NeuroRehabilitation 32 (2013) 351–358 351

DOI:10.3233/NRE-130855
IOS Press

Alleviating psychosocial issues for

individuals with communication impairments
and their families following stroke: A case
series of interdisciplinary assessment and
intervention
Ciara Jones∗ , Kiadhnait O’Keeffe, Craig Kingston and Aine Carroll
Brain Injury Programme, National Rehabilitation Hospital, Co. Dublin, Ireland

Abstract.
INTRODUCTION: A high incidence of depression following a stroke has been reported. Many studies exclude those with
communication impairments. However, there is an increased risk of psychosocial issues for individuals with communication
difficulties. Psychosocial issues have a significant impact on the individual and their families. There is very limited research in
this area.
METHODS: A retrospective case review of the assessment and intervention with three individuals with significant communica-
tion difficulties following stroke was completed. Key interdisciplinary intervention factors were identified.
RESULTS: Psychosocial issues were identified in all three cases. The assessment of cognitive difficulties, interdisciplinary
intervention targeting communication between family members, facilitation of emotional expression and liaison with appropriate
community services were identified as key interventions. These interventions targeted at psychosocial issues resulted in a positive
outcome for the individuals and their family.
DISCUSSION AND CONCLUSION: Psychosocial issues are prevalent in individuals and their families with significant com-
munication impairments following stroke. Clinically, these issues may be overlooked. The complexity of working with individuals
with cognitive and communication impairments also contributes to poor identification of psychosocial issues. This case series
clearly highlights that intervening at the psychosocial level through interdisciplinary working can facilitate meaningful outcomes
for the individual and their family.

Keywords: Communication disorders, stroke, psychosocial issues, interdisciplinary assessment and interventions, carer stress

1. Introduction Thompson & Ryan, 2009). A high incidence of depres-

sion and low mood following a stroke has been reported,
The myriad of emotional and psychosocial conse- with evidence that up to 55% of individuals experi-
quences following a stroke have been well documented ence depression following stroke (Ng et al., 1995; Gbiri,
in the literature (e.g. Greenwood & Mackenzie, 2010; Akinpelu & Odole, 2010; Hackett et al., 2005; Beek-
∗ Address for correspondence: Ciara Jones, Speech and Language
man et al., 1998). The reported frequency of depression
Therapist, Brain Injury Programme, National Rehabilitation Hospital,
varies across studies, depending on measures used and
Rochestown Avenue, Dun Laoghaire, Co. Dublin, Ireland. Tel.: +353 inclusion criteria. In a review of 51 studies, Hackett
1 2355336; Fax: +353 2854370; E-mail: ciara.jones@nrh.ie. et al. (2005) reported a conservative pooled estimate

1053-8135/13/$27.50 © 2013 – IOS Press and the authors. All rights reserved
352 C. Jones et al. / A case series of interdisciplinary assessment and intervention

of 33% of all stroke survivors experiencing depression. tion and behavioural problems were a source of stress
Post stroke depression has been linked to level of phys- for partners.
ical disability, stroke severity and cognitive impairment In summary, emotional and psychosocial difficulties
(Hackett et al., 2005). Communication impairments are common following stroke. There is an increased
have also been identified as a predictor of distress risk of psychosocial issues for individuals with com-
(Brumfitt & Sheeran, 1999; Cruice et al., 2011). Hilari munication difficulties. These psychosocial issues can
et al. (2010) found low mood in up to 93% of individuals have a significant impact on both the individual them-
with aphasia following stroke. selves and their partners or carers. There is very limited
Of note, many of the studies in the literature exclude research in this area.
those with communication impairments. For example, Clinically, we have observed that psychosocial issues
in a systematic review of depressive symptoms after are common in individuals who have communication
stroke, 17 out of 20 studies excluded individuals with impairments following stroke. Here, we present a case
communication difficulties following stroke (Hackett series detailing the psychosocial challenges and out-
and Anderson, 2005). Considering between 25–33% comes of three patients and their partners at a National
of people experience communication difficulties of Neurorehabilitation hospital.
varying degrees following stroke (National Institute of
Neurological Disorders and Stroke, 2011; The Stroke
2. Method
Association, 2009), this potentially excludes a large
proportion of stroke survivors’ experiences. The lim-
A retrospective case review of three individuals with
ited literature that does exist focuses on aphasia rather
significant communication difficulties following stroke
than acquired motor speech disorders such as dysarthria
was completed. The interdisciplinary assessment and
or apraxia of speech.
intervention provided was examined and key interdis-
In a review of a range of databases available, only
ciplinary intervention factors were identified in relation
two studies relating to the psychosocial impact of
to psychosocial issues. Consent was obtained from the
an acquired motor speech disorder were identified.
individuals and their partners. All identifying informa-
Both studies (Walsh, Peach, & Miller, 2003; Brady,
tion was anonymised.
Clark, Dickson, Paton & Barbour, 2011) concluded
that dysarthria has a considerable negative emotional
impact on the individual. Brady et al. (2011) found that 3. Results
in individuals with motor speech disorders, the level of
intelligibility does not necessarily reflect the psychoso- 3.1. Case 1: ‘Jack’
cial impact. Successful communication requires both
the person with the impairment and the conversation 3.1.1. Background
partner to adapt (Purdy & Hindenlang, 2005). ‘Jack’, a 42 year old male, was initially admitted to
There are significant challenges associated with car- the inpatient neurorehabilitation unit following a large
ing for an individual with acquired brain injury (ABI) right frontoparietal infarct and a sub acute left parietal
due to the presence of physical, communication and/or infarct. Jack had a background history of a previous
cognitive deficits (Williams, 1993). Anxiety, depres- stroke and a TIA. On admission, he mobilised with
sion and caregiver burden has been reported throughout assistance in a wheelchair due to right hemiparesis. His
the first year of a family member having a stroke impairments included incontinence and a severe com-
(Grant et al., 2000; Anderson et al., 1995; Wade et al., munication impairment and right sided neglect. He was
1986; Wyler et al., 2003). Poor health status, depres- unable to achieve voicing during his first admission.
sion and caregiver burden can last for many years post His first 3 month admission focused on independence
onset of the individual’s stroke (Scholte op Reimer, de with his ADL’s, strength and balance, and commu-
Haan, Rijnders, Limburg, & G. A. M., 1998; Mori- nication. Jack was discharged to a local community
moto et al., 2003; Van den Heuval et al., 2001; White hospital while he and his family were awaiting appropri-
et al., 2003; Wilkinson et al., 1997). Better client men- ate wheelchair accessible housing. He received Speech
tal health and cognitive functioning has been linked and Language Therapy (SLT), Occupational Therapy
with better carer mental health (Tooth et al., 2005). and Physiotherapy within the community hospital. In a
Michallet, Tétreault and Le Dorze, (2003) reported follow up outpatient review 10 months later, Jack was
that the lifestyle changes resulting from communica- observed to have no verbal output. His wife reported
 C. Jones et al. / A case series of interdisciplinary assessment and intervention 353

that Jack had episodes of intermittent screaming at an issue during his inpatient admission. The issue of
home and that she was feeling stressed and finding it Jack’s screaming behaviour was explored through fam-
difficult to cope. Jack was readmitted for further explo- ily sessions and this behaviour was identified as Jack’s
ration of these psychosocial difficulties. method of communicating that he needed space or that
he was frustrated. Jack and his son were facilitated in
3.1.2. Communication and cognition assessment practicing an agreed way of interacting with each other
Due to the complex nature of Jack’s communication and adaptations to Jack’s communication device were
impairment, differential diagnosis was challenging. recommended based on this agreed interaction method.
Jack demonstrated adequate auditory comprehension Family sessions also explored Jack’s and his son’s
to participate in conversations when he was facilitated leisure time to enhance and increase their positive
appropriately. Jack understood written words and short experiences of spending time together. Jack’s son also
sentences but was unable to write due to his limb attended an individual psychology session on his own
apraxia, possible dysgraphia and reported premorbid during which he was able to express his own concerns
literacy difficulties. Jack experienced difficulty initi- and worries about his parents, family and Jack’s stroke.
ating communication but could verbalise infrequently Feedback and strategies regarding Jack’s cognitive
when highly self motivated and was not under pressure. and communication difficulties were incorporated into
It was hypothesised that this was due to severe oral and psychoeducation sessions around the impact of stroke.
verbal dyspraxia and cognitive communication impair- Family sessions focused on the development of Jack’s
ment; however severe expressive aphasia or dysarthria family’s skills in communicating with Jack and facili-
could not be ruled out. tating Jack’s communication. Jack, his wife and his son
Despite Jack’s severe communication impairment, all demonstrated more successful interactions during
he could consistently communicate when facilitated sessions and in the environment of the hospital.
appropriately by a communication partner, using a Jack and his wife identified sex as an issue which Jack
yes/no chart and giving Jack spoken and written word brought up regularly. These issues were discussed and
choices. Jack used facial expression and gesture inde- Jack and his wife were referred to and attended the clin-
pendently, in addition to a simple communication ical nurse specialist in sexuality during the admission.
device when prompted. On discharge, a referral was made for support in
Jack communicated that he often felt ‘confused and accessing any community services that would increase
mixed up’. Modified standardised assessment of Jack’s Jack’s activity participation outside of the house. This
non-verbal reasoning and matching and a recognition included specialist acquired brain injury services with
memory task were administered. Jack’s performance on day services and psychology support. Close consulta-
these tasks indicated mild to moderate impairment. tion with community SLT also followed, emphasising
the need for family-based SLT sessions to continue
3.1.3. Psychosocial intervention and enhance family communication. It was also rec-
Jack attended joint SLT and psychology sessions ommended that Jack’s son be referred to local child
throughout his rehabilitation programme. Sessions and adolescent psychology services for support.
were initially held with Jack alone. Later sessions
included Jack, his wife and son. 3.1.4. Outcome
Initial sessions facilitated Jack in expressing his By discharge, Jack and his wife reported improved
opinions, concerns and emotions which he had been communication between each other and improved inter-
experiencing at home. Jack expressed feelings of action with Jack’s son. Jack communicated that he was
fear, confusion, frustration, anger and tension. Jack happy that his feelings and wishes had been heard by
requested that he be supported in communicating these others and particularly by his family. Appropriate ongo-
issues with his wife. The family sessions which fol- ing support for the family was put in place through
lowed then facilitated discussions around Jack’s stroke referral to specialist community services.
and its consequences, Jack’s relationships with his wife,
son and wider extended family and improving family 3.2. Case 2: ‘Martin’
communication to facilitate Jack’s participation.
Jack’s wife had reported prior to Jack’s re-admission 3.2.1. Background
that he screamed on occasion, often when his son was ‘Martin’, a 57 year old male, was initially admitted
trying to hug Jack. Screaming was not noted to be for rehabilitation following subarachnoid haemorrhage,
354 C. Jones et al. / A case series of interdisciplinary assessment and intervention

secondary to left posterior cerebral artery aneurysm. Martin’s behaviour and personality since his stroke.
The aneurysm was coiled successfully. During his There were also some reports of paranoia and delu-
immediate rehabilitation, his deficits included spastic sional beliefs around Martin’s wife meeting other men.
quadraparesis, ataxia, dysphasia, dysarthria, cognitive Martin’s wife reported a number of anger outbursts
linguistic impairments and incontinence. He was dis- directed at her. These had, on occasion, led to her getting
charged to a nursing home prior to house alterations physically hurt by Martin.
being made with a view to his family caring for him at On assessment, Martin presented as anxious, having
home subsequently. difficulties regulating his emotions and having recur-
Martin was reviewed in the outpatient clinic 6 months rent and rigid thoughts. On an objective measure of
following discharge from the rehabilitation hospital. He mood (Hospital Anxiety and Depression Scale, Zig-
was wheelchair dependent and had very limited func- mond and Snaith, 1983), Martin’s ratings indicated mild
tional use of his arms and hands. At the time of his symptoms of both anxiety and low mood. He identi-
outpatient review, Martin was still in a nursing home fied thoughts that affect his mood such as “Why did
and it was felt that psychosocial issues, such as anger this happen to me”, “Why me, I did no harm to any-
and challenging behaviour, were a significant barrier one”. Martin also identified his worries and concerns
to him returning home. The family had been referred around his wife leaving him and meeting someone
to specialist acquired brain injury services in the com- new. These worries had often led to repetitive ques-
munity but they had not fully engaged with all of the tioning regarding Martin’s wife’s daily activities and
support services. Martin was re-admitted to the reha- increased distress for both Martin and his wife. Mar-
bilitation unit for psychosocial intervention. tin’s wife completed the Neurobehavioural Functioning
Inventory (Kreutzer, Seel & Marwitz, 1999). Of note,
3.2.2. Communication and cognition her highest ratings for Martin were on items related
Martin presented with a moderate dysarthria char- to depression, which were in the clinically significant
acterised by a strained/strangled voice quality, poor range. These ratings were followed by motor difficul-
coordination of respiration and phonation, a mono- ties, communication, memory/attention and aggression.
tone voice quality and reduced articulation. He was Martin and his wife completed the Frontal Systems
largely intelligible to familiar listeners but he could be Behaviour Scale (FrSBe, Grace & Malloy, 2001) self-
very unintelligible to unfamiliar listeners. Martin was rating and family-rating form, respectively. The FrSBe
also compensating inappropriately for his dysarthria is a subjective and objective measure of change in
and demonstrated poor self monitoring and carryover behaviour observed since acquired brain injury. Both
of strategies on his second admission. Martin partic- Martin and Martin’s wife rated significant observed
ipated in on-going SLT during this second admission changes in Martin’s behaviour since his stroke, par-
but his gains plateaued about half way through this ticularly in the area of apathy and overall executive
admission. A break from impairment-based SLT was functioning behaviour.
deemed appropriate and therapy focused on Martin’s Intervention involved both Martin and his wife
psychosocial intervention. attending psychology sessions. During these sessions,
Martin underwent a neuropsychological assessment the focus was on identifying and talking about appro-
during his second admission. Overall, Martin’s neu- priate and inappropriate ways of responding to distress,
ropsychological strengths were in the areas of verbal identifying triggers for anger outbursts, negotiating
comprehension, general knowledge and verbal rea- agreement around support strategies, such as avoid-
soning. Martin presented with generalised slowed ing escalating behaviours by identifying triggers early,
information processing which subsequently impacted disengaging from escalated interactions (e.g. Martin’s
on his memory and executive functions. He also wife saying “Stop”) time out and practising relax-
presented with borderline impairment in perceptual rea- ation and calming exercises. An agreed behaviour
soning and visual problem-solving. support plan was developed. Some cognitive strategies
of Thought-Event and Thought-Action defusion were
3.2.3. Psychosocial intervention discussed – e.g. Martin recognising that “Thoughts are
Martin was referred to psychology for assessment just thoughts”. Martin found some sessions particu-
of mood and behaviour during his second inpatient larly challenging, and these sessions were used as a
rehabilitation programme. This followed reports from way of modelling and practising some of the strategies
Martin’s wife of difficulty dealing with changes in discussed within sessions.
 C. Jones et al. / A case series of interdisciplinary assessment and intervention 355

Feedback from the neuropsychological assessment admission, as a number of issues had been identified by
was also provided to both Martin and his wife. Strate- Peter, his partner and the team.
gies for managing the neuropsychological difficulties
were discussed and it was recommended that Martin
have all information presented to him in a slow man- 3.3.2. Communication and cognition
ner be it verbal or written. He benefited from repetition Peter presented with a moderate dysarthria primarily
of information to support consolidation of new learn- as a result of his facial nerve palsy, although Peter also
ing. He performed best in a quiet environment when demonstrated poor respiration resulting in poor breath
trying to engage in conversations or mentally trying support for speech and mild weakness of his tongue.
activities. Martin continued to suffer from cognitive Peter was intelligible to familiar listeners most of the
fatigue. time, but unintelligible to unfamiliar listeners. He was
There was regular and frequent liaison with commu- aware of strategies to aid improved intelligibility but
nity services prior to Martin’s discharge. Martin and his did not use them consistently even with prompting.
wife were re-referred for psychosocial support in the Peter’s speech was most unintelligible when he was
community with a community service specialising in frustrated or upset about something. Peter demonstrated
acquired brain injury. Martin was also reviewed by the poor information processing and recall, poor prospec-
specialist neurobehavioural clinic in the rehabilitation tive memory, reduced flexibility, poor new learning
hospital, where recommendations were made relating skills, unrealistic goal setting, poor insight into his
to his medications by a specialist neuropsychiatrist, impairments and poor self-monitoring skills.
neuropsychologist and Consultant in Rehabilitation
Medicine. His Escitalopram dose was increased for 3.3.3. Psychosocial intervention
treatment of depression. Both Peter and Peter’s wife reported that they were
finding it difficult to adjust to Peter’s disabilities and
3.2.4. Outcome accept the consequences of his tumour, surgery and sub-
Martin’s wife reported finding it very helpful to have sequent stroke. Peter reported finding his slow progress
discussed the difficult psychosocial issues and to have in his rehabilitation particularly frustrating and disap-
negotiated an agreed behaviour support plan with Mar- pointing. Peter’s wife reported that Peter had become
tin. Martin and his wife successfully re-engaged with demanding and impatient. Prior to his haemorrhage,
community specialist services for ongoing psycholog- Peter’s wife described Peter as ‘placid’ and ‘easy-
ical and social support. going’. Peter reported that he was not aware of any
change in his behaviour. Peter said that he felt frustrated,
disappointed and angry.
3.3. Case 3: ‘Peter’ Psychological intervention included sessions with
Peter and Peter’s wife. This involved normalising feel-
3.3.1. Background ings of frustration, anger and disappointment for both
‘Peter’, a 51 year old gentleman, was admitted for Peter and Peter’s wife. There were also provided with
neurorehabilitation lasting 3 months following resec- psychoeducation about the range of consequences of
tion of posterior fossa tumour. This procedure was acquired brain injury, including changes in behaviour
complicated by post-operative haemorrhage requiring and emotional regulation. Strategies to help both Peter
shunt insertion. On arrival to the rehabilitation hospital, and Peter’s wife manage included:
he was noted to have left-sided 3rd, 7th, 8th and 12th
cranial nerve palsies and poor hearing on the left. He – Communication with each other to help support
had marked quadraparesis, was feeding via an NG tube and understand each other better
and had dysarthria secondary to his 7th nerve palsy and – Peter’s wife to give Peter agreed feedback if she
cerebellar damage. Initially his rehabilitation concen- feels he is being demanding and insistent.
trated on improving his strength, mobility, speech and – Peter’s wife will keep Peter informed of any
swallow difficulties. Good progress was made in the developments around the house renovations, adap-
respective areas of rehabilitation, though 4 months into tations etc.
the admission both Peter and his partner’s mood were – The option of supportive counselling in the com-
noted to have deteriorated. Psychosocial intervention munity was discussed with Peter and his wife and
became more of a priority for the second half of his both agreed that it may be helpful in adjusting
356 C. Jones et al. / A case series of interdisciplinary assessment and intervention

and accepting the consequences of Peter’s tumour, secondary to the low mood, frustration, anxiety and
surgery and stroke. inability to successfully communicate with their fam-
ily. The negotiation and introduction of behaviour and
A referral to a local community service specialising communication strategies resulted in an alleviation of
in acquired brain injury was made for this purpose. the observed challenging behaviours.
Assessing and identifying the specific cognitive,
3.3.4. Outcome emotional, behavioural and personality changes that
Peter and his wife reported that being supported to can occur following an acquired brain injury was also
‘talk it out’ helped effective communication about the a key intervention in all three cases. These changes can
challenges of adjusting to ABI. Both engaged with spe- often be overlooked when there are severe physical and
cialist community services for ongoing psychosocial communication difficulties that are prioritised in the
support. initial stages of rehabilitation. Additionally, standard
cognitive assessment can be challenging to adminis-
ter and are often neglected when there are significant
4. Discussion communication and physical impairments. However,
the cognitive consequences, relating to memory, atten-
All three cases described made good initial medi- tion, initiation and executive functions, which extended
cal recovery in the acute period. The initial focus at beyond their linguistic and communication difficulties
the post-acute phase for all three cases was on physical were a significant factor in all three cases described
rehabilitation. All three had reached a plateau in terms here. Psychoeducation around the cognitive difficulties
of physical gains and were left with significant physical contributed to the progress made.
disabilities. A common theme for the three cases was Increasing the individual and family engagement
the significant communication difficulties (dysarthria, in specialist ABI local community support facilitated
oral dyspraxia and/or aphasia) that would persist. Psy- continuity of psychosocial intervention. Recognising
chosocial difficulties became more apparent at a later carer and family stress and supporting family members
stage in the rehabilitation process. accessing appropriate support in their local communi-
Common themes that arose for all three cases were ties was important and beneficial.
the difficulties for the individual, the partner and their The cases presented here highlight the importance
families in adjusting to the long-term severe physi- of assessing, identifying and monitoring the psychoso-
cal, communication and cognitive disabilities following cial needs of individuals with severe physical and
acquired brain injury. The long-term impairments had communication disabilities following ABI. High lev-
a profound impact on independence, roles and identity, els of emotional distress and low mood associated with
social functioning, and psychosocial well-being for the communication impairments following ABI have been
individuals with ABI and their families. identified in the literature (e.g. Brumfitt & Sheeran,
Psychosocial issues that emerged included inter- 1999; Cruice et al., 2011).
personal relationship difficulties; partner’s difficulties In the cases discussed here, and as supported in pre-
enabling and facilitating the communication; challeng- vious studies (e.g. Scholt et al., 1998), caregiver stress
ing behaviour; significant mood and mental health and burden has an impact on the relationship dynamic
issues for both the stroke survivors and their partners. and the resolution of the psychosocial issues between
Joint sessions with SLT and psychology empowered the individuals with ABI and their partners.
each of the individuals with ABI to express their emo- As described in Purdy and Hindenlang (2005), and as
tions and experiences. Joint sessions also enhanced the was apparent in all three cases presented here, the role
communication partners’ ability to better construct a of those in the environment of the individual with ABI
two-way dialogue. Sessions also facilitated the part- in facilitating communication is intrinsic in allowing
ner in giving the patient the opportunity to make them to communicate successfully and alleviating the
choices and a more equal say in important issues psychosocial issues.
and decisions. The individuals with ABI and fami- This case series and literature review highlights
lies benefited from exploring and understanding the a number of crucial clinical learning points when
new behaviours that had developed as a result of the working with individuals with significant commu-
psychosocial difficulties, such as the screaming, grab- nication impairments following ABI. Key clinical
bing and being demanding. These behaviours arose recommendations include:
 C. Jones et al. / A case series of interdisciplinary assessment and intervention 357

• Interdisciplinary short, medium and long-term measures for assessment of cognitive difficulties in indi-
follow-up and intervention by rehabilitation ser- viduals with significant upper limb motor deficits and/
vices relating to psychosocial well-being and or communication impairments. This is another area of
adjustment to disability clinical research that requires further exploration and
• Health professionals should be aware of the psy- attention.
chosocial impact on quality of life when working Research could also explore how recent technologi-
with this population cal advances, such as telemedicine, videoconferencing
• Health professionals also need to recognise that and web-based support could be used for facilitating
unmet psychosocial needs can lead to secondary communication and consultation between specialist and
difficulties including challenging behaviour, community services. Furthermore, studies have shown
stress, frustration and depression for both the that caregivers can be successfully supported through
stroke survivor and their family members internet and telephone support (Pierce et al., 2004). The
• Individuals with communication impairments effectiveness of these supports could be investigated
should be appropriately facilitated in the com- with caregivers of individuals with ABI.
munication of emotions and issues and concerns,
which may contribute to psychosocial difficulties
• Caregiver well-being needs to be supported 5. Conclusion
through appropriate community support services,
due to the reciprocal impact on both individuals in In conclusion, psychosocial issues are prevalent in
the relationship individuals and their families with significant commu-
• Identification of risk issues (e.g. verbal or physical nication impairments following ABI. However, this is
aggression) is vital when working with vulnerable a vastly under-researched area. Clinically, these issues
adults and their partners may be overlooked, partly due to the priority given to
• The assessment of cognitive strengths and other aspects of the rehabilitation process (e.g. physical
weaknesses in individuals with communication rehabilitation). The complexity of working with indi-
impairments is essential to having a fully inte- viduals with cognitive and communication impairments
grated understanding of the consequences of the also contributes to poor identification of psychosocial
individual’s brain injury issues. This case series clearly highlights that interven-
• Liaison, effective communication and consultation ing at the psychosocial level through interdisciplinary
between all services and disciplines (i.e. inpatient, working can facilitate meaningful outcomes for the
community and specialist ABI services) is nec- individual and their family.
essary to ensure appropriate service and support
provision
• There is a need for further development of consul-
tation and outreach from specialist ABI agencies Acknowledgments
to support community services working with this
population. The authors would like to express their sincere thanks
to all three clients and their families who agreed to be
As identified in the review, individuals with commu- part of this case review.
nication impairments are often excluded from studies
that examine the psychosocial impact of stroke (Hackett
& Anderson, 2005). Furthermore, only two studies were References
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