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The Role of Self-Efficacy in the Recovery Process of Stroke Survivors

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Introduction: Belief in one's personal capabilities are conducive to achieving success and provides additional energy for action. The stronger the conviction of one's self-efficacy, the higher the self-goals and the stronger the commitment to achieving them, despite any adversities. Our knowledge regarding the role of self-efficacy in post-stroke rehabilitation is still scarce. Aim of the study: The study aimed to analyze characteristics related to high self-efficacy levels before and after rehabilitation and to determine the role of self-efficacy in this process. Materials and methods: The study involved 99 stroke survivors. Participants' mental and functional state were assessed using Generalized Self-Efficacy Scale (GSES), Barthel Index (BI), Acceptance of Illness Scale (AIS), Geriatric Depression Scale (GDS), Visual Analogue Scale for Pain (VAS), Instrumental Activities of Daily Living (IADL) and Rivermead Mobility Index (RMI). Patients were evaluated twice: on admission (T1) and 3 weeks into rehabilitation (T2). Results: Patients without self-efficacy improvement after 3 weeks of rehabilitation, on discharge from the ward demonstrated poorer well-being (p = 0.002, Hedges' g = 0.63, 95% CI [0.24-1.08]), lower illness acceptance levels (p < 0.001, Hedges' g = -0.78, 95% CI [-1.25 - -0.41]), poorer functional status in basic activities of daily living (p = 0.003, Hedges' g = -0.62, 95% CI [-1 - -0.25]), locomotive abilities (p = 0.004, Hedges' g = -0.58, 95% CI [-1.12 - -0.15]) and instrumental activities of daily living (p = 0.001, Hedges' g = -0.71, 95% CI [-1.15 - -0.34]). Conclusion: Self-efficacy level is significantly related to rehabilitation outcomes. A routine self-efficacy assessment during the rehabilitation process seems very important. Patients whose initial self-efficacy is low or remains unchanged despite rehabilitation require special attention. Close cooperation between all members of the therapeutic team is essential to strengthen, at each stage, the sense of self-efficacy in stroke survivors.
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ORIGINAL RESEARCH
The Role of Self-Efcacy in the Recovery Process
of Stroke Survivors
This article was published in the following Dove Press journal:
Psychology Research and Behavior Management
Joanna Szczepańska-
Gieracha
1
Justyna Mazurek
2
1
Faculty of Physiotherapy, University
School of Physical Education in Wroclaw,
Wroclaw, Poland;
2
Department and
Division of Medical Rehabilitation,
Wroclaw Medical University, Wroclaw,
Poland
Introduction: Belief in one’s personal capabilities are conducive to achieving success and
provides additional energy for action. The stronger the conviction of one’s self-efcacy, the
higher the self-goals and the stronger the commitment to achieving them, despite any adversities.
Our knowledge regarding the role of self-efcacy in post-stroke rehabilitation is still scarce.
Aim of the Study: The study aimed to analyze characteristics related to high self-efcacy
levels before and after rehabilitation and to determine the role of self-efcacy in this process.
Materials and Methods: The study involved 99 stroke survivors. Participants’ mental and
functional state were assessed using Generalized Self-Efcacy Scale (GSES), Barthel Index (BI),
Acceptance of Illness Scale (AIS), Geriatric Depression Scale (GDS), Visual Analogue Scale for
Pain (VAS), Instrumental Activities of Daily Living (IADL) and Rivermead Mobility Index
(RMI). Patients were evaluated twice: on admission (T
1
) and 3 weeks into rehabilitation (T
2
).
Results: Patients without self-efcacy improvement after 3 weeks of rehabilitation, on
discharge from the ward demonstrated poorer well-being (p = 0.002, Hedges’ g = 0.63,
95% CI [0.24–1.08]), lower illness acceptance levels (p < 0.001, Hedges’ g = −0.78,
95% CI [−1.25 – −0.41]), poorer functional status in basic activities of daily living (p =
0.003, Hedges’ g = −0.62, 95% CI [−1 – −0.25]), locomotive abilities (p = 0.004,
Hedges’ g = −0.58, 95% CI [−1.12 – −0.15]) and instrumental activities of daily living
(p = 0.001, Hedges’ g = −0.71, 95% CI [−1.15 – −0.34]).
Conclusion: Self-efcacy level is signicantly related to rehabilitation outcomes. A routine
self-efcacy assessment during the rehabilitation process seems very important. Patients
whose initial self-efcacy is low or remains unchanged despite rehabilitation require special
attention. Close cooperation between all members of the therapeutic team is essential to
strengthen, at each stage, the sense of self-efcacy in stroke survivors.
Keywords: self-efcacy, rehabilitation outcomes, depression, acceptance of illness, behavior
management
Introduction
Sudden change in the life of people after stroke can lead to a wide range of negative
psychological and behavioral symptoms, including anxiety, feeling of helplessness
and mood disorders.
1
Most patients must face various functional, mental, and social
constraints. Reduced mobility is a serious problem, as it hinders the performance of
everyday tasks and results in isolation due to job loss and inability to resume pre-
stroke leisure activities. Deterioration of the quality of life is inevitable
2
and often
leads to depression.
3
Belief in one’s personal capabilities is conducive to achieving success and provides
additional energy for action. The stronger the conviction of one’s self-efcacy, the
Correspondence: Justyna Mazurek
Department and Division of Medical
Rehabilitation, Wroclaw Medical University,
Borowska 213, Wroclaw 50-556, Poland
Email justyna.mazurek@umed.wroc.pl
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higher the self-goals and the stronger the commitment to
achieving them, even in the face of adversities.
4
On the
other hand, a low sense of self-efcacy is associated with
depression, anxiety and helplessness, while a lack of self-
efcacy can completely reduce one’s motivational potential.
The sense of self-efcacy differentiates people in terms of
thinking, feeling and acting.
5
Assessing the level of self-efcacy and working to
improve this characteristic can help stroke survivors gain
greater control over many important aspects of their dis-
ease and improve their chances for better and more sus-
tained rehabilitation effects. There has been growing
evidence that interventions aimed at increasing self-
efcacy have a signicant impact on the efcacy of
chronic illness therapy, including stroke therapy, and that
physiotherapists may have an important role to fulll in
the process.
6–8
Such an approach ts well with the biopsychosocial
model of illness, particularly in the context of patient-
centred care. There is now a wealth of evidence supporting
its validity as a powerful holistic model which, by increas-
ing attention upon the patient as a person and requiring
greater collaboration and sharing of care and resources,
has the potential to contribute to a more successful and
sustainable healthcare system.
9
Therefore, the purpose of
our study was to analyze the characteristics related to high
self-efcacy levels before and after rehabilitation and to
determine the role of self-efcacy in the rehabilitation
process.
Materials and Methods
Study Group
The study was carried out at a neurological rehabilitation
ward in the Silesian Rehabilitation Centre, Poland. The
study was conducted for a year and during this time all the
successively admitted patients who met the inclusion cri-
teria were qualied to take part. The inclusion criteria were
as follows: rst ischemic brain stroke, no symptoms of
dementia (Mini-Mental State Examination, MMSE 24)
and over 50 years of age. The applied exclusion criteria
were as follows: no possibility of performing a cognitive
function examination (due to severe loss of vision or apha-
sia), a history of prior stroke, the presence – at examination
or in medical records – of intellectual disability, conscious-
ness disorders or other severe mental disorders, as well as
addiction to medication or other psychoactive substances.
Participation in the study was entirely voluntary, the
patients provided their written consent prior to enrolment
and were informed that they could leave the research project
at any given moment, without consequences to their clinical
care. All the participants understood the study purpose. The
study received approval from the Scientic Research Ethics
Committee (reference number: 30/2017) at the University
School of Physical Education in Wroclaw, Poland in
December 2017 and was conducted in accordance with the
Declaration of Helsinki.
One hundred participants were qualied for the study.
They were evaluated twice: on admission (T
1
) and 3 weeks
into rehabilitation (T
2
). Full assessment at both measure-
ment points was obtained in 99 patients. Mean age of the
respondents was 61 years (SD = 6.2) and 58.6% of the
study group were men. Most of the participants (64.6%)
lived in a city and were admitted to the rehabilitation ward
from home (63.6%). Mean period since stroke was 17
days. Among the study group, 56.6% of the respondents
were married and 45.5% declared their families to have
full care capacity. Slightly over a half of the participants
(53.5%) were retired. Fifty-four point ve percent of the
group had secondary or higher education. Fifty-six point
six percent performed physical work (eg, farmer, car
mechanic, cleaner, electrician) and 43.4% were mental
workers (eg, ofce worker, accountant, teacher). Left-
sided paresis prevailed in the study group (58.6%). Only
26.3% of the patients had no comorbidities while 18.2%
had one additional illness and 55.5% of patients had two
or more additional chronic illnesses. Mean Body Mass
Index (BMI) score was 27.2 (SD = 3.3) among the exam-
ined women and 28.9 (SD = 3.1) among the men. Detailed
sociodemographic and clinical data are presented in
Table 1.
Methods
The primary research tool was the Generalized Self-
Efcacy Scale (GSES) which refers to the concept of self-
efcacy as formulated by its creator, Albert Bandura. The
scale consists of 10 statements aimed at assessing an
individual’s perceived ability to cope in difcult situations
and overcome obstacles. The higher the score, the greater
the sense of self-efcacy.
10,11
Level of acceptance of illness was measured using the
Acceptance of Illness Scale (AIS). The instrument consists
of eight items describing the consequences of poor health
and illness. The statements acknowledge the constraints
imposed by illness, lack of self-sufciency, the sense of
dependence on others and reduced self-esteem. The higher
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the score, the better the adjustment to illness, which is
manifested by the absence of negative illness-related
emotions.
12
The sense of well-being and mood of the participants
were measured with the Geriatric Depression Scale (GDS-
30). In this scale, a score above 10 indicates depression,
with the severity of symptoms increasing along with the
score.
13
Pain intensity was measured using the Visual
Analogue Scale for Pain (VAS) with two verbal descrip-
tors, “no pain” for the score of 0 and “worst pain imagin-
able” for the score of 10.
The Barthel Index (BI) was used to assess the partici-
pants’ functional state in terms of basic activities of daily
living
14
and the Instrumental Activities of Daily Living
(IADL) Scale for more complex tasks.
15
Patient mobility
was evaluated with the Rivermead Mobility Index
(RMI).
16
In all the above scales, the higher the score, the
better the patient’s functioning.
All assessments were performed at two measuring
points: within two days of admission to the ward (T
1
)
and after 3 weeks of neurological rehabilitation (T
2
).
Participants assessed their family care capacity (FCC)
only once, on admission (T
1
), rating it as: ‘0ʹ – lack of
capacity, ‘1ʹ incomplete capacity (the family is able to
provide care on a limited basis) and ‘2ʹ – full care capacity
of the family. A cut-off point of 60 years of age was
adopted to assess the differences between the older and
younger patients.
The efcacy of rehabilitation was assessed in
a dichotomous division, where in case of improvement,
its extent was assessed (a number of points on an appro-
priate scale), and other outcomes (lack of improvement or
regress) were assigned the value of 0. With the applied
method of assessment of rehabilitation efcacy, the num-
ber of 0 scores was relatively large and, in consequence,
the distribution of point assessments for improvement was
decidedly skewed.
Post-Stroke Rehabilitation
Neurological rehabilitation was carried out in hospital
setting at a neurological rehabilitation ward. The rehabili-
tation program was designed individually for each patient
due to the varying levels of functional ability on admis-
sion. However, the amount of therapy received (the dura-
tion of a single session and number of rehabilitation
sessions per week) was the same for each participant and
included the following activities: individual exercises tak-
ing into account individual neurological and functional
decits, active and passive kinesitherapy of upper and
lower limbs, balance and gait re-education exercises,
hydrotherapy and electrostimulation. Physiotherapy (run
by a physiotherapist) was combined with occupational
therapy run by an occupational therapist. Participants
also received psychological support which included
a diagnosis of cognitive function, and emotional support
if the psychologist deemed it necessary.
Statistical Methods
Statistical description of characteristics with continuous
distributions included determination of mean values and
standard deviations. Distributions of characteristics with
discrete distributions were presented as distribution series.
The Kolmogorov–Smirnov test was used to verify the
normality of distribution of continuous characteristics.
Parametric testing (Student’s t-test for independent sam-
ples) was used to assess differences between mean values
and the single-factor variance analysis (ANOVA) to com-
pare a greater number of means. Correlations between
characteristics were assessed by determination of the
Table 1 Sociodemographic Characteristics of the Study Group
Variables (%)
Gender Female
Male
41
58
Dwelling place City
Rural area
64
35
Admitted from Home
Hospital
63
36
Occupational status Disability pension
Retirement pension
Employed
Unemployed
18
53
22
6
Education Primary
Vocational
Secondary
Higher
15
30
34
20
Work type before stroke Physical
Mental
56
43
Marital status Single
Married
Widow/widower
18
56
25
Family care capacity Lack
Incomplete
Full
21
33
45
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Pearson’s r linear correlation coefcient. With the null
hypothesis on the normality of distribution rejected, corre-
lation was assessed by determining the Spearman’s rank
correlation coefcient (ρ).
17
The correlation of the observed GSES score improve-
ment with the improvement in each of the other scales was
assessed using the non-parametric Spearman’s rank corre-
lation coefcient. Verication of the null hypotheses was
performed at the critical level of p < 0.05. All calculations
were carried out using the STATISTICA 13.3 software by
Dell.
Results
The Sense of Self-Efcacy on Admission
to the Ward
At T
1
there was no signicant difference between men
and women in terms of self-efcacy (p = 0.62, Hedges’
g = −0.098, 95% CI [−0.51 - −0.31]). However, a difference
was observed between the older and younger patients. Self-
efcacy was signicantly higher in people aged 60 years
and older (p = 0.02, Hedges’ g = −0.63, 95% CI [−1.12
−0.23]). No link was detected between the sense of self-
efcacy and education or the type of performed work. There
was, however, a statistically signicant relationship
between the mean self-efcacy and marital status (p <
0.001, Ges = 0.325, 95% CI [0.18–0.45]) of participants
as well as care capacity of their families (p < 0.001, Ges =
0.323, 95% CI [0.17–0.45]). The lowest self-efcacy level
was found in participants who were single and whose
families lacked care capacity, and the highest in people
who were married and had families with full care capacity
(Table 2).
The Efcacy of Post-Stroke Rehabilitation
After three weeks of post-stroke rehabilitation, we
recorded a signicant improvement in almost all of the
parameters analyzed. One exception was the level of
depression, where no signicant changes were recorded.
The change of self-efcacy was statistically signicant
(p = 0.0002, Hedges’ g = 0.36, 95% CI [0.17–0.56]).
Improvement of the self-efcacy correlated signicantly
with a reduction of depressive symptoms, an increase in
illness acceptance level and an improvement in terms of
basic activities of daily life (Table 3). The highest num-
ber of cases of improvement in the self-efcacy was
recorded in participants with higher education who were
married, whose families had full care capacity, and who
had performed mental type of work before stroke
(Figure 1).
Table 2 The Relationship Between the Value of Self-Efcacy and the Sociodemographic Characteristics on Admission to the Ward
(T
1
)
Characteristics Category M ± SD p | post hoc Effect size [95% CI]*
Gender Female
Male
27.9 ± 10.0
28.8 ± 9.2
0.62 0.098
[0.51 - 0.31]
Age ≥60
>60
25.5 ± 10.0
31.3 ± 8.1
0.02 0.63
[1.12 – 0.23]
Education Primary
Vocational
Secondary
Higher
29.5 ± 10.5
27.5 ± 7.4
26.8 ± 10.1
31.8 ± 10.2
0.266 0.041
[0–0.12]
Work type before stroke Physical
Mental
27.5 ± 8.8
29.7 ±10.3
0.248 0.23
[0.68–0.17]
Marital status Single
a
Married
b
Widow/widower
c
18.1 ± 7.3
32.4 ± 7.2
27.0 ± 9.5
a vs b <0.001
a vs c 0.0011
b vs c 0.015
0.325
[0.18–0.45]
Family care capacity Lack
a
Incomplete
b
Full
c
19.3 ± 7.3
27.5 ± 9.3
33.3 ± 7.0
a vs b <0.001
a vs c <0.001
b vs c 0.005
0.323
[0.17–0.45]
Notes: Tests: Student’s t-test (with two groups) or ANOVA (for more than two groups) with Tukey HSD post hoc analysis, Effect size – *Hedges’ g (for two groups), Ges:
generalized eta squared (for more than two groups).
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Change in Self-Efcacy During
Rehabilitation
In the nal part of the statistical analysis, the study group
was divided into two subgroups: participants with
improvement in the self-efcacy after 3 weeks of rehabi-
litation (n = 43) and participants without such improve-
ment (n = 56). Statistical analysis showed that the rst
group had a signicantly better mental and functional state
at T
2
in all the characteristics studied. The sole exception
was the level of pain sensations (Table 4).
No signicant relationship was detected between the
improvement in self-efcacy and such clinical data as the
side of paresis or number of comorbidities. By comparing
sociodemographic characteristics in participants who
achieved improvement in self-efcacy after the three-
week rehabilitation (n = 43) and in those without such
improvement (n = 56), we found that a signicant differ-
ence between the groups is only visible for the level of the
family care capacity (p = 0.021, OR = 3.53, 95% CI
[1.08–11.51]). A self-efcacy improvement occurred
most frequently in those participants whose families had
full care capacity.
Discussion
Many authors have conrmed the importance of self-
efcacy as a self-regulatory mechanism in various chronic
diseases, such as cancer, infectious diseases, neurodegen-
erative diseases or cystic brosis. Patients with high self-
efcacy values are better at coping with the negative
consequences of their disease and with its treatment.
18–21
The importance of self-efcacy seems even greater in the
case of diseases that limit physical function and require
long-term rehabilitation. The stronger the conviction of
one’s self-efcacy, the higher the self-goals one sets for
oneself and the stronger the commitment to achieving
them.
4
Such a goal may be to regain full physical tness
or to return to one’s professional and social roles from
before the onset of the disease.
The level of self-efcacy is based on life experience
and contains aspects of the patient’s pre-disease identity.
Therefore, in this study, we tried to determine which
sociodemographic characteristics are related to self-
efcacy. Statistical analysis demonstrated that participants
who were older (over 60 years of age), married partici-
pants and those whose families had a full care capacity
obtained higher self-efcacy scores prior to rehabilitation.
Interestingly, two of these characteristics (marital status
and family care capacity) are related to patients’ social
situation and not their internal, psychological resources.
It appears that younger people (between 50 and 60 years of
age) experience a greater loss due to stroke than older
patients, especially those who are already retired. For
Table 3 The Efcacy of Post-Stroke Rehabilitation After the First 3 Weeks of Participants’ Stay at the Ward
Characteristics Time
point
M ± SD Mean change
(95% CI)
p (Wilcoxon test)
effect size [95% CI]
Association with Self-Efcacy
Improvement OR (95% CI)
Depression T
1
T
2
8.10 ± 5.85
7.84 ± 6.20
0.26
(0.81–0.28)
0.2978
–0.096 [0.31–0.1]
4.61
(2.00–11.1)
Acceptance of illness T
1
T
2
23.44 ± 9.13
25.16 ± 9.96
1.72
(0.88–2.54)
0.0001
0.41 [0.21–0.63]
4.31
(1.86–10.5)
Pain T
1
T
2
0.94 ± 2.26
0.69 ± 1.75
0.25
(0.39 – 0.11)
0.0015
–0.36 [0.47 0.26]
0.35
(0.07–1.22)
Self-efcacy T
1
T
2
28.43 ± 9.49
29.86 ± 9.95
1.42
(0.65–2.20)
0.0002
0.36 [0.17–0.56]
Basic activities
of daily living
T
1
T
2
55.66 ± 16.56
69.49 ± 13.97
13.84
(11.39–16.29)
<0.0001
1.13 [0.96–1.32]
6.31
(2.16–23.2)
Mobility T
1
T
2
6.96 ± 2.32
8.78 ± 1.92
1.82
(1.45–2.19)
<0.0001
0.99 [0.66–1.39]
3.9
(1.3–14.5)
Instrumental activities
of daily living
T
1
T
2
17.00 ± 4.12
18.48 ± 3.53
1.48
(1.12–1.85)
<0.0001
0.82 [0.67–0.98]
1.39
(0.63–3.12)
Notes: T
1
– rst measuring point (on admission), T
2
– second measuring point (after 3 weeks of rehabilitation), *Hedges’ g.
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younger, professionally active people stroke means not
only the loss of independence, but also the loss of the
possibility to continue working in their profession,
whereas the age of 50+ years may be a period of intense
activity, both professional and social. The problem affects
both people in physical jobs (eg, farmer, mechanic,
Figure 1 Percentage of cases of improved sense of self-efcacy after post-stroke rehabilitation. As the percentage values were determined in relation to the size of each
category of characteristics, they do not add up to 100% within each characteristic.
Table 4 Functional and Mental State of Participants After 3 Weeks of Post-Stroke Rehabilitation in Groups of Patients with and
without Improvement in Self-Efcacy
Characteristics Self-efcacy g [95% CI] p
No Improvement M± SD Improvement M ±SD Mean diff. (95% CI)
Depression 9.48 ± 6.24 5.70 ± 5.52 3.78 (1.43–6.13) 0.63 [0.24–1.08] 0.002
Acceptance of illness 22.00 ± 9.73 29.28 ± 8.75 7.28 (10.98 3.58) 0.78 [1.25 0.41] <0.001
Pain 0.88 ± 1.95 0.44 ± 1.45 0.43 (0.24–1.11) 0.25 [0.11–0.64] 0.225
Basic activities 65.89 ± 14.59 74.19 ± 11.70 8.29 (13.54 – 3.05) 0.62 [1 – 0.25] 0.003
Mobility 8.30 ± 1.80 9.40 ± 1.92 1.09 (1.84 0.34) 0.58 [1.12 0.15] 0.004
Instrumental activities 17.46 ± 3.83 19.81 ± 2.58 2.35 (3.63 1.07) 0.71 [1.15 0.34] 0.001
Notes: g – Effect size (Hedges’ g), p – Student’s t-test.
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cleaner), due to physical disability, and those performing
mental type of work (eg, ofce worker, accountant, tea-
cher), due to impaired concentration and decits in cogni-
tive functions. Finding support in one’s spouse or family
can be very important in dealing constructively with such
a difcult situation.
The situation is quite similar when we look at who has
the best chance of improving self-efcacy during rehabi-
litation. These will still be the patients who are married
and whose families have a full family care capacity, but
also people with higher education and those who did
mental type of work before the stroke. This is probably
due to the fact that after stroke, one must try to look for
new ways of coping in daily life. This is perhaps easier for
the so-called white-collar workers, ie, people working in
positions where they have to manage others, as they are
used to facing new situations and solving various problems
for their whole team. It might also be easier for such
people to nd solutions to their own problems by search-
ing for sources of knowledge on the Internet or in medical
publications. The fact of seeking knowledge and following
the example of other people who have coped with a similar
problem is the determinant of an active ght against the
disease and has a better chance of success than a passive
attitude.
Thus, on admission to rehabilitation wards particular
attention should be paid to younger patients without family
support and those working in low-education jobs.
Korpershoek et al state that interventions aimed at increas-
ing the sense of self-efcacy, such as task-oriented walk-
ing group exercise program and group education
intervention are effective and contribute to improvement
of various patient outcomes, resulting in better mobility,
independence in activities of daily living, lower risk of
depression and higher quality of life.
22
Therefore, patients
falling into the categories mentioned above should, rst
and foremost, participate in such self-efcacy improve-
ment interventions. In a study by Gillham et al, patients
after stroke who received “enhanced secondary preven-
tion” (additional advice, motivational interviewing and
telephone support) to change health behavior achieved
signicant improvements for change in a self-reported
exercise (p = 0.007).
23
There is evidence that a stroke
survivor’s internal drive, resilience, and sense of self-
efcacy play a role in adopting good behaviors.
24
What
is more, engagement in a stroke-specic self-management
program can improve client-perceived occupational perfor-
mance and satisfaction. Self-efcacy was shown to be
a mediating variable to occupational performance
improvements.
25
This fact seems extremely important in
the case of younger stroke survivors who still have a good
chance and the need to return to professional activity.
In their study, Torrisi et al demonstrated that rehabilita-
tion outcomes and self-efcacy levels may signicantly
inuence the level of mood, but not vice versa. The lowest
levels of depression were detected in stroke survivors in
good functional state after a completed physiotherapy, who
demonstrated a high sense of self-efcacy. Neither logo-
pedic nor neuropsychological treatment was provided in
this study.
26
Volz et al proved that a low self-efcacy level
is a driving factor for depression during the rst two years
post-stroke. It follows that the impact of self-efcacy on
depressive symptoms is stronger than the other way round.
Their results show the crucial role of declining self-
efcacy in the emergence of depression after stroke.
27
Robinson-Smith et al have shown that patients with low
self-efcacy scores have higher levels of depression, both
at one and six months after stroke, and that higher self-
efcacy is also signicantly correlated with higher quality
of life.
28
In our study, we looked at the concept of self-efcacy
also in terms of the change that occurs during rehabilita-
tion. We found that participants who did not show an
improvement in self-efcacy after 3 weeks of treatment
had poorer well-being, lower levels of illness acceptance
and poorer functional status. Our ndings are consistent
with the results obtained by Volz et al, who concluded that
dissatisfaction with recovery after stroke might lead to
decreased self-efcacy.
29
The results presented above
were also conrmed in a systematic literature review that
demonstrated self-efcacy to be positively linked to better
mobility, greater independence in daily life activities and
better quality of life, and to be negatively linked to the
level of post-stroke depression.
22
Crucial ndings were
published by Svendsen et al who compared patients with
stroke who underwent rehabilitation and those who were
provided with “usual care”. The authors found that after
12–22 years after stroke, the group who had taken part in
rehabilitation showed a signicantly higher level of self-
efcacy and had higher quality of life than the group who
had not undergone a rehabilitation program.
30
It therefore seems that a high level of self-efcacy
allows for more effective solutions and strategies to be
applied in the recovery process. For this reason, interven-
tions aimed at increasing self-efcacy and concerning
stroke survivors should be included in the daily program
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carried out by physiotherapists working with this group of
patients. Current British guidelines regarding procedure to
be applied after stroke explicitly recommend that patients
participate in “self-management programs based on self-
efcacy”.
31
That is why physiotherapists should not only
focus on the physical, but also psychological and social
aspects in the process of recovery.
32
Such an approach is
indeed possible if the specialists involved in treating
a stroke survivor constitute an actual, cooperating team
where the members share information and observations
regarding the patient and his or her needs and where
they together plan and execute the rehabilitation process
in line with the biopsychosocial model. Going beyond
standard methods at each stage of rehabilitation and hand-
ing over to the patient increasingly more responsibility for
the course of this process are the pillars of patient-centered
care.
Patient safety is an important element in this approach,
as strict procedures usually guarantee greater safety, but
fail to take into account differences between stroke survi-
vors and restrict the involved specialists in developing an
individual approach to each patient. Clearly dened ther-
apeutic procedures are also intended to protect workers
from being held responsible for possible accidents. Stroke
impairs locomotive abilities and leads to balance and
coordination disorders which, if combined with disorders
of cognition and visual-spatial perception or aphasia, make
for a very complicated rehabilitation process where acci-
dents (mostly falls) are not uncommon. And that is exactly
why actual cooperation of the therapeutic team, holistic
approach to the patient and joint risk-taking are so impor-
tant. Tasks assigned to the patient should be a challenge
requiring effort but not exceeding the patient’s capabilities
and should, as much as possible, reect the tasks he or she
will have to face on return home. Therefore, knowledge of
the conditions in which stroke survivors function in their
natural environment is extremely important to prepare
them well for leaving the rehabilitation ward. It has been
found that, with adequate support from the therapeutic
team, even the oldest patients are able to quickly recover
the skills necessary for daily living (especially those who
cannot count on anyone’s help at home).
33
Clinical Recommendations Based on
Study Findings
At present, the issue of self-efcacy in stroke survivors is
still too rarely taken into account in their rehabilitation
process. Physiotherapy is largely medication-based and
strictly supervised by qualied medical staff. However,
at each stage of post-stroke rehabilitation, it is possible to
develop a number of exercises and tasks that are quite
safe for the patient and to entrust him or her with the
responsibility to perform them every day after the sched-
uled rehabilitation routine. Thanks to such a model, the
patient receives tools to be used also after leaving the
rehabilitation ward, as well as the valuable awareness that
he or she can actively participate in the physiotherapy
process and not just follow a specialist’s instructions. It is
not our suggestion to create completely new rehabilitation
procedures to replace the existing ones, but to give the
specialist team working together with an opportunity to
develop an individual rehabilitation plan for each patient,
because stroke survivors are very different from each
other, depending on the extent of the ischemic lesion
and its location in the brain, and consequently, the
range of functional, cognitive and emotional problems
that affect them.
We fully agree with Korpershoek’s statement that
the management of stroke units in hospitals, rehabilitation
centres and nursing homes need to facilitate the use of
self-efcacy in the daily care. They need to create time,
space and nancial support in their policy to make it
possible for nurses to offer patients the opportunity to
learn about self-efcacy, practise and share experiences
with other patients.
22
In our opinion, similar tasks should be given to phy-
siotherapists and occupational therapists. A routine self-
efcacy assessment on admission to a rehabilitation unit
appears even more important than assessment of the level
of depression. In the case of depression, pharmacotherapy
often becomes the easiest solution, which unfortunately
robs patients of control over their own mental state. In
our view, rst priority should be given to interventions
aimed at increasing self-efcacy in the rehabilitation pro-
cess, as there is a high probability that improvement in the
functional state will result in reduction of depressive
symptoms. From a psychological perspective, such
a situation is preferable, because the change is related
directly to the patient’s own activity, and not to psychoac-
tive drugs.
Limitations
The greatest limitation of our study was the lack of long-
term self-efcacy assessment in the recovery process after
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stroke. That is why it would be important to carry out
further multi-center studies, taking into account different
methods and models of rehabilitation and allowing for
longer observation of the rehabilitation process. Another
limitation of the presented study could be selection bias.
The study included only individuals with ischemic stroke
and without previous history of stroke, meaning that no
patients with hemorrhagic stroke or with multiple stroke
episodes were examined. As epidemiological data show
that they constitute a signicant proportion of patients with
stroke, the study group should be expanded in the future to
include a representative sample of the entire population of
stroke survivors. Another limitation is using the
Generalized Self-Efcacy Scale which refers directly to
the denition created by A. Bandura, while there is
another available tool, ie, the Stroke Self-Efciency
Questionnaire which refers to situations related to stroke.
It would be worthwhile if future studies used the latter
questionnaire and compared the obtained ndings.
Conclusions
The self-efcacy level is signicantly related to the pro-
cess of rehabilitation. On admission to rehabilitation
wards particular attention should be paid to younger
patients (under 60 years of age), without family support
and working in low-education jobs. It seems necessary to
reformulate the objectives of rehabilitation so that
strengthening the sense of self-efcacy becomes the key
task in the process of rehabilitation aimed at regaining
self-sufciency and improving life management skills.
A routine self-efcacy assessment on commencement
and completion of rehabilitation at a hospital ward
seems legitimate and important. On discharge from the
ward, patients whose initial self-efcacy level was low
and remained unchanged during rehabilitation should
receive special attention. The development of scientic
evidence-based interventions aimed at increasing self-
efcacy in stroke survivors is an important challenge
faced by today’s post-stroke rehabilitation. Future
research projects should focus on further exploration of
strategies facilitating self-efcacy during stroke self-
management programs in order to maximize the effects
of rehabilitation.
Disclosure
The authors report no conicts of interest for this work.
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... [14][15][16] In sum, individuals who display higher levels of self-efficacy post-stroke experience and perceive less functional decline, greater control over many important aspects of their life and improve their chances for better and sustained rehabilitation effects. 17 For this reason, self-efficacy is considered to be an important psychological construct in stroke rehabilitation. 17 In this light monitoring the individual's selfefficacy in stroke rehabilitation is an essential aspect during the rehabilitation process. ...
... 17 For this reason, self-efficacy is considered to be an important psychological construct in stroke rehabilitation. 17 In this light monitoring the individual's selfefficacy in stroke rehabilitation is an essential aspect during the rehabilitation process. Measurement tools measuring self-efficacy with sound psychometric properties are needed. ...
Article
Background In stroke rehabilitation, measurement tools measuring self-efficacy with sound psychometric properties are needed. The Stroke Self-Efficacy Questionnaire (SSEQ) has recently been translated and validated into a Danish version (SSEQ–DK). Objectives To evaluate the test–retest reliability of the SSEQ-DK. Methods Fifty people with stroke ≥ 18 years in the sub-acute and chronic phase were included from February 2019 to August 2020. The SSEQ-DK was completed twice; on day 1 and day 7–14. Test–retest reliability of the single items was assessed using weighted Cohen’s kappa and percentage agreement. The activity and self-management scales were assessed by the intraclass correlation coefficient (ICC). Measurement error was assessed by calculating the Smallest Detectable Change (SDC) based on the standard error of measurement. Results Overall, kappa values showed fair to substantial test–retest reliability of the single items. However, several kappa values were missing as the statistical prerequisites were not present. The percentage agreement ranged from 78% to 94%. Based on the reported confidence interval of the estimated intraclass correlation coefficient, the test–retest reliability of the activity and self-management scales was poor to excellent in all analysis. Ceiling effects appeared in the single items. Conversely, no floor effect was seen. Conclusion The SSEQ-DK showed good test–retest reliability of the single items based on agreement among a population with stroke in the subacute and chronic phase. Broad ICC confidence intervals bar any firm conclusions concerning the test–retest reliability of the activity and self-management scales. Trial registration ClinicalTrials.gov NCT03183960. Reg. 15 June 2017.
... Not only that, self-efficacy determines someone's goals to achieve something including predicting various events that will be faced (Rafiola et al., 2020). It means self-efficacy can help the ability of stroke patients in their daily care (Szczepańska-Gieracha & Mazurek, 2020). One study said stroke survivors experienced feelings of fear of the absence of interpersonal acceptance and rejection (López-Espuela et al., 2018). ...
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Stroke patients generally experience daily self-care disorders due to old age (elderly), so that motor skills are low. One factor affecting the ability to take care of oneself every day and be motivated to be independent is self-efficacy. The purpose of this study was to analyze the effect of self-efficacy-based education on the daily self-care of stroke patients at the Haji Adam Malik General Hospital and its implications with counselling guidance. The type of research used is a quasi-experimental design using the nonequivalent control group pre- post-test only design method. The population in this study were all ischemic stroke patients at Haji Adam Malik Hospital Medan and a sample of 36 people. Researchers provided educational interventions based on self-efficacy using visual media, discussions, motor skills training, and occupational exercises for three meetings per week with a duration of 30 minutes each session for six weeks. Data collection with primary and secondary data and analyzed by statistical test Paired Sample t-Test. The results showed an effect of self-efficacy-based education on the daily care of stroke patients at Haji Adam Malik Hospital Medan (p-value = 0.000 0.05) such as motor function and improving their daily activities.
... Similarly, in the subgroup analysis of studies examining IADL, significant subgroup difference was found between Asiansand Caucasians-based studies, suggesting that cultural or demographical backgrounds might have affected the effectiveness of self-management interventions. Szczepa nska-Gieracha and Mazurek [70] investigated sociodemographic characteristics relating to self-efficacy improvements, which found that only the level of family care capacity was significantly different between groups with and without self-efficacy improvements after rehabilitation. While this was not explored in the included studies of this review, it signals that the effectiveness of self-management interventions differs for various undetermined subgroups of stroke survivors. ...
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Purpose This systematic review and meta-analysis aims to synthesise the evidence of the effectiveness of self-management interventions with action-taking components in improving self-efficacy, health-related quality of life, basic and instrumental activities of daily living, and depression for adult stroke survivors. Materials and methods Nine electronic databases were searched for relevant studies, including grey literature and ongoing studies. Randomised controlled trials targeting adult stroke survivors comparing health-related outcomes of patients receiving self-management interventions with action-taking components to usual care, placebo, or no-treatment were included. Screening, data extraction, and methodological quality assessment were conducted by two reviewers. Meta-analyses were performed. Overall quality of evidence was assessed using the GRADE tool. Results A total of seventeen studies were included. Meta-analyses showed that the intervention may result in a slight increase in self-efficacy (SMD = 0.29, 95% CI [0.07–0.52], p = 0.010, I² = 47%) and basic activities of daily living (SMD = 0.31, 95% CI [0.16–0.46], p < 0.001, I² = 0%), but not for the other outcomes. Conclusions Self-management interventions with action-taking components may result in a slight improvement in self-efficacy and rehabilitation of basic activities of daily living. Future research should investigate which core self-management skill, or combination of them, is most effective in improving short-term and long-term outcomes. • IMPLICATIONS FOR REHABILITATION • Stroke can be a chronic condition as approximately half of stroke survivors suffer from permanent disabilities. • Self-management interventions are one form of rehabilitation programmes available to stroke survivors. • Self-management interventions with action-taking components may result in a slight increase in patient self-efficacy and carrying out basic activities of daily living compared to usual care given.
... This is a process of transformation, where the patient-a person who is being treated/rehabilitatedbecomes the person who feels co-responsible for his or her recovery process and its final results. The assumption is confirmed by research conducted in the neurological rehabilitation department, where 99 disabled patients were monitored [35]. ...
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Background: The sudden live changes of stroke survivors may lead to negative psychological and behavioral outcomes, including anxiety and depressive mood, which may compromise the rehabilitation process. Some personality features, such as self-efficacy, could play an important role in mediating the degree of post-stroke depression. Aim of this study is to investigate the possible correlation between specific psychological dimensions, such as poststroke depression and self-efficacy, and rehabilitation outcomes. Materials and methods: Thirty-eight patients, affected by stroke, completed a four-hour-daily training lasting up to 8 weeks, including traditional and robotic-assisted physiotherapy. Patients were assessed at admission (T0) and at the end (T1) of the motor training, by means of the Montgomery-Asberg Depression Scale, the General Self-Efficacy Scale, and the Functional Independent Measure. Results: We observed a significant T0-T1 difference in MADRS scores in patients with a better functional recovery (t = 5.76; P < .0001) and higher self-efficacy (t = 4.74; P < .001), but no significant T0-T1 difference in individuals without functional recovery (t = 1.21; P = .239) and low self-efficacy (t = 1.72; P = .103). Conclusions: Our study shows that rehabilitation outcomes and self-efficacy may influence mood, but not vice versa. Thus, to potentiate self-efficacy in the rehabilitation setting may help clinicians in obtaining better functional outcomes, including depression reduction.
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Purpose: This study explored the impact of a 12-week stroke self-management program on occupational performance, the role of self-efficacy on improving occupational performance and the potential barriers and facilitators to self-efficacy as reported by clients and careers. Materials and methods: Participants (n = 40) were recruited to participate in a self-management program after admission to hospital with diagnosis of stroke. A pre-post study was conducted and data were obtained from participants using: the Canadian Occupational Performance Measure, Stroke Self-efficacy Questionnaire, and semi-structured interviews with five participants and two careers. Data analysis was conducted using parametric statistics and thematic analysis. Results: Significant improvements were observed in occupational performance (t = 11.2; p = 0.001) and satisfaction (t = 9.7; p = 0.001). Self-efficacy was shown to be a significant mediator to improvements in occupational performance (F = 7.08; p < 0.01) and satisfaction (F = 6.52; p = 0.02). Three key barriers and facilitators emerged from the thematic analysis: “Support in making the transition home,” “Getting back to normal,” and “Reflecting on shared experiences.” Conclusions: Engagement in a stroke-specific self-management program can improve client-perceived occupational performance and satisfaction. Self-efficacy was shown to be a mediating variable to occupational performance improvements. Future research should explore further the facilitatory strategies of self-efficacy during stroke self-management programs to maximize rehabilitation outcomes. • Implications for rehabilitation • Multi-modal self-management programs are recommended as effective for improving client-perceived occupational performance of people who have experienced stroke. • Returning to valued occupations, goal setting, shared experiences, and local support are recommended components of a self-management program for stroke survivors. • Focusing on enhancing client confidence, competence, and self-efficacy is recommended to achieve occupational performance gains through self-management. • Occupational therapy coaching is recommended to guide participants through the self-management processes of goal-setting, shared problem-solving, performance evaluation, and reflection.
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https://content.iospress.com/articles/work/wor162823 Background: A large proportion of individuals with a stroke are unable to return to work, although figures vary greatly. Due to the very high cost of post-stroke care, both tangible and intangible, in the form of long-term social consequences, it seems extremely important to search for factors responsible for the low efficiency of the rehabilitation and recovery process, because this fact has direct influence on future employment. Such knowledge would enable physiotherapists to quickly identify those patients who are at risk of rehabilitation breakdown, in order to provide them with special care and include them in intensive therapeutic treatments. Objective: The aim of the study was to assess the efficacy of post-stroke rehabilitation, evaluated within the biopsychosocial aspect. Methods: The study consisted of 120 patients after first stroke, including 48 women and 72 men aged 58.0 (±8.6). The measure of the effects of physiotherapy in the present study was not only the improvement of the functional state (simple and complex activities of daily life, locomotive activities), but also the improvement of the mental state (mood and the sense of well-being, level of acceptance of illness, perceived self-efficacy) and the reduction of pain. The Mini-Mental State Examination, the Geriatric Depression Scale, the Generalized Self-Efficacy Scale, the Acceptance of Illness Scale, the Visual Analogue Scale, the Barthel Index, the Instrumental Activity of Daily Living and the Rivermead Mobility Index were used. All parameters were measured twice: on admission to the ward and after three weeks of physiotherapy. The characteristics of the study group were presented using descriptive statistics. The analysis of interdependence of the efficacy of physiotherapy used two non-parametric tests: the Mann-Whitney U test to compare two groups, and the Kruskal-Wallis ANOVA test to compare a greater number of groups. Correlations between characteristics with continuous distributions were assessed using Spearman's rank correlation coefficient (ρ), and in case of categorical variables, Pearson's chi-squared (χ2) correlation coefficient. Linear regression was used to determine the hierarchy of the influence of particular characteristics on the efficacy of physiotherapy. Results: Statistical analyzes show that patient's age, time since stroke, number of comorbidities, family care capacity, marital status of the patient and also a low level of acceptance of illness, depression symptoms and lack of a sense of self-efficacy were related with low efficacy of post-stroke rehabilitationCONCLUSIONS:Comprehensive neurological rehabilitation, taking into account mental challenges and socio-economic circumstances of individuals with a stroke is essential in order to achieve high efficacy of physiotherapy. Important external factors may play a pivotal role in returning to work as well and should be taken into account during rehabilitation. Of interest should be to assess more biopsychological factors, such as acceptance of illness and a sense of self-efficacy referred to as barriers to return to work.
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Post-stroke depression (PSD) is the most common psychiatric condition after stroke, affecting one third of survivors. Despite identification of meaningful predictors, knowledge about the interplay between these factors remains fragmentary. General self-efficacy (GSE) is closely linked to PSD, yet direction and magnitude of this relationship remains unclear. The authors assessed the relationship between GSE and depression during the first two years post-stroke while controlling for stable inter-individual differences using continuous time (CT) structural equation modelling (SEM). Patients of two German rehabilitation centres (N = 294, mean age = 63.78 years, SD = 10.83) were assessed six weeks after ischemic stroke and at four follow-ups covering two years. GSE Scale and Geriatric Depression Scale (GDS) were used to assess GSE and depression. CT-analysis revealed significantly higher within-person cross-effects of GSE on GDS (a21 = −.29) than vice versa (a12 = −.17). Maximal cross-lagged effects emerged six months post-stroke. Our results show that decreasing GSE led to increasing depressiveness, and only to a smaller extent vice versa. This suggests that fostering GSE by strengthening perceived control after stroke can counter PSD emersion and exacerbation. Six months post-stroke, when patients face social re-integration, programmes focusing on GSE could potentially help to prevent later PSD.
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The biopsychosocial model outlined in Engel's classic Science paper four decades ago emerged from dissatisfaction with the biomedical model of illness, which remains the dominant healthcare model. Engel's call to arms for a biopsychosocial model has been taken up in several healthcare fields, but it has not been accepted in the more economically dominant and politically powerful acute medical and surgical domains. It is widely used in research into complex healthcare interventions, it is the basis of the World Health Organisation's International Classification of Functioning (WHO ICF), it is used clinically, and it is used to structure clinical guidelines. Critically, it is now generally accepted that illness and health are the result of an interaction between biological, psychological, and social factors. Despite the evidence supporting its validity and utility, the biopsychosocial model has had little influence on the larger scale organization and funding of healthcare provision. With chronic diseases now accounting for most morbidity and many deaths in Western countries, healthcare systems designed around acute biomedical care models are struggling to improve patient-reported outcomes and reduce healthcare costs. Consequently, there is now a greater need to apply the biopsychological model to healthcare management. The increasing proportion of healthcare resource devoted to chronic disorders and the accompanying need to improve patient outcomes requires action; better understanding and employment of the biopsychosocial model by those charged with healthcare funding could help improve healthcare outcome while also controlling costs.
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Presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from 4 principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. Factors influencing the cognitive processing of efficacy information arise from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and behavioral changes. (21/2 p ref)
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The study involved 39 patients aged 76.0 (SD = 10.9) years (minimum 47 years, maximum 91 years). The examined patients came from families with varying degrees of caring capacity and, on these grounds, were assigned into subgroups. We used Mini-Mental State Examination, the Geriatric Depression Scale, and the Barthel Index. The greatest improvement in functional status after rehabilitation occurred in patients with a family characterized by a lack of caring capacity, and the smallest improvement was in the group of patients with full caring capacity. The greatest improvements in the performance of basic activities of daily living were reported in singles or people from families with a total lack of care.
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Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the two first-line treatments for depression, but little is known about their effects on quality of life (QOL). A meta-analysis was conducted to examine changes in QOL in adults with major depressive disorder who received CBT (24 studies examining 1969 patients) or SSRI treatment (13 studies examining 4286 patients) for their depression. Moderate improvements in QOL from pre to post-treatment were observed in both CBT (Hedges’ g = .63) and SSRI (Hedges’ g = .79) treatments. The effect size remained stable over the course of the follow-up period for CBT. No data were available to examine follow-ups in the SSRI group. QOL effect sizes decreased linearly with publication year, and greater improvements in depression were significantly associated with greater improvements in QOL for CBT, but not for SSRIs. CBT and SSRIs for depression were both associated with moderate improvements in QOL, but are possibly caused by different mechanisms.