Family Support – Subacute / Chronic

Evidence Reviewed as of before: 25-08-2011
Author(s): Dr. Nicol Korner-Bitensky (PhD); Annabel McDermott (OT)
Table of contents

Introduction

Stroke can impact substantially on many aspects of life for the person who experiences a stroke, as well as his/her family. This module provides information on the value of various interventions such as education about stroke, counselling, and specific training regarding how to manage after a stroke.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) 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. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Numerous studies have explored aspects of family-directed intervention in the acute, subacute and chronic phases of stroke rehabilitation. For the purpose of these modules, research that investigates interventions during the acute phase of stroke recovery has been examined separately to those that investigate interventions used during the subacute and chronic phases of stroke recovery.

Studies have examined the effects of approaches such as group education programs, counseling and education programs, carer training programs, web education programs and telephone support services. Outcomes that are typically evaluated in both the patient with stroke and their carer include emotional well-being, stroke-related knowledge, satisfaction with information/intervention, activity and participation, quality of life and health status.

In the subacute and chronic phases of stroke recovery, patients’ emotional wellbeing and adjustment to stroke improved with combined counselling and education programs, while carer emotional wellbeing benefited from telephone support programs only. Carer strain and burden, and patients’ and carers’ mood and quality of life improved following carer training programs. Carers’ knowledge of stroke improved following several interventions including home visit programs, group education programs and combined counselling and education programs, while carers’ problem solving skills were found to benefit from telephone interventions. No studies reported on patient knowledge of stroke. Patient function and recovery improved following several interventions including carer training programs and combined counselling and education programs. Family function was also found to benefit from combined education and counselling programs. Interestingly, patients’ use of health care services improved following web education programs. Elements such as carers’ perceived social support, patients’ and carers’ satisfaction with intervention, patients’ and carers’ use of social resources, patients’ and carers’ health status and ADLs, patients’ mortality/institutionalisation were not found to benefit from any particular intervention.

Outcomes

Carer Training Programs

Activities of Daily Living (ADLs) - Patients
Effective
1B

One high quality RCT (Kalra et al., 2004) examined the effects of carer training program on activities of daily living (ADLs) in patients with subacute or chronic stroke. This high quality RCT randomized patients and their carers to either a carer training group or a control group who received conventional care. ADLs were measured by the Barthel Index at 3 and 12 months post-stroke. A significant between-group difference in ADLs was seen at 3 months, in favour of the carer training group compared to the control group, however this was not maintained at 12 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a carer training program is more effective than conventional care in improving ADLs of patients with subacute or chronic stroke in the short term.

Activities of Daily Living (IADLs) - Patients
Not effective
1B

One high quality RCT (Kalra et al., 2004) examined the effects of carer training program on instrumental activities of daily living (IADLs) in patients with subacute or chronic stroke. This high quality RCT randomized patients and their carers to either a carer training group or a control group who received conventional care. IADLs were measured by the Frenchay Activities Index at 12 months post-stroke. No significant between-group differences were found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a carer training program is not more effective than conventional care in improving IADLs in patients with subacute or chronic stroke.

Burden - Carers
Effective
1B

One high quality RCT (Kalra et al., 2004) has investigated the effect of a carer training program on burden of carers of patients with subacute or chronic stroke. This high quality RCT randomized patients and their carers to either a carer training group or a control group who received conventional care. Carer burden was measured by the Caregiving Burden Scale at 3 and 12 months post-stroke. A significant between-group difference in carer burden was found at both time points, in favour of the carer training group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a carer training program is more effective than conventional care in reducing burden in carers of patients with subacute or chronic stroke.

Functional Independence - Patients
Not effective
1B

One high quality RCT (Kalra et al., 2004) has investigated the effect of a carer training program on functional independence of patients with subacute or chronic stroke. This high quality RCT randomized patients and their carers to either a carer training group or a control group who received conventional care. Functional independence was measured by the Modified Rankin Scale at 3 and 12 months post-stroke. No significant between-group differences in functional independence were found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a carer training program is not more effective than conventional care in improving functional independence in patients with subacute or chronic stroke.

Instrumental activities of daily living (IADLs) – Carers
Not effective
1B

One high quality RCT (Kalra et al., 2004) examined the effects of carer training program on instrumental activities of daily living (IADLs) in carers of patients with subacute or chronic stroke. This high quality RCT randomized patients and their carers to either a carer training group or a control group who received conventional care. IADLs were measured by the Frenchay Activities Index at 12 months post-stroke. No significant between-group differences were found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a carer training program is not more effective than conventional care in improving instrumental activities of daily living in carers of patients with subacute or chronic stroke.

Mood - Carers
Effective
1B

One high quality RCT (Kalra et al., 2004) and one poor quality RCT (Perrin et al., 2010) have investigated the effect of a carer training program on mood of carers of patients with subacute or chronic stroke.

The high quality RCT (Kalra et al., 2004) randomized patients and their carers to either a carer training group or a control group who received conventional care. Mood was measured by the Hospital Anxiety and Depression Scale at 12 months post-stroke. A significant between-group difference was found in favour of the carer training group as compared to the control group.

The poor quality RCT (Perrin et al., 2010) randomised carers of patients to an intervention group that received a Transition Assistance Program (TAP) or a control group that received standard care. Carer depression was measured by the Center for Epidemiologic Studies Depression Scale (CESD-10). A significant between-group difference in depression was found at 3 months post-discharge, in favour of the TAP group compared to the control group.

Note: The significant between-group difference was only found when baseline differences in depression were controlled and the significance level was adjusted to 0.10.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one poorquality RCT that a carer training program is more effective than conventional care in improving mood of carers of patients with subacute or chronic stroke.

Mood - Patients
Effective
1B

One high quality RCT (Kalra et al., 2004) has investigated the effect of a carer training program on mood of patients with subacute or chronic stroke. This high quality RCT randomized patients and their carers to either a carer training group or a control group who received conventional care. Mood was measured by the Hospital Anxiety and Depression Scale at 12 months post-stroke. A significant between-group difference was found in favour of the carer training group as compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one highquality RCTthat a carer training program is more effective than conventional care in improving mood of patients with subacute or chronic stroke.

Mortality and Institutionalisation - Patients
Not effective
1B

One high quality RCT (Kalra et al., 2004) has investigated the effect of a carer training program on mortality and institutionalisation in patients with subacute or chronic stroke. This high quality RCT randomized patients and their carers to either a carer training group or a control group who received conventional care. Mortality and institutionalisation rates were documented at 3 and 12 months post-stroke. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a carer training program is not more effective than conventional care in minimising mortality and institutionalisation in patients with subacute or chronic stroke.

Quality of life - Carers
Effective
1B

One high quality RCT (Kalra et al., 2004) has investigated the effect of a carer training program on quality of life of carers of patients with subacute or chronic stroke. This high quality RCT randomized patients and their carers to either a carer training group or a control group who received conventional care. Quality of life was measured by the EuroQOL visual analogue scale at 3 and 12 months post-stroke. A significant between-group difference in quality of life was found at both time points, in favour of the carer training group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a carer training program is more effective than conventional care in improving the quality of life of carers of patients with subacute or chronic stroke.

Quality of life - Patients
Effective
1B

One high quality RCT (Kalra et al., 2004) has investigated the effect of a carer training program on quality of life of patients with subacute or chronic stroke. This high quality RCT randomized patients and their carers to either a carer training group or a control group who received conventional care. Quality of life was measured by the EuroQOL visual analogue scale at 3 and 12 months post-stroke. A significant between-group difference in quality of life was found at both time points, in favour of the carer training group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a carer training program is more effective than conventional care in improving quality of life of patients with subacute or chronic stroke.

Strain - Carers
Effective
2B

One poor quality RCT (Perrin et al., 2010) has investigated the effect of a carer training program on strain in carers of patients with subacute or chronic stroke. This poor quality RCT randomised participants to an intervention group that received a carer Transition Assistance Program (TAP) or a control group that received standard care. Carer strain was measured by the Caregiver Strain Index. A significant between-group difference in carer strain was reported at 1 month and 3 months post-discharge in favour of the TAP group. Carers from the control group demonstrated a significant increase in carer strain from 1 to 3 months post-discharge, while carers from the TAP group demonstrated reduced strain over this time.

Note: Although the authors reported a significant between-group difference in carer strain at 1 and 3 months, statistical data were not provided.

Conclusion: There is limited evidence (level 2b) from one poor quality RCT that a carer training program is more effective than conventional care in reducing strain in carers of patients with subacute or chronic stroke.

Combined Counselling and Education Programs

Activities of daily living - Patients
Effective
1B

One high quality RCT (Clark et al., 2003) examined the effects of counselling and written information on activities of daily living (ADLs) of patients with subacute stroke. This high quality RCT randomised patients and their spouses to receive an information package and counselling or no intervention. ADLs of daily living were measured by the Barthel Index and the Adelaide Activities Profile (AAP). At 6 months follow-up significant between-group differences were seen in favour of the intervention group compared to the control group. Results from the AAP showed that the intervention group demonstrated greater participation in domestic chores, household maintenance and social activities, but not service to others.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a combined counselling and education program is more effective than regular care in improving activities of daily living in patients with subacute stroke.

Emotional wellbeing - Patients
Effective
1B

One high quality RCT (Clark et al., 2003) examined the effects of counselling and written information on emotional wellbeing of patients with subacute stroke. This high quality RCT randomised patients and their spouses to receive an information package and counselling or no intervention. Anxiety was assessed using the Hospital Anxiety and Depression Scale and depression was assessed using the short form of the Geriatric Depression Scale. At 6 month follow-up there was no significant between-group difference in depression, however patients in the intervention group were significantly less anxious as compared to those in the control group.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a combined counselling and education program is more effective than regular care in reducing anxiety but not depression in patients with subacute stroke.

Family functioning - Carers
Effective
1B

One high quality RCT (Clark et al., 2003) and one fair quality RCT (Evans et al., 1988) investigated the effectiveness of counselling and education in improving family functioning for carers of patients with stroke.

The high quality RCT (Clark et al., 2003) randomised patients with subacute stroke and their spouses to receive an information package and counselling or no intervention. Family functioning amongst carers was measured using the McMaster Family Assessment Device. At 6 months follow-up, there was a significant between-group difference in family functioning, in favour of patients in the intervention group compared to those in the control group.

The fair quality RCT (Evans et al., 1988) randomized carers of patients with stroke (time since stroke not specified) to an education group (EG), a counselling + education group (CEG), or a control group (no education or counselling). Family function in carers was measured using the McMaster Family Assessment Device. At 6 months and 1 year post-stroke, significant between-group differences were seen in favour of both the EG and CEG compared to the control group for some aspects of family function (problem-solving, communication, and global family function subtests).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that a combined counselling and education program is more effective than regular care in improving family function in carers of patients with stroke.

Family functioning - Patients
Effective
1b

One high quality RCT (Clark et al., 2003) examined the effects of counselling and written information on family functioning for patients with subacute stroke. This high quality RCT randomised patients and their spouses to receive an information package and counselling or no intervention. Family function in patients was measured with the McMaster Family Assessment Device (FAD). At 6 months follow-up, significant between-group differences in family functioning were seen in favour of the intervention group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a combined counselling and education program is more effective than regular care in improving family functioning of patients with subacute stroke.

Health status and quality of life – Carers
Not effective
1B

One high quality RCT (Clark et al., 2003) investigated the effects of counselling and written information on health status and quality of life of spouses of patients with subacute stroke. The high quality RCT randomised patients and their spouses to receive an information package and counselling or no intervention. Carers’ health status and quality of life was measured by the Short Form-36 Health Survey (SF-36). At 6 months follow-up, there were no significant between-group differences in carers’ physical or mental health scores.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a combined counselling and education program is not more effective than regular care in improving quality of life and health status of carers for patients with subacute stroke.

Health status and quality of life – Patients
Not effective
1B

One high quality RCT (Clark et al., 2003) investigated the effects of counselling and written information on health status and quality of life of patients with subacute stroke. The high quality RCT randomised patients and their spouses to receive an information package and counselling or no intervention. Health status and quality of life and was measured using the Short Form-36 Health Survey (SF-36). At 6 months follow-up there were no significant between-group differences on SF-36 subscale scores of pain, physical health, or mental health.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a combined counselling and education program is not more effective than regular care in improving health-related quality of life in patients with subacute stroke.

Knowledge of stroke - Carers
Effective
2A

One fair quality RCT (Evans et al., 1988) investigated the effects of counselling and education on knowledge of stroke in carers of patients with stroke. This high quality RCT randomised carers of patients with stroke (time since stroke not specified) to an education group (EG), a counselling + education group (CEG), or a control group (no education or counselling). Carers’ knowledge of stroke was measured using the Stroke Care Information Test. At 6 months and 1 year after stroke, significant between-group differences were seen for carer knowledge of stroke in favour of both CEG and EG compared to the control group.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that a combined counselling and education program is more effective than regular care in improving knowledge of stroke among carers of patients with subacute or chronic stroke.

Mastery - Patients
Not effective
1B

One high quality RCT (Clark et al., 2003) examined the effects of counselling and written information on mastery for patients with subacute stroke. This high quality RCT randomised patients with and their spouses to receive an information package and counselling or no intervention. Patients were assessed with the Mastery Scale. No significant between-group differences in patient mastery were seen at 6 months follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a combined counselling and education program is not more effective than regular care in improving sense of mastery in patients with subacute stroke.

Patient adjustment
Effective
2a

One fair quality RCT (Evans et al., 1988) investigated the effects of counselling and education on personal adjustment in patients with stroke. This high quality RCT randomised patients with stroke (time since stroke not specified) to an education group (EG), a counselling + education group (CEG), or a control group (no education or counselling). Patient adjustment was measured by the Personal Adjustment and Role Skills Scale (PARS). At 6 months and 1 year after stroke, patients’ adjustment scores were significantly better in the CEG compared to the EG and the control group.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that a combined counselling and education program is more effective than education alone or regular care in improving personal adjustment of patients with subacute or chronic stroke.

Use of social resources - Carers
Not effective
2A

One fair quality RCT (Evans et al., 1988) investigated the effects of counselling and education on use of social resources in carers of patients with stroke. This high quality RCT randomised carers of patients with stroke (time since stroke not specified) to an education group (EG), a counselling + education group (CEG), or a control group (no education or counselling). Use of social resources was measured using the ESCROW Profile. No significant between-group differences were seen with regard to carers’ use of social resources at 6 months or 1 year after stroke.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that a combined counselling and education program is not more effective than regular care in improving use of social resources by carers of patients with subacute or chronic stroke.

Group Education Program or Lectures

Activities of Daily Living - Patients
Not Effective
1B

One high quality RCT (Franzen-Dahlin et al., 2008) and one poor quality RCT ( Draper et al., 2007) investigated the effects of a group education program on performance of activities of daily living (ADLs) by patients with stroke.

The high quality RCT (Franzen-Dahlin et al., 2008) randomised patients with stroke (stage of stroke not specified) and their spouses to either an intervention group that attended lectures and group discussions on stroke-related topics, or to a control group that received regular care. Both groups were able to attend weekly information sessions at the Stroke Unit during the patient’s hospital stay. ADLs were measured using the Barthel Index. There were no significant between-group differences in patients’ functional ability at 6 or 12 months.

The poor quality RCT (Draper et al., 2007) randomised carers of patients with aphasia post-stroke (stage of stroke not specified) to a 4-week group education program or a wait list control group that received the same program after 3 months (delayed treatment). ADLs were measured by the Barthel Index and instrumental activities of daily living (IADLs) were measured using the Frenchay Activities Index. No significant changes were seen within either group from baseline to post-intervention or follow-up.

Note: As this study did not report between-group differences, these results are not considered in the conclusion below.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a group education program is not more effective than regular care in improving activities of daily living in patients with stroke.

Burden - Carers
Effective
2A

One fair quality RCT (Hartke et al., 2003) and one poor quality RCT (Draper et al., 2007) investigated the effects of a group education program on burden of carers of patients with stroke.

The fair quality RCT (Hartke et al., 2003) randomized spouses of patients with stroke (stage of stroke not specified) to either a telephone psycho-education group or a control group that received regular care. Both groups received written stress management advice. Carer burden was assessed by the Burden Interview. At 6 months follow-up a significant between-group difference was found for burden in favour of the intervention group compared to the control group.

The poor quality RCT (Draper et al., 2007) randomised carers of patients with aphasia post-stroke (stage of stroke not specified) to a 4-week group education program or a wait list control group that received the same program after 3 months (delayed treatment). Carer burden was measured by the Relatives’ Stress Scale. No significant changes in carer burden were seen within either group from baseline to post-intervention or follow-up.

Note: As this study did not report between-group differences, these results are not considered in the conclusion below.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that a group education program is more effective than regular care in reducing burden of carers of patients with stroke.

Communication - Carers
Insufficient evidence
5

One poor quality RCT (Draper et al., 2007) investigated the effects of a group education program on communication of carers of patients with stroke. This poor quality RCT randomised carers of patients with aphasia post-stroke (stage of stroke not specified) to a 4-week group education program or a wait list control group that received the same program after 3 months (delayed treatment). Carer communication was measured by a non-standardised questionnaire. No significant changes in carer communication were seen within either group from baseline to post-intervention or follow-up.

Note: As this study did not report between-group differences, these results are not considered in the conclusion below.

Conclusion: There is insufficient evidence (level 5) to indicate whether a group education program is more effective than regular care in improving communication of carers of patients with subacute or chronic stroke.

Emotional wellbeing - Carers
Not effective
1b

One high quality RCT (Franzen-Dahlin et al., 2008), two fair quality RCTs (Hartke et al., 2003, van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) and one poor quality RCT (Draper et al., 2007) examined the effects of an education group on emotional wellbeing of carers of patients with stroke.

The high quality RCT (Franzen-Dahlin et al., 2008) randomized patients with stroke (stage of stroke not specified) and their spouses to either an intervention group that attended lectures on stroke-related topics and group discussions, or to a control group that received regular care. Both groups were able to attend weekly information sessions at the Stroke Unit during the patient’s hospital stay. Spouses’ ability to cope with stress was assessed by examining their sense of coherence using the short version of Antonovsky’s questionnaire. At 6 months and 12 months, no significant between-group differences were found for spouses’ ability to cope with stress.

The first fair quality RCT (Hartke et al., 2003) randomized spouses of patients with stroke (stage of stroke not specified) to either a telephone psycho-education group or a control group that received regular care. Both groups received written stress management advice. Carer emotional wellbeing was assessed by the Center for Epidemiologic Studies Depression Scale (CES-D), UCLA Loneliness Scale, Pressing Problem Index (PPI) and Caregiver Competence Scale (CCS). At 6 months follow-up a significant between-group difference was found for carer competence (CCS), in favour of the intervention group compared to the control group. Although the treatment group demonstrated significantly reduced stress (PPI) over time, no significant between-group differences were found for stress, depression, or loneliness.

The second fair quality RCT (van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) randomized patients with subacute or chronic stroke and their carers to a group education program (GP), a home visit education program (HP), or a control group. Carers’ emotional wellbeing was measured according to use of coping strategies by a short version of the Utrecht coping list (‘confronting’ and ‘seeking social support’ subscales), strain by the Caregiver Strain Index (CSI), and assertiveness by a questionnaire developed for the study. At 1 month and 7 months post-intervention, the GP group had significantly increased use of the coping strategy ‘seeking social support’ (Utrecht Coping List – short version) when compared to the control group only. There were no significant between-group differences between the GP and HP groups, or the HP and control groups. No significant differences were seen between groups for use of the ‘confronting’ coping strategy, strain or assertiveness.

The poor quality RCT (Draper et al., 2007) randomised carers of patients with aphasia post-stroke (stage of stroke not specified) to a 4-week group education program or a wait list control group that received the same program after 3 months (delayed treatment). Psychological distress was measured by the General Health Questionnaire (GHQ-28). The education group demonstrated a significant improvement in psychological distress from baseline to post-treatment, however these results were not seen at follow-up. The wait list group did not demonstrate a significant improvement in psychological distress over time.

Note: As this study did not report between-group differences, these results are not considered in the conclusion below.

Conclusion: There is limited evidence (level 1b) from one high quality RCT that a group education program is not more effective than regular care in improving emotional wellbeing (e.g. ability to cope with stress) in carers of patients with stroke.

>Note: However, two fair quality RCTs found that group education programs are more effective than regular care in improving factors such as carer competence and ability to seek social support in carers of patients with stroke.

Emotional wellbeing - Patients
Insufficient evidence
5

One poor quality RCT (Draper et al., 2007) investigated the effects of a group education program on the emotional well-being of patients with stroke. This poor quality RCT randomised carers of patients with aphasia post-stroke (stage of stroke not specified) to a 4-week group education program or a wait list control group that received the same program after 3 months (delayed treatment). Patient behaviour and mood was measured by the Behaviour and Mood Disturbance Questionnaire. No significant changes were seen within either group from baseline to post-intervention or follow-up.

Note: As this study did not report between-group differences, these results are not considered in the conclusion below.

Conclusion: There is insufficient evidence (level 5) to indicate whether a group education program is more effective than regular care in improving emotional wellbeing of carers of patients with subacute or chronic stroke.

Family functioning – Carers
Effective
2A

One fair quality RCT (Evans et al., 1988) investigated the effects of an education group on family function in carers of patients with stroke. This high quality RCT randomised carers of patients with stroke (time since stroke not specified) to an education group (EG), a counselling + education group (CEG), or a control group (no education or counselling). Family function was measured by the Family Assessment Device (FAD). At 6 months post-stroke, significant between-group differences were found for problem-solving, communication and global family function (FAD subscores), in favour of both the EG and CEG as compared to the control group. At 1 year post-stroke significant between-group differences were found for problem-solving, communication, global family function and affective involvement (FAD subscores) in favour of both the EG and CEG compared to the control group.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT that a group education program is more effective than regular care in improving family function in carers of patients with stroke.

Health status and quality of life – Carers
Not effective
1A

One high quality RCT (Franzen-Dahlin et al., 2008), two fair quality RCTs (Larson et al., 2005; van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) and one poor quality RCT (Draper et al., 2007) investigated the effectiveness of an education group on the health status and quality of life of carers of patients with stroke.

The high quality RCT (Franzen-Dahlin et al., 2008) randomized patients with stroke (stage of stroke not specified) and their spouses to either an intervention group that attended lectures on stroke-related topics and group discussions, or to a control group that received regular care. Both groups were able to attend weekly information sessions at the Stroke Unit during the patient’s hospital stay. Spouses’ psychological health was assessed by the Comprehensive Psychopathological Rating Scale –Self-Affective (CPRS-S-A). At 6 and 12 months, no significant between-group differences were found. However, a sub-analysis of the intervention group alone found that carers who participated in meetings more frequently had better psychological health than those who participated less frequently.

The first fair quality RCT (Larson et al., 2005) randomized spouses of patients with subacute stroke to either a support and education program that provided lectures and facilitated discussions on stroke-related topics, or a control group that received regular information and could attend an open education session. Spouses’ quality of life was measured by a quality of life visual analogue scale, Life Situation among Spouses after the Stroke Event (LISS-questionnaire), Bradley’s wellbeing questionnaire, and graded visual analogue scale of the EuroQoL instrument. At 6 and 12 months, no significant between-group differences were reported on any measure.

The second fair quality RCT (van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) randomized patients with subacute or chronic stroke and their carers to a group education program (GP), a home visit education program (HP), or no education program (control group). Spouses’ physical wellbeing and vitality were measured by the Short Form-36 (SF-36). No significant between-group differences were found at 1 month or 7 months post-intervention.

The poor quality RCT (Draper et al., 2007) randomised carers of patients with aphasic stroke (stage of stroke not specified) to a 4-week group education program or a wait list control group that received the same program after 3 months (delayed treatment). Carer quality of life was measured by the Quality of Life Questionnaire. No significant changes in quality of life were seen within either group from baseline to post-intervention or follow-up.

Note: As this study did not report between-group differences, these results are not considered in the conclusion below.

Conclusion: There is strong evidence (level 1a) from one high quality RCT and two fair quality RCTs that a group education program is not more effective than regular care in improving health status and quality of life in carers of patients with stroke.

Health status and quality of life – Patients
Not effective
1B

One high quality RCT (Franzen-Dahlin et al., 2008) investigated the effects of an education group on health status and quality of life of patients with stroke. This high quality RCT randomised patients with stroke (stage of stroke not specified) to either an intervention group that attended lectures on stroke-related topics and group discussions, or to a control group that received regular care. Both groups were able to attend weekly information sessions at the Stroke Unit during the patient’s hospital stay. Spouses’ perception of the patient’s health state was assessed with the EuroQoL graded visual analogue scale (EuroQOL VAS). No significant between-group differences in perceived health state of patients were found at 6 or 12 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a group education program is not more effective that regular care in improving quality of life and health status in patients with stroke.

Knowledge of stroke - Carers
Effective
1a

One high quality RCT (Franzen-Dahlin et al., 2008), two fair quality RCTs (van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002; Evans et al., 1988), and one pre-post study (Braithwaite et al., 1993) investigated the effects of a group education program on carers’ knowledge of stroke.

The high quality RCT (Franzen-Dahlin et al., 2008) randomized patients with stroke (stage of stroke not specified) and their spouses to either an intervention group that attended lectures and group discussions on stroke-related topics, or to a control group that received regular care. Both groups were able to attend weekly information sessions at the Stroke Unit during the patient’s hospital stay. A non-standardized questionnaire was used to measure carers’ knowledge of stroke. At 6 months, there was no significant difference between groups in relation to carers’ knowledge of stroke. However, reassessment at 12 months indicated a significant between-group difference in carers’ knowledge of stroke, in favor of the intervention group compared to the control group.

The first fair quality RCT (van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) randomized patients with subacute or chronic stroke and their carers to a group education program (GP), a home visit education program (HP), or a control group. Confidence in knowledge about patient care and self-efficacy were measured using a non-standardized instrument designed for the study. At 1-month post-intervention a significant between-group difference in confidence in knowledge about patient care was found in favour of both the HP group and the GP group compared to the control group. This remained significant at 7 months post-intervention for the GP group compared to the control group only. There were no significant differences between the HP and GP groups. No significant differences were found regarding confidence in knowledge regarding self-efficacy.

Note: The control group demonstrated significantly higher knowledge of patient care at baseline, which may have skewed the results.

A second fair quality RCT (Evans et al., 1988) randomized carers of patients with stroke (time since stroke not specified) to an education group (Ed), a counselling group (CEd), or a control group (no education or counselling). Carer knowledge of stroke was assessed by the Stroke Care Information Test (SCIT). At 6 months and 12 months post-stroke, there was a significant difference in carers’ knowledge of stroke, in favour of both the Ed and CEd groups when compared to the control group.

The pre-post study (Braithwaite et al., 1993) investigated the effects of a seminar on knowledge of stroke in patients with chronic stroke. Carers’ knowledge of stroke was assessed by a non-standardized 13-item knowledge scale. Carers’ post-seminar scores were higher than pre-seminar scores.

Conclusion: There is strong evidence (level 1a) from one high quality RCT and two fair quality RCTs that a group education program is more effective than regular care in improving knowledge of stroke in carers of patients with subacute or chronic stroke. One pre-post study also found improved carer knowledge of stroke following a group education program.

Note: However, the high quality RCT did not see the significant difference in knowledge until reassessment at 12 months.

Perceived social support - Carers
Not effective
1B

One high quality RCT (Franzen-Dahlin et al., 2008) and one fair quality RCT (van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) investigated the effects of a group education program on the perceived social support of carers of patients with stroke.

The high quality RCT (Franzen-Dahlin et al., 2008) randomized patients with stroke (stage of stroke not specified) and their spouses to either an intervention group that attended lectures on stroke-related topics and group discussions, or to a control group that received regular care. Both groups were able to attend weekly information sessions at the Stroke Unit during the patient’s hospital stay. Perceived social support was assessed by the abbreviated Swedish version of the Interview Schedule of Social Interaction. No significant between-group differences in perceived social support were found at 6 or 12 months.

The fair quality RCT (van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) randomized patients with subacute or chronic stroke and their carers to a group education program (GP), a home visit education program (HP), or a control group. Social support and satisfaction with social support were evaluated by adapted versions of the Social Support List-Interaction and the Social Support List-Discrepancy. At 7 months post-intervention there was a significant between-group difference in social support, in favour of the GP group compared to the control group. There were no significant differences between the HV and GP groups or between the HV and control groups.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a group education program is not more effective than regular care in improving perceived social support in carers of patients with stroke.

Note: However, one fair quality RCT found that carers in a group education program had more social support than carers in the control group at 7 months post-intervention.

Personal adjustment – Patients
Not effective
2A

One fair quality RCT (Evans et al., 1988) investigated the effects of a group education program on personal adjustment in patients with stroke. This fair quality RCT randomised carers of patients with stroke (time since stroke not specified) to an education group (EG), a counselling + education group (CEG), or a control group (no education or counselling). Patient adjustment was measured by the Personal Adjustment and Role Skills Scale (PARS). No significant between-group differences were found in relation to patients’ adjustment at 6 or 12 months.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that a group education program is not more effective than regular care in improving personal adjustment in patients with stroke.

Satisfaction with intervention - Carers
Not effective
1B

One high quality RCT (Franzen-Dahlin et al., 2008) examined the effectiveness of a group education program on satisfaction with information and services among carers of patients with stroke. This high quality RCT randomised patients with stroke (stage of stroke not specified) and their spouses to either an intervention group that attended lectures on stroke-related topics and group discussions, or to a control group that received regular care. Both groups were able to attend weekly information sessions at the Stroke Unit during the patient’s hospital stay. Carers’ satisfaction with information and services was measured by a non-standardized questionnaire. No significant between-group differences in satisfaction with the intervention program were found at 6 or 12 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a group education program is not more effective than regular care in improving level of satisfaction with information or services amongst carers of patients with stroke.

Satisfaction with intervention - Patients
Not effective
1B

One high quality RCT (Franzen-Dahlin et al., 2008) examined the effectiveness of a group education program on satisfaction with information and services among patients with stroke. This high quality RCT randomised patients with stroke (stage of stroke not specified) and their spouses to either an intervention group that attended lectures on stroke-related topics and group discussions, or to a control group that received regular care. Both groups were able to attend weekly information sessions at the Stroke Unit during the patient’s hospital stay. Patients’ satisfaction with information and services was measured by a non-standardized questionnaire. No significant between-group differences were found at 6 or 12 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a group education program is not more effective than regular care in improving level of satisfaction of patients with stroke.

Use of social resources - Carers
Not efective
2A

One fair quality RCT (Evans et al., 1988) and one poor quality RCT (Draper et al., 2007) investigated the effects of an education group on use of social resources amongst carers of patients with stroke.

The fair quality RCT (Evans et al., 1988) randomised carers of patients with stroke (time since stroke not specified) to an education group (EG), a counselling group (CEG), or a control group (no education or counselling). Carers’ use of social resources was assessed by the ESCROW Profile. No significant between-group differences were found at 6 months or 1 year post-stroke.

The poor quality RCT (Draper et al., 2007) randomised carers of patients with aphasic stroke (stage of stroke not specified) to a 4-week group education program or a wait list control group that received the same program after 3 months (delayed treatment). Carers’ use of community services was measured by the Social Support Questionnaire. Carer participation in social and recreational activities was measured by the Measure of Social and Recreational Activities. No significant changes were seen within either group from baseline to post-intervention or follow-up.

Note: As this study did not report between-group differences, these results are not considered in the conclusion below.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT that a group education program is not more effective than regular care in improving use of social resources by carers of patients stroke.

Home Visits

Emotional wellbeing - Carers
Not effective
2A

One fair quality RCT (van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) examined the effects of home visits on emotional wellbeing in carers of patients with subacute or chronic stroke. This fair quality RCT randomised patients and their carers to a group program (GP), a home visit program (HP), or a control group. Carers’ emotional wellbeing was measured according to use of coping strategies by a short version of the Utrecht coping list (‘confronting’ and ‘seeking social support’ subscales), strain by the Caregiver Strain Index (CSI), and assertiveness by a questionnaire developed for the study. At 1 month and 7 months post-intervention there was a significant between-group difference in the coping strategy ‘seeking social support’, in favour of the GP group compared to the control group. There were no significant between-group differences between the GP and HV groups, or the HV and control groups. No significant differences were seen between groups for use of the ‘confronting’ coping strategy, strain or assertiveness.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that a home visit program is not more effective than regular care or a group program in improving emotional wellbeing in carers of patients with subacute or chronic stroke.

Health status - Carers
Not effective
2A

One fair quality RCT (van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) examined the effectiveness of home visits on health status in carers of patients with subacute or chronic stroke. This fair quality RCT randomised patients and their carers to a group program (GP), a home visit program (HP), or no education program (control group). Physical wellbeing, mental wellbeing, and vitality were measured by the Short Form-36 (SF-36). No significant between-group differences were found at 1 month or 7 months post-intervention.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that a home visit program is not more effective than regular care or a group education program in improving health status of carers of patients with subacute or chronic stroke.

Knowledge of stroke – Carers
Effective
2A

One fair quality RCT (van den Heuvel et al., 2000 – and 7 months post intervention study vn den Heuvel et al., 2002) examined the effectiveness of home visits on knowledge of stroke in carers of patients with subacute or chronic stroke. This fair quality RCT randomised patients and their carers to a group program (GP), a home visit program (HP), or a control group. Knowledge of stroke was measured by a 30-item instrument evaluating carers’ confidence in their knowledge of patient care and self-efficacy. At 1-month post-intervention a significant between-group difference in confidence in knowledge about patient care was found in favour of both the HV group and the GP group compared to the control group. This difference did not remain significant at 7 months post-intervention for the HV group compared to the control group. There were no significant differences between the HP and GP groups. No significant differences were found regarding confidence in knowledge regarding self-efficacy.

Note: The control group demonstrated significantly higher knowledge of patient care at baseline, which may have skewed the results.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that a home visit program is more effective than regular care (but is not more effective than a group program) in improving knowledge of stroke among carers of patients with subacute or chronic stroke, in the short term.

Note: These results should be interpreted with caution as the control group demonstrated significantly higher knowledge of patient care at baseline.

Social support - carers
Not effective
2A

One fair quality RCT (van den Heuvel et al., 2000 – and 7 months post intervention study van den Heuvel et al., 2002) examined the effectiveness of home visits on social support in carers of patients with subacute or chronic stroke. This fair quality RCT randomised patients and their carers to a group program (GP), a home visit program (HP), or no education program (control group). Social support and satisfaction with social support were assessed by the Social Support List – Interaction and the Social Support List – Discrepancy. At 7 months post-intervention there was a significant between-group difference in social support, in favour of the GP group only compared to the control group. There were no significant differences between the HV and GP groups or between the HV and control groups.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT suggesting that a home visit program is not more effective than regular care or a group education program in improving social support among carers of patients with stroke.

Psychosocial Intervention Programs

Functional abilities – Patients
Not effective
1B

One high quality RCT (Glass et al., 2004) has investigated the impact of family intervention programs on the functional abilities of patients with subacute stroke. This high quality RCT ) randomized patients to either an intervention group that received the Families In Recovery From Stroke Trial (FIRST) psychosocial program, or a control group that received usual care. At 6 months post-randomization there were no significant between-group differences in functional abilities, as measured by the Barthel Index.

Conclusion 1: There is moderate evidence (level 1b) from one high quality RCT that a psychosocial family intervention program is not more effective than regular care in improving functional outcomes in patients with subacute stroke.

Telephone Intervention

Emotional wellbeing - Carers
Effective
1A

Two high quality RCTs (Grant et al., 1999, Grant et al., 2002) and one fair quality RCT (Hartke et al., 2003) examined the effects of telephone intervention in improving emotional wellbeing in carers of patients with stroke.

The first high quality RCT (Grant et al., 1999) randomized carers of patients to a telephone group, a home visit group, or a control group. The telephone group and home visit group learned problem solving techniques while the control group received sham telephone contact. At 2, 5, and 13 weeks, carers were assessed for depression by the Center for Epidemiological Studies Depression Scale, carer preparedness by the Preparedness for Caregiving Scale, and carer burden by the Caregiver Burden Scale. The telephone group demonstrated significantly reduced depression and significantly improved preparedness at 2 and 5 weeks as compared to the home visit group and control group, but these between-group differences were insignificant at 13 weeks. No significant between-group differences were found in carer burden at any assessment point.

The second high quality RCT (Grant et al., 2002) randomized patients with stroke (time since stroke not specified) and their carers to receive social problem-solving telephone partnership (SPTP) treatment, sham treatment, or regular care (control group). Outcomes were administered during the intervention (5 and 9 weeks post-discharge) and after the intervention (13 weeks post-discharge), and included: depression by the Center for Epidemiological Studies Depression Scale, preparedness by the Preparedness for Caregiving Scale, and burden by the Caregiving Burden Scale. Significant between-group differences in carer preparedness and depression were found at all time points, in favour of the SPTP group compared to the sham group and the control group. There were no significant between-group differences in carer burden at any time point.

The fair quality RCT (Hartke et al., 2003) randomized spouses of patients with stroke (time since stroke not specified) to either an intervention group that received telephone group education and written stress management advice, or a control group that received written stress management advice only. Carer emotional wellbeing was evaluated according to depression by the Center for Epidemiologic Studies Depression Scale (CES-D), burden by the Burden Interview (BI), loneliness by the UCLA Loneliness Scale, and stress by the Pressing Problem Index (PPI). Carers’ competence was assessed by the Caregiver Competence Scale (CCS). At 6 months follow-up, significant between-group differences were found for burden and carer competence in favour of the intervention group compared to the control group. No significant between-group differences were found for depression, loneliness, or stress.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one fair quality RCT that telephone interventions are more effective than control treatments (e.g. home visit group, sham treatment, written information or regular care) in improving emotional wellbeing in carers of patients with stroke.

Note: The two high quality RCTs that used problem-solving telephone partnerships found significant differences in carer depression and carer preparedness but no improvement in carer burden. The fair quality RCT that used telephone education groups found significantly improved carer burden and carer competence but no improvement in carer depression, loneliness or stress.

Health status - Carers
Not effective
1A

Two high quality RCTs (Grant et al., 1999, Grant et al., 2002) examined the effectiveness of telephone interventions in improving health status in carers of patients with stroke.

The first high quality RCT (Grant et al., 1999) randomized carers of patients to a telephone group, a home visit group, or a control group. The telephone group and home visit group learned problem solving techniques while the control group received sham telephone contact. At 2, 5, and 13 weeks, carers’ health status was assessed by the physical functioning and general health subscales of the Medical Outcomes Study Short Form Health Survey (SF-36). There were no significant between-group differences for general health at any assessment point.

The second high quality RCT (Grant et al., 2002) randomized patients with stroke (time since stroke not specified) and their carers to receive social problem-solving telephone partnership (SPTP) treatment, sham treatment, or regular care (control group). Carers were assessed during intervention (5 and 9 weeks post-discharge) and after intervention (13 weeks post-discharge) for general health by the Medical Outcomes Study Short Form Health Survey (SF-36). Significant between-group differences were found on the social functioning dimension of the SF-36 at all time points, in favour of the SPTP group compared to the sham treatment group and the control group. The SPTP group demonstrated significant improvements over time on the SF-36 vitality, mental health and role limitations due to emotional problems dimensions. No other significant between-group differences for general health were seen at any time points. Interestingly, the control group demonstrated a significant deterioration on the SF-36 mental health dimension over time.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that telephone interventions are not more effective than control treatments (e.g. home visit group, sham treatment or regular care) in improving health status in carers of patients with stroke.

Note: However, one high quality RCT reported a significant between-group difference in social functioning.

Problem solving ability - Carers
Effective
1A

Two high quality RCTs (Grant et al., 1999, Grant et al., 2002) examined the effectiveness of telephone interventions in improving problem-solving ability in carers of patients with stroke.

The first high quality RCT (Grant et al., 1999) randomized carers of patients to a telephone group, a home visit group, or a control group. The telephone group and home visit group learned problem solving techniques while the control group received sham telephone contact. At 2, 5, and 13 weeks, carers were assessed for problem solving ability by the Problem Solving Inventory. The telephone group had significantly better problem-solving skills at 2 and 5 weeks as compared to the home visit group and control group, but these between-group differences were insignificant at 13 weeks.

The second high quality RCT (Grant et al., 2002) randomized patients with stroke (time since stroke not specified) and their carers to receive social problem-solving telephone partnership (SPTP) treatment, sham treatment, or regular care (control group). Carers were assessed during intervention (5 and 9 weeks post-discharge) and after intervention (13 weeks post-discharge), for problem-solving ability by the Social Problem Solving Inventory-Revised. Significant between-group difference in social problem solving skills (less negative orientation, less impulsivity/carelessness and more rational problem solving) were seen in favour of the SPTP group compared to the sham group and control group at all time points. Interestingly, the control group demonstrated a significant deterioration in positive problem orientation over time.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that telephone interventions that provide problem-solving training are more effective than control treatments (e.g. home visit group, sham treatment or regular care) in improving problem solving skills in carers of patients with stroke.

Note: However, 1 of the high quality RCTs had significant differences at 2 and 5 weeks, but not at 13 weeks.

Satisfaction with care - Carers
Not effective
1A

Two high quality RCTs (Grant et al., 1999, Grant et al., 2002) examined the effectiveness of telephone interventions in improving satisfaction with care in carers of patients with stroke.

The first high quality RCT (Grant et al., 1999) randomized carers of patients to a telephone group, a home visit group, or a control group. The telephone group and home visit group learned problem solving techniques while the control group received sham telephone contact. At 2, 5, and 13 weeks, carers were assessed for satisfaction with care by the Client Satisfaction Questionnaire. No significant between-group differences were found at any assessment point.

The second high quality RCT (Grant et al., 2002) randomized patients and their carers to receive social problem-solving telephone partnership (SPTP) treatment, sham treatment, or regular care (control group). Carers were assessed during intervention (5 and 9 weeks post-discharge) and after intervention (13 weeks post-discharge), for satisfaction with care by the client Satisfaction Questionnaire. No significant between-group differences were found at any time points.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that telephone interventions are not more effective than control treatments (e.g. home visit group, sham treatment or regular care) in improving satisfaction with care among carers of patients with stroke.

Web Education Programs

Emotional wellbeing - Carers
Not effective
1B

One high quality RCT (Pierce et al., 2009) examined the effectiveness of web-based stroke intervention on the emotional wellbeing of carers of patients with subacute or chronic stroke. This high quality RCT randomized carers to either a Web user group or a non-Web user group. Wellbeing of carers was assessed by the Centre for Epidemiological Studies Depression scale (CES-D) and the Satisfaction with Life Scale (SWLS). No significant between-group differences were found for carer wellbeing during the 1-year intervention.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a web-based stroke intervention is not more effective than regular care in improving emotional wellbeing in carers of patients with subacute or chronicstroke.

Health care service use - Patients
Effective
1B

One high quality RCT (Pierce et al., 2009) examined the effectiveness of web-based stroke intervention on the health care service use in patients with subacute or chronic stroke. This high quality RCT randomised carers of patients to either a Web user group or a non-Web user group. Health care service use was measured by self-reported visits to a provider and/or an emergency department and re-admissions to a hospital, or placements in a nursing home. There were significant between-group differences for emergency department visits and hospital re-admissions, with significantly fewer visits and re-admissions among patients in the Web user group as compared to the non-Web user group during the one-year intervention. No significant between-group differences were found in the number of provider visits during the 1-year intervention. Because of the small number of occurrences, nursing home placements were not statistically analysed.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a web-based stroke intervention is more effective than regular care in reducing use of hospital services (i.e. emergency department visits and hospital re-admissions) but not provider services in patients with subacute or chronic stroke.

References

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Clark, M.S., Rubenach, S., & Winsor, A. (2003). A randomized controlled trial of an education and counselling intervention for families after stroke. Clinical Rehabilitation, 17, 703-712.

Draper, B., Bowring, G., Thompson, C., Van Heyst, J., Conroy, P. & Thompson, J. (2007). Stress in caregivers of aphasic stroke patients: a randomized controlled trial. Clinical Rehabilitation, 21, 122-130.

Evans, R.L., Matlock, A.L., Bishop, D.S., Stranahan, S., & Pederson C. (1988). Family intervention after stroke: Does counselling or education help? Stroke, 19, 1243-1249.

Franzén-Dahlin, Å. J., Larson, J.V., Murray, V.R., Wredling, R., & Billing E. (2008). A randomized controlled trial evaluating the effect of a support and education programme for spouses of people affected by stroke. Clinical Rehabilitation, 22, 722–730.

Glass, T.A., Berkman, L.F., Hiltunen, E.F., Furie, K., Glymour, M.M., Fay, M.E., & Ware J. (2004). The Families In Recovery from Stroke Trial (FIRST): Primary study results. Psychosomatic Medicine, 66, 889-897.

Grant, J.S. (1999). Social problem-solving partnerships with family caregivers. Rehabilitation Nursing, 24, 254-260.

Grant, J.S., Elliott, T.R., Weaver, M., Bartolucci, A.A., & Giger, J.N. (2002). Telephone intervention with family caregivers of stroke survivors after rehabilitation. Stroke, 33, 2060-2065.

Hartke, R.J., & King, R.B. (2003). Telephone group intervention for older caregivers. Topics in Stroke Rehabilitation, 9(4), 65-81.

Kalra, L., Evans, A., Perez, I., Melbourn, A., Patel, A., Knapp, M., & Donaldson, N. (2004). Training carers of stroke patients: Randomized controlled trial. British Medical Journal, 328(7448), 1099-1103.

Larson, J., Billing, E., von Arbin, M., Murray, V., & Wredling R. (2005). The impact of a nurse-led support and education programme for spouses of stroke patients: A randomized controlled trial. Journal Of Clinical Nursing, 14, 995–1003.

Perrin, P. B., Johnston, A., Vogel, B., Heesacker, M., Vega-Trujillo, M., Anderson, J., & Rittman, M. (2010). A culturally sensitive Transition Assistance Program for stroke caregivers: Examining caregiver mental health and stroke rehabilitation. Journal of Rehabilitation Research and Development, 47(7), 605-616.

Pierce, L.L., Steiner, V.L., Khuder, S.A., Govoni, A.L., & Horn, L.J. (2009). The effect of a Web-based stroke intervention on carers’ well-being and survivors’ use of healthcare services. Disability and Rehabilitation, 31, 1676-1684.

van den Heuvel, E., de Witte, L., Nooyen-Haazen, I., Sanderman, R., & Meyboom-de Jong, B. (2000). Short-term effects of a group support program and an individual support program for caregivers of stroke patients. Patient Education and Counselling, 40, 109-120.

van den Heuvel, E.T.P., De Witte, L.P., Stewart, R.E, Schure, L.M., Sanderman, R., & Meyboom-de Jong, B. (2002). Long-term effects of a group support program and an individual support program for informal carers of stroke patients: Which carers benefit the most? Patient Education and Counselling, 47, 291-299.

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