Strategy Training During Inpatient Rehabilitation May Prevent Apathy Symptoms After Acute Stroke

Abstract

Background: Apathy, or lack of motivation for goal-directed activities, contributes to reduced engagement in and benefit from rehabilitation, impeding recovery from stroke.

Objective: To examine the effects of strategy training, a behavioral intervention used to augment usual inpatient rehabilitation, on apathy symptoms over the first 6 months after stroke.

Design: Secondary analysis of randomized controlled trial.

Setting: Acute inpatient rehabilitation.

Participants: Participants with acute stroke who exhibited cognitive impairments (Quick Executive Interview Scores ≥3) and were admitted for inpatient rehabilitation were randomized to receive strategy training (n = 15, 1 session per day, 5 days per week, in addition to usual inpatient rehabilitation) or reflective listening (n = 15, same dose).

Methods: Strategy training sessions focused on participant-selected goals and participant-derived strategies to address these goals, using a global strategy training method (Goal-Plan-Do-Check). Reflective listening sessions focused on participant reflections on their rehabilitation goals and experiences, facilitated by open-ended questions and active listening skills (attending, following, and responding).

Main outcome measures: Trained raters blinded to group assignment administered the Apathy Evaluation Scale at study admission, 3 months, and 6 months. Data were analyzed with repeated-measures fixed-effects models.

Results: Participants in both groups had similar subsyndromal levels of apathy symptoms at study admission (strategy training, mean = 25.79, standard deviation = 7.62; reflective listening, mean = 25.18, standard deviation = 4.40). A significant group × time interaction (F2,28 = 3.61, P = .040) indicated that changes in apathy symptom levels differed between groups over time. The magnitude of group differences in change scores was large (d = -0.99, t28 = -2.64, P = .013) at month 3 and moderate to large (d = -0.70, t28 = -1.86, P = .073) at month 6.

Conclusion: Strategy training shows promise as an adjunct to usual rehabilitation for maintaining low levels of poststroke apathy.

Figure 1

CONSORT Flow Diagram

Figure 2

ApathyEvaluation Scale Scores, Unadjusted Means, By Time Point

Figure 3. Apathy Evaluation Scale Dimension Scores, Unadjusted Means, By Time Point

Note. Dimensions scores derived from sums of items as recommended by Marin. Cognitive=Apathy Evaluation Scale items 1,3–5,8, 11, 13, 16; Behavioral=Apathy Evaluation Scale items 2, 6, 9, 10, 12; Emotional=Apathy Evaluation Scale items=7,14.