Introduction
Sexual issues are among the most important in recovery, but they can be the hardest for strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. survivors and their partners to discuss. However sexuality is a topic that can be addressed by one of the client’s health care providers (e.g. NeurologistThis team member is responsible for “the diagnostic evaluation, medical treatment, prevention of stroke recurrence, patient and family education, staff and trainee education, research, program evaluation.”(Suggested by Philips et al, 2002)
, Physical therapistIn charge of the “assessment and treatment of motor functioning, including motor control, strength and physical conditioning; balance, gait and mobility retraining; home and community visits; patient and family education regarding mobility and safety issues.” (Suggested by Philips et al, 2002)
, Occupational therapistIn charge of the “assessment of personal and domestic care activities; evaluation and treatment of functional impairments related to change in sensorimotor, cognitive and perceptual abilities; prescription of wheelchairs and bathroom appliances; home visits; patient and family education.”(Suggested by Philips et al, 2002)
, Speech pathologist, Physician, Urologist, or Gynecologist). Given that sex is a private matter, the therapist may feel uncomfortable addressing it with a client, or the client may feel uncomfortable or shy to ask questions. It is important to realize that sexuality can be a serious concern for clients after a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., and that there are ways of making sex easier for clients, as long as they are willing to share their concerns and ask questions.
The patient/family section addresses common fears and concerns regarding sex and intimacy, timing for resuming sexual activity, special physical challenges, sexual positions, among other topics.
Approximately 50% of individuals experiencing sexual dysfunction following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Difficulties resuming sexual activity may relate to physical, psychological and/or emotional deficits resulting from or related to the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. However, sexuality is not frequently addressed in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation and there is limited research regarding sexual rehabilitation following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The clinician information reviewed three types of interventions: psychoeducation/counselling, pelvic floor muscle retraining, and physical therapy focussing on a return to sexual activity.
Patient/Family Information
Is it normal to have difficulties with sex?
Yes. Many people who have had a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. experience decreased sexual activity. Problems with sexual performance can occur for a number of reasons.
After a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. men and women can experience various physical impairments, such as:
- Fatigue
- Muscle weakness, stiffness or tightness
- Pain
- Reduced mobility
- Urinary incontinence (inability to hold in urine)
- Speech impairment (aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada))
People also experience emotional or psychological problems, such as:
- DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
, anxiety and mood changes
- Memory loss
- Insecurity (feeling less attractive)
- Fear of partner rejection
Body changes specific to sex can also occur, such as:
- Erectile difficulties
- Decreased vaginal lubrication
- Problems with ejaculation
- Problems with orgasm
- Decreased libido (desire)
These difficulties can impact on your ability to resume a sexual relationship. However, sex can still be a part of your life after your stroke.
How long after should I wait before becoming sexually active again?
You can try to become sexually active again as soon as you feel comfortable. It is normal and common to feel nervous about having sex after your stroke, or to lose interest in sex after a stroke. It is important to be open with your partner so that you can work together to bring sexuality back into your life. It is often helpful to start by reintroducing familiar activities into your relationship, such as hugging, kissing and cuddling. Talk with your partner about how you feel, any changes you have experienced, and any concerns you may have. Talking together can help you feel connected and can strengthen your relationship. If you are concerned about your health and need guidance before becoming sexually active again, seek the help of a healthcare professional.
Who else can I talk to about having sex?
You can talk about sex with your health care providers. However, since sex is a private matter, the therapist may feel uncomfortable addressing it with you, or you may feel uncomfortable or shy asking them questions. Do not hesitate to seek information from one of your health care providers about any concerns or questions you may have. People you can ask include:
- NeurologistThis team member is responsible for “the diagnostic evaluation, medical treatment, prevention of stroke recurrence, patient and family education, staff and trainee education, research, program evaluation.”(Suggested by Philips et al, 2002)
- Physical therapistIn charge of the “assessment and treatment of motor functioning, including motor control, strength and physical conditioning; balance, gait and mobility retraining; home and community visits; patient and family education regarding mobility and safety issues.” (Suggested by Philips et al, 2002)
- Occupational therapistIn charge of the “assessment of personal and domestic care activities; evaluation and treatment of functional impairments related to change in sensorimotor, cognitive and perceptual abilities; prescription of wheelchairs and bathroom appliances; home visits; patient and family education.”(Suggested by Philips et al, 2002)
- Speech pathologist
- Neurophysiologist
- Physician
- Urologist (specializes in male urinary and reproductive/sexual problems)
- Gynaecologist (specializes in female reproductive and sexual problems)
I am afraid that sexual activity can cause another event. Is this possible?
There is no evidence that sex can cause another strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The following information comes from research and may help you return safely and confidently to sexual activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
after a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Foreplay: Studies show that foreplay is very important. Spending more time on foreplay will cause your heart rate to increase at a slower rate. This will reduce physical effort and cardiac stress during sexual intercourse.
Self-stimulation and partner stimulation: Self-stimulation or stimulation by your partner is less physically demanding than sexual intercourse. These forms of sexual activity are likely to cause a smaller increase in heart rate and can be very satisfying.
Masturbation: Research has shown that masturbation does not increase your risk of having another strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Position: Research shows that for men, the male-on-bottom position is less physically demanding than the male-on-top position. Take the time to find positions that are comfortable for you and your partner (if applicable), and that allow easy movement.
Time: It is advised that you do not engage in sexual activity immediately or shortly after a meal, as your body takes time and uses energy to digest food. Wait a couple of hours before having sex to reduce the demands on your body. Similarly, plan for sexual intimacy when you are not too tired and have time to enjoy the interactions.
Do physical changes affect sexual behaviour or ability?
After a stroke many people experience pain, muscle paralysis, weakness or muscle stiffness on one side of their body. These changes can impact on the way a person experiences touch to the affected arm/leg, and their ability to move or find a comfortable position for sex. Taking the time to find comforting touch and comfortable positions is a good way to make sex enjoyable. For instance, it might be easier for the person who has had a stroke to lie on their back, or to lie side-by-side. If you experience altered sensation or pain on one side of your body, your partner can touch and caress the non-affected arm/leg.
Your Physical Therapist and Occupational Therapist may be able to recommend assistive devices to help with moving and to support safe, comfortable sexual activities and positions. Talk with your doctor if you experience pain, spasticity (i.e. tight muscles) or other concerning symptoms.
Do psychological changes affect sexual behaviour or ability?
The physical changes that occur after a stroke can impact on self-confidence. Loss of independence can impact on self-worth. Emotional difficulties such as depression, anxiety, decreased self-esteem, impaired body image or fear of having another stroke can impact on a person’s ability to return to sexual activity and enjoy sex. Changes in memory after a stroke can also affect your sexual relationship. It is important to have accurate information. Talk with your health care provider or a specialist such as a psychiatrist, psychologist or sex therapist. Take the time to discuss your concerns and ask any questions. It is also important to look after yourself – find ways to feel independent, maintain your personal hygiene and grooming, find hobbies that interest you, eat nutritious foods and keep up regular gentle exercise. These activities will help you feel positive and healthy. Communicating with your partner (if applicable) about psychological changes from the stroke can also benefit your sexual relationship.
I have difficulty communicating with my partner. What should I do?
Some people have difficulty communicating after a stroke. Aphasia is a disorder that affects the ability to produce speech or understand what others are saying. Communication problems can make it difficult to have intimate conversations and express your feelings to your partner. If you have difficulty using words, find other ways to get your message across. Body language (e.g. gestures, facial expressions) can support your words. Draw or write down what you want to say. Find simple hand signals to communicate a feeling to your partner (e.g. pointing to your heart with your hand can be your way of saying “I love you”). Talk with your Speech & Language Pathologist about management of aphasia after stroke.
Are there treatments available to regain sexual function?
There is not enough research on specific treatments that improve sexual function after stroke. There are medications to address specific sexual impairments, special materials or devices to help sexual activity. Lifestyle changes such as stopping smoking, reducing alcohol, modifying your diet or losing weight may be of benefit to some people. Consult with your health care provider and physician before using any medications prescribed for sexual function. Therapy sessions with a psychologist or sex therapist can be useful for people with psychological concerns about sex after a stroke.
I am taking new medications. Can medications have an impact on my sexual functioning?
Some medications can impact on sexual activity. Talk with your physician if you have any concerns regarding your medication. Do not stop taking medication without consulting your physician.
FOR THE SPOUSE/PARTNER
My partner has different sexual behaviours that they did not have before. What is causing this?
Changes in sexual activity are common after strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The physical and emotional difficulties from strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. can impact on your partner’s sexual activity.
In rare cases, some people show unexpected changes in their sexual behaviour after a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., such as:
- Changes in libido
- Changes in sexual activity
- Inappropriately removing clothes
- Inappropriately physically touching others
- Masturbating at inappropriate times or in inappropriate places
The exact cause of these behaviours is unknown, but may relate to damage to specific regions of the brain. If your spouse shows any of these activities, talk to the healthcare team for suggestions on how to handle the behaviours.
Is it possible to be carer and sexual partner at the same time?
As much as possible, the role of carer should be separated from the role of sexual partner. To achieve this balance, support your partner’s independence where possible. If possible, find someone to help with your partner’s physical care. Find moments to enjoy together – laugh, talk and connect over shared interests and memories. Remember that it is important for you to continue to participate in activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
that you enjoy and to spend some time alone without feeling guilty. Research has shown that in taking care of yourself, you will be better able to care for your partner.
Clinician Information
When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (
RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared; if a treatment is not effective, it implies that it was not more effective than the control treatment. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.
Sexual dysfunction occurs in approximately 50% of individuals following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (Stratton et al., 2020). Reduced sexual activity and sexual satisfaction can be caused by a range of physical, psychological and/or emotional factors resulting from or related to the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. – spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, muscle weakness, disrupted sensation, pain, fatigue, depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and emotional lability, communication difficulties, medication side effects, decreased libido, loss of independence, changes in body function and body image, and safety concerns (Kautz & Van Horn, 2017; Winstein et al., 2016). Despite the high incidence of sexual dysfunction following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., sexuality is not commonly addressed in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation (Schmitz & Finkelstein 2010). While guidelines recommend providing sexual education to patients recovering from strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (Winstein et al., 2016), patients’ and partners’ unmet need and desire for sexual rehabilitation is attributable to a lack of professional training and standardised practices (Grenier-Genest et al., 2017).
This Stroke Engine clinician information section includes a total of four studies (two high quality RCTs, one fair quality RCT and one non-randomized study) that investigate non-pharmacological post-stroke sexual rehabilitation interventions. Two of these studies examined single-session psychoeducation/counselling, one study examined a 12-week physical therapy pelvic floor muscle retraining program, and the fourth study examined a 2-week physical therapy rehabilitation program with a focus on return to sexual activity (e.g. positioning, bed mobility, etc).
Results from this review are reported according to stage of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. One study (and its pilot study) was conducted with participants in the acute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery, and found that a single-session psychoeducation / counselling session was no more effective than written educational materials in improving functional independence, mood, quality of life or sexual behaviour. A study conducted with individuals in the subacute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery found that pelvic floor muscle training was no more effective than no treatment for improving erectile dysfunction in this phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery. A third study conducted with patients across the subacute/chronic phases of recovery showed that a 2-week physical therapy sexual rehabilitation programme was more effective than conventional physical therapy for improving mood and sexual behaviour among these participants. The final study did not define the stage of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery of its participants, but reported that a single-session sexual rehabilitation programme with written information was more effective than no treatment for improving sexual behaviour, knowledge and satisfaction.
Overall, results from this review support earlier views that there is insufficient evidence regarding the efficacy of post-stroke sexual rehabilitation interventions. A recent Cochrane review on the topic (Stratton et al., 2020) comprised three RCTs (two are included in this Stroke Engine module; the third was outside the scope of this review) and similarly concluded that there is insufficient evidence regarding the effectiveness of sexual rehabilitation programs to reduce post-stroke sexual dysfunction.
Results Table
View results table
Outcomes
Acute phase - Sexual rehabilitation programmes
Functional independence
Not effective
1b
One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (Ng et al., 2017) and its pilot study (Samson et al., 2015) investigated the effect of a sexual rehabilitation programme on functional independence in the acute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery.
The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (Ng et al., 2017) randomized patients to receive a single-session sexual rehabilitation programme + written material or written material alone. Functional independence was measured by the Functional Independence Measure (FIM – Motor total : Self-care, Sphincter control, Mobility, Locomotion; Cognitive total : Communication, Social, cognition scores) at 6 weeks and at 6 months post-stroke. No significant between-group difference was found at either timepoint.
The pilot study to Ng et al., 2017 (Samson et al., 2015) randomized patients to receive a single-session sexual rehabilitation programme + written material or written material alone. Functional independence was measured by the FIM (Total, Motor total : Self-care, Sphincter control, Mobility, Locomotion; Cognitive total : Communication, Social, cognition scores) at 6 weeks. No significant between-group difference was found.
Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a sexual rehabilitation programme + written material are not more effective than a comparison intervention (written material alone) for improving functional independence in the acute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery.
Note: The pilot study was not considered to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines).
One high quality RCT (Ng et al., 2017) and its pilot study (Samson et al., 2015) investigated the effect of a sexual rehabilitation programme on mood in the acute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery.
The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (Ng et al., 2017) randomized patients to receive a single-session sexual rehabilitation programme + written material or written material alone. Mood was measured by the DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
, Anxiety and Stress Scale (DASS – Total, DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
, Anxiety, Stress scores) at 6 weeks and at 6 months post-stroke. No significant between-group difference was found at either timepoint.
The pilot study to Ng et al., 2017 (Samson et al., 2015) randomized patients to receive a single-session sexual rehabilitation programme + written material or written material alone. Mood was measured by the DASS (Total, DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
, Anxiety, Stress scores) at 6 weeks. No significant between-group difference was found.
Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that a sexual rehabilitation programme + written material are not more effective than a comparison intervention (written material alone) for improving mood in the acute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery.
Note: The pilot study was not considered to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines).
Quality of life
Not effective
1b
One high quality RCT (Ng et al., 2017) and its pilot study (Samson et al., 2015) investigated the effect of a sexual rehabilitation programme on quality of life in the acute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery.
The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (Ng et al., 2017) randomized patients to receive a single-session sexual rehabilitation programme + written material or written material alone. Quality of life was measured by the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and AphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) Quality of Life Scale – 39 Generic (SAQOL-39g – Total, Physical, Communication, Psychosocial scores) at 6 weeks and at 6 months post-stroke. No significant between-group difference was found at either timepoint.
The pilot study to Ng et al., 2017 (Samson et al., 2015) randomized patients to receive a single-session sexual rehabilitation programme + written material or written material alone. Quality of Life was measured by the SAQOL-39g (Total, Physical, Psychosocial, Communication scores) at 6 weeks. No significant between-group difference was found.
Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that a sexual rehabilitation programme + written material are not more effective than a comparison intervention (written material alone) for improving quality of life in the acute phase of stroke recovery.
Note: The pilot study was not considered to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines).
Sexual behaviour
Not effective
1b
One high quality RCT (Ng et al., 2017) and its pilot study (Samson et al., 2015) investigated the effect of a sexual rehabilitation programme on sexual behaviour in the acute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery.
The high quality RCT (Ng et al., 2017) randomized patients to receive a single-session sexual rehabilitation programme + written material or written material alone. Sexual behaviour was measured by the Change in Sexual Functioning Questionnaire – Short Form (CSFQ-14 – Total, Pleasure, Frequency, Interest, Arousal, Orgasm scores) at 6 weeks and at 6 months post-stroke. A significant between-group difference was found on only one measure (CSFQ-14 – Arousal) at 6 months post-stroke, in favour of written material alone vs. sexual rehabilitation + written material.
The pilot study to Ng et al., 2017 (Samson et al., 2015) randomized patients to receive a single-session sexual rehabilitation programme + written material or written material alone. Sexual behaviour was measured by the CSFQ-14 (Total, Pleasure, Frequency, Interest, Arousal, Orgasm scores) at 6 weeks. No significant between-group difference was found.
Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that a sexual rehabilitation programme + written material are not more effective than a comparison intervention (written material alone) for improving sexual behaviour in the acute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery.
Note: The pilot study was not considered to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines).
Subacute phase - Pelvic floor muscle training
Erectile dysfunction
Not effective
1b
One high quality study (Tibaek et al., 2015) investigated the effect of a sexual rehabilitation programme on erectile dysfunction in the subacute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery. This high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. randomized male patients to receive pelvic floor muscle training or no treatment. Erectile dysfunction was measured using the International Index of Erectile Function (IIEF-5) questionnaire and a two-pronged Bother question (5-point satisfaction scale, Binominal scale regarding use of aids/appliances/medicine) at post-treatment (12 weeks) and follow-up (6 months). No significant between-group differences were found at either timepoint.
Note: The treatment group showed a significant improvement in Erectile Function (IIEF-5) scores from baseline to post-treatment.
Conclusion: There is moderate evidence (level 1b) from one high quality RCT that pelvic floor muscle training is not more effective than no treatment for improving erectile dysfunction in the subacute phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. recovery.
Note: However, the group that received pelvic floor muscle training showed a significant improvement in erectile function at post-treatment.
Phase not specific to one period: Sexual rehabilitation programmes
One fair quality RCT (Vajrala et al., 2019) investigated the effect of a sexual rehabilitation programme on mood following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. This fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. randomized patients with subacute/chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. to receive sexual rehabilitation + counselling or conventional physical therapy + counselling with no focus on sexual health for 2 weeks. Mood was measured by the DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
, Anxiety and Stress Scale (DASS – DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
, Anxiety, Stress scores) at follow-up (6 months). Significant between-group differences were found on all measures of mood, in favour of sexual rehabilitation + counselling vs. conventional physical therapy + counselling.
Conclusion: There is limited evidence (level 2a) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that a sexual rehabilitation programme + counselling are more effective than a comparison intervention (physical therapy + counselling) for improving mood following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Sexual behaviour
Effective
2a
One fair quality RCT (Vajrala et al., 2019) and one non-randomized controlled trial (Song et al., 2011) investigated the effect of a sexual rehabilitation programme on sexual behaviour following stroke.
The fair quality RCT (Vajrala et al., 2019) randomized patients with subacute/chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. to receive sexual rehabilitation + counselling or conventional physical therapy + counselling (with no focus on sexual health) for 2 weeks. Sexual behaviour was measured by the Change in Sexual Functioning Questionnaire – Short Form (CSFQ-14) at follow-up (6 months). A significant between-group difference was found, in favour of sexual rehabilitation + counselling vs. conventional physical therapy + counselling.
The non-randomized controlled trial (Song et al., 2011) assigned patients (time since strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. not specified) to receive a single-session sexual rehabilitation programme + written information or no treatment. Sexual behaviour was measured at 1 month using a 4-item, 5-point sexual frequency scale (Sexual activity, Sexual intercourse). Significant between-group differences were found on both measures, in favour of a sexual rehabilitation programme vs. no treatment.
Conclusion: There is limited evidence (level 2a) from one fair quality RCT and one non-randomized controlled trial that sexual rehabilitation programmes (provided with counselling or written information) are more effective than no treatment and a comparison intervention (physical therapy + counselling) for improving sexual behaviour following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Sexual beliefs and knowledge
Not effective
2b
One non-randomized controlled trial (Song et al., 2011) investigated the effect of a sexual rehabilitation programme on sexual beliefs and knowledge following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. This controlled trial assigned patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (time since strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. not specified) to receive a single-session sexual rehabilitation programme + written information, or no treatment. Sexual beliefs and knowledge were measured at 1 month using the Sexual Beliefs and Information Questionnaire (Korean version). No significant between-group difference was found.
Conclusion: There is limited evidence (level 2b) from one controlled clinical trial that a sexual rehabilitation programme + written information are not more effective than no treatment for improving sexual beliefs and knowledge following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Sexual satisfaction
Effective
2b
One non-randomized controlled trial (Song et al., 2011) investigated the effect of a sexual rehabilitation programme on sexual satisfaction following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. This controlled trial assigned patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (time since strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. not specified) to receive a single-session sexual rehabilitation programme + written information, or no treatment. Sexual satisfaction was measured at 1 month using the Derogatis Sexual Functioning Inventory (Korean version). A significant between-group difference was found, in favour of sexual rehabilitation + written information vs. no treatment.
Conclusion: There is limited evidence (level 2b) from one controlled trial that a sexual rehabilitation programme + written information are more effective than no treatment for improving sexual satisfaction following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
References
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Kautz, D.D. & Van Horn, E.R. (2017). Sex and intimacy after stroke. Rehabilitation Nursing, 42(6), 333-40. DOI: 10.1002/rnj.296.
Ng, L., Sansom, J., Zhang, N., Amatya, B., & Khan, F. (2017). Effectiveness of a structured sexual rehabilitation programme following stroke: a randomised controlled trial. Journal of Rehabilitation Medicine, 49, 333-40. DOI: 10.2340/16501977-2219.
Sansom, J., Ng, L., Zhang, N., & Khan, F. (2015). Let’s talk about sex: a pilot randomised controlled trial of a structured sexual rehabilitation programme in an Australian stroke cohort. International Journal of Therapy and Rehabilitation, 22(1), 21-8. DOI: 10.12968/ijtr.2015.22.1.21.
Schmitz, M.A. & Finkelstein, M. (2010). Perspectives on poststroke sexual issues and rehabilitation needs. Topics in Stroke Rehabilitation, 17(3), 204-13. DOI: 10.1310/tsr1703-204.
Song, H.S., Oh, H.S., Kim, H.S., & Seo, W.S. (2011). Effects of a sexual rehabilitation intervention program on stroke patients and their spouses. NeuroRehabilitation, 28, 143-50. DOI: 10.3233/NRE-2011-0642.
Stratton, H., Sansom, J., Brown-Major, A., Anderson, P., & Ng, L. (2020). Interventions for sexual dysfunction following stroke. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD011189. DOI: 10.1002/14651848.CD011189.pub2.
Tibaek, S., Gard, G., Dehlendorff, C., Iversen, H.K., Erdal, J., Biering-Sorensen, F., Dorey, G., & Jensen, R. (2015). The effect of pelvic floor muscle training on sexual function in men with lower urinary tract symptoms after stroke. Topics in Stroke Rehabilitation, 22(3), 185-93. DOI: 10.1179/1074935714Z0000000019.
Vajrala, K.R., Potturi, G., & Agarwal, A. (2019). A pilot study of randomized clinical controlled trial on role of physiotherapy on physical and psychological dimensions of sexual health in post stroke patients. Indian Journal of Physiotherapy and Occupational Therapy, 13(4), 73-7. DOI: 10.5958/0973-5674.2019.00135.7.
Winstein, C.J., Stein, J., Arena, R., Bates, B., Cherney, L.R., Cramer, S.C., Deruyter, F., Eng, J.J., Fisher, B., Harvey, R.L., Lang, C.E., MacKay-Lyons, M., Ottenbacher, K.J., Pugh, S., Reeves, M.J., Richards, L.G., Stiers, W., Zorowitz, R.D. (2016). Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 47(6), e98-169. DOI: 10.1161/STR.0000000000000098.