valuable member of my Capstone Committee. I so appreciated your feedback on my products and support for my participation in the project.

To Hope Kelly, SPT and Maddie Tavino, SPT, for reviewing and re-reviewing my products, listening to me talk through my thought process, and supporting me every step of the way despite being from the blue school down the road.

 

References from Post

1.    Fulk GD, Boyne P, Hauger M, et al. The Impact of Sleep Disorders on Functional Recovery and Participation Following Stroke: A Systematic Review and Meta-Analysis. Neurorehabil Neural Repair. 2020;34(11):1050-1061. doi:10.1177/1545968320962501
2.    Hasan F, Gordon C, Wu D, et al. Dynamic Prevalence of Sleep Disorders Following Stroke or Transient Ischemic Attack: Systematic Review and Meta-Analysis. Stroke. 2021;52(2):655-663. doi:10.1161/STROKEAHA.120.029847
3.    Byun E, Kohen R, Becker KJ, Kirkness CJ, Khot S, Mitchell PH. Stroke impact symptoms are associated with sleep-related impairment. Heart Lung. 2020;49(2):117-122. doi:10.1016/j.hrtlng.2019.10.010
4.    Khot SP, Morgenstern LB. Sleep and Stroke. Stroke. 2019;50(6):1612-1617. doi:10.1161/STROKEAHA.118.023553

References: Patient and Caregiver Module

1.    Davis JC, Falck RS, Best JR, Chan P, Doherty S, Liu-Ambrose T. Examining the Inter-relations of Depression, Physical Function, and Cognition with Subjective Sleep Parameters among Stroke Survivors: A Cross-sectional Analysis. J Stroke Cerebrovasc Dis. 2019;28(8):2115-2123. doi:10.1016/j.jstrokecerebrovasdis.2019.04.010
2.    Duss SB, Seiler A, Schmidt MH, et al. The role of sleep in recovery following ischemic stroke: A review of human and animal data. Neurobiol Sleep Circadian Rhythms. 2017;2:94-105. doi:10.1016/j.nbscr.2016.11.003
3.    Fulk GD, Boyne P, Hauger M, et al. The Impact of Sleep Disorders on Functional Recovery and Participation Following Stroke: A Systematic Review and Meta-Analysis. Neurorehabil Neural Repair. 2020;34(11):1050-1061. doi:10.1177/1545968320962501
4.    Fulk G, Duncan P, Klingman KJ. Sleep problems worsen health-related quality of life and participation during the first 12 months of stroke rehabilitation. Clin Rehabil. 2020;34(11):1400-1408. doi:10.1177/0269215520935940
5.    de Oliveira DC, Ferreira PRC, Silveira Fernandes ABG, et al. Circadian activity rhythm and fragmentation are associated with sleep-wake patterns and sleep quality in patients with stroke. NeuroRehabilitation. 2019;44(3):353-360. doi:10.3233/NRE-182665
6.    Byun E, Kohen R, Becker KJ, Kirkness CJ, Khot S, Mitchell PH. Stroke impact symptoms are associated with sleep-related impairment. Heart Lung. 2020;49(2):117-122. doi:10.1016/j.hrtlng.2019.10.010
7.    Kim W-H, Yoo Y-H, Lim J-Y, et al. Objective and subjective sleep problems and quality of life of rehabilitation in patients with mild to moderate stroke. Top Stroke Rehabil. 2020;27(3):199-207. doi:10.1080/10749357.2019.1673591
8.    Cai H, Wang X-P, Yang G-Y. Sleep disorders in stroke: an update on management. Aging Dis. 2021;12(2):570-585. doi:10.14336/AD.2020.0707
9.    Gottlieb E, Egorova N, Khlif MS, et al. Regional neurodegeneration correlates with sleep-wake dysfunction after stroke. Sleep. 2020;43(9). doi:10.1093/sleep/zsaa054
10.   Hershner S, Shaika I. Healthy Sleep Habits . American Academy of Sleep Medicine. Published online January 10, 2020. Accessed January 5, 2022. https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/
11.   Ryan CM, Bayley M, Green R, Murray BJ, Bradley TD. Influence of continuous positive airway pressure on outcomes of rehabilitation in stroke patients with obstructive sleep apnea. Stroke. 2011;42(4):1062-1067. doi:10.1161/STROKEAHA.110.597468
12.   West A, Simonsen SA, Jennum P, et al. An exploratory investigation of the effect of naturalistic light on fatigue and subjective sleep quality in stroke patients admitted for rehabilitation: A randomized controlled trial. NeuroRehabilitation. 2019;45(2):187-200. doi:10.3233/NRE-192752
13.   Hasan F, Gordon C, Wu D, et al. Dynamic Prevalence of Sleep Disorders Following Stroke or Transient Ischemic Attack: Systematic Review and Meta-Analysis. Stroke. 2021;52(2):655-663. doi:10.1161/STROKEAHA.120.029847
14.   Blissitt PA. Sleep-Disordered Breathing After Stroke: Nursing Implications. Stroke. 2017;48(3):e81-e84. doi:10.1161/STROKEAHA.116.013087
15.   Iddagoda MT, Inderjeeth CA, Chan K, Raymond WD. Post-stroke sleep disturbances and rehabilitation outcomes: a prospective cohort study. Intern Med J. 2020;50(2):208-213. doi:10.1111/imj.14372

References: Clinician Module

1. Davis JC, Falck RS, Best JR, Chan P, Doherty S, Liu-Ambrose T. Examining the Inter- relations of Depression, Physical Function, and Cognition with Subjective Sleep Parameters among Stroke Survivors: A Cross-sectional Analysis. J Stroke Cerebrovasc Dis. 2019;28(8):2115-2123. doi:10.1016/j.jstrokecerebrovasdis.2019.04.010
2. Fulk GD, Boyne P, Hauger M, et al. The Impact of Sleep Disorders on Functional Recovery and Participation Following Stroke: A Systematic Review and Meta-Analysis. Neurorehabil Neural Repair. 2020;34(11):1050-1061. doi:10.1177/1545968320962501
3. Hasan F, Gordon C, Wu D, et al. Dynamic Prevalence of Sleep Disorders Following Stroke or Transient Ischemic Attack: Systematic Review and Meta-Analysis. Stroke. 2021;52(2):655-663. doi:10.1161/STROKEAHA.120.029847
4. Blissitt PA. Sleep-Disordered Breathing After Stroke: Nursing Implications. Stroke. 2017;48(3):e81-e84. doi:10.1161/STROKEAHA.116.013087
5. Gottlieb E, Egorova N, Khlif MS, et al. Regional neurodegeneration correlates with sleep- wake dysfunction after stroke. Sleep. 2020;43(9). doi:10.1093/sleep/zsaa054
6. Khot SP, Morgenstern LB. Sleep and Stroke. Stroke. 2019;50(6):1612-1617. doi:10.1161/STROKEAHA.118.023553
7. Hepburn M, Bollu PC, French B, Sahota P. Sleep medicine: stroke and sleep. Mo Med. 2018;115(6):527-532.
8. Fulk G, Duncan P, Klingman KJ. Sleep problems worsen health-related quality of life and participation during the first 12 months of stroke rehabilitation. Clin Rehabil. 2020;34(11):1400-1408. doi:10.1177/0269215520935940
9. Duss SB, Seiler A, Schmidt MH, et al. The role of sleep in recovery following ischemic stroke: A review of human and animal data. Neurobiol Sleep Circadian Rhythms. 2017;2:94-105. doi:10.1016/j.nbscr.2016.11.003
10. Backhaus W, Braass H, Gerloff C, Hummel FC. Can daytime napping assist the process of skills acquisition after stroke? Front Neurol. 2018;9:1002. doi:10.3389/fneur.2018.01002
11. Cai H, Wang X-P, Yang G-Y. Sleep disorders in stroke: an update on management. Aging Dis. 2021;12(2):570-585. doi:10.14336/AD.2020.0707
12. Hershner S, Shaika I. Healthy Sleep Habits . American Academy of Sleep Medicine. Published online January 10, 2020. Accessed January 5, 2022. https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/
13. West A, Simonsen SA, Jennum P, et al. An exploratory investigation of the effect of naturalistic light on fatigue and subjective sleep quality in stroke patients admitted for rehabilitation: A randomized controlled trial. NeuroRehabilitation. 2019;45(2):187-200. doi:10.3233/NRE-192752