Resilience defines a person’s capacity to successfully remain physically healthy, psychologically positive, and socially active when facing significant adversity or cumulative risks and stressors (Stewart and Yuen, Reference Stewart and Yuen2011). The concept of resilience has gained a great deal of interest in the last few decades, on account of being a dynamic construct, tightly connected to numerous other protective factors acting as buffers against emotional distress.
Early research conducted on resilience focused mainly on children and adolescents who were at risk of mental illness due to various external factors, such as absent or poor parenting or impoverished living conditions (Johnson and Wiechelt, Reference Johnson and Wiechelt2004). As the study of resilience broadened, research parameters expanded to include several other categories of individuals, including those with chronic illness (Cal etal., Reference Cal, Ribeiro de Sa, Glustak and Barreto Santiago2015), which also comprised stroke patients (Carod-Artal, Reference Carod-Artal2012). Regardless of the medical condition being investigated, resilience was found to have a general positive effect on the psychological functioning of affected individuals. Resilience was especially linked to higher levels of self-esteem, self-efficacy, internal locus of control, optimism, mastery, hardiness, hope, self-empowerment, acceptance of illness, and self-determination, all of which could be improved by using interventions based on social support, spirituality, and benefit-finding (Stewart and Yuen, Reference Stewart and Yuen2011; De Santis etal., Reference De Santis, Florom-Smith, Vermeesch, Barroso and DeLeon2013; Tan-Kristanto and Kiropoulos, Reference Tan-Kristanto and Kiropoulos2015). In the case of highly prevalent diseases with a significant public impact, such as cardiovascular diseases, diabetes mellitus, Parkinson’s disease, or multiple sclerosis, resilience has been demonstrated to significantly improve patients’ psychosocial adjustment to their illness (Stewart and Yuen, Reference Stewart and Yuen2011). Furthermore, cancer patients with higher levels of resilience reported significant resilience-related benefits in coping with their disease (Armando etal., Reference Armando, da Motta, Pinto, Matiello, Da Silva and Ferreira Filho2010), as well as more efficient use of their social support networks (Costa etal., Reference Costa, Heitkemper, Alencar, Damiani, Da Silva and Jarrett2016). In long-term survivors of chronic illness, interventions targeting resilience have been proven to successfully facilitate mental adaptation, reduce emotional and physical burden, and increase patients’ overall quality of life (QOL) during the treatment and rehabilitation process (Guccione, Reference Guccione2014). Still, when considering the efficacy of resilience in association with other variables, the current literature is inconclusive; several studies have identified resilience as being an independent, stand-alone predictor of QOL (Liu etal., Reference Liu, Zhou, Zhang and Zhou2019), while other studies have asserted that it is only a mediator between social support and QOL (Wu etal., Reference Wu2017).
In the case of patients affected by stroke, resilience is particularly challenged, as this disease typically generates a wide range of long-term consequences; common complaints include physical impairment, changes in patients’ daily activities, and social roles, as well as uncertainty about the future. This sudden undesired situation threatening patients’ lifestyle and having great potential to cause emotional imbalance may favor, along with other factors, the development of psychiatric diseases, such as anxiety and depression, in these individuals (Liu etal., Reference Liu, Zhou, Zhang and Zhou2019). However, the exact role of resilience in stroke remains a topic of debate, since few studies have been conducted on this subject and there is no widely accepted methodological approach available to researchers (Ungar, Reference Ungar2011). In this respect, knowing more about the distinct contribution of resilience toward helping stroke patients could be very useful for clinicians, especially since resilience may be addressed through psychotherapeutic intervention. Resilience could alleviate the impact of other negative predictors in stroke, which are more difficult or impossible to modify (age, gender or disease-related characteristics) (Liu etal., Reference Liu, Zhou, Zhang and Zhou2019). Moreover, it could represent a key variable to address when designing, adjusting or implementing better, more successful protocols of psychotherapeutic assistance for patients affected by stroke.
Previous studies have revealed several significant factors which could be used to predict low QOL in stroke patients. These include demographic factors (age, gender, marital status, and low educational level), severity of neurological deficit, specific physical conditions (e.g. dysphagia, chronic pain, and post-stroke sexual dysfunction), functional disability, and psychosocial factors (anxiety, depression, maladaptive coping styles, dysfunctional family, low social support, and perceived economic burden) (Carod-Artal, Reference Carod-Artal2012). Despite the previously mentioned indisputable benefits of resilience in chronic disease patients in general, its precise role in the context of these numerous factors negatively impacting QOL in stroke patients remains unclear.
So far, very few theoretical and empirical studies specifically focusing on providing in-depth insight about resilience in stroke patients (Ungar, Reference Ungar2011) or its relationship to QOL in these individuals have been conducted. This could be due to a plethora of reasons, including methodological reasons, as these patients are difficult to properly select and approach, or difficulty in obtaining reliable self-reports on QOL in stroke. One of the studies published on this topic, conducted by De Lima etal. (Reference De Lima2016), comprised an integrative literature review using the limited number of studies available; however, they encountered some difficulties in the selection process, as papers about resilience and stroke were very scarce. Nevertheless, they concluded that resilience is a primordial factor related to improved QOL and welfare, in the case of stroke patients. Similarly, a paper by Michael (Reference Michael2014) explained, from a theoretical perspective, the rationale for addressing resilience in the rehabilitation process of patients with stroke; the paper suggested that resilience is crucial in the process of developing patients’ ability to be independent, thus increasing their QOL. Michael (Reference Michael2014) also recommended additional empirical testing related to the efficacy of current specific interventions in stroke, in order to maximize the physical and psychological benefits of resilience in these patients. Sadler etal. (Reference Sadler, Sarre, Tinker, Bhalla and McKevitt2016) elaborated a mixed methods design study of a novel intervention promoting resilience after stroke, with the aim of improving patients’ mental health and QOL. They demonstrated that a range of resilience practices to promote adjustment after stroke can be targeted in a theoretically and empirically robust intervention; however, the assessment of the intervention’s feasibility was conducted on a small sample of participants. Numerous cross-sectional studies, performed on larger samples, also focused on the investigation of the relationship between resilience and QOL in stroke patients. Liu etal. (Reference Liu, Zhou, Zhang and Zhou2019) confirmed that resilience is an extremely important predictor of QOL in patients with early ischemic stroke, while Ajayi etal. (Reference Ajayi, Salawu and Ayodele2020) also provided evidence that resilience is a powerful predictor of stroke patients’ QOL. Up to this point, to our knowledge, no longitudinal research has been conducted pertaining to the direct impact of resilience on QOL in stroke patients.
In this context, the recent study authored by Liu etal. (Reference Liu, Zhou, Zhang and Zhou2020) can be considered an important contribution toward investigating the exact role of resilience in improving QOL in first-episode ischemic stroke patients.
At the conceptual level, the study provides interdisciplinary content, which is rarely encountered in the literature of this domain. The authors address the multi-layered determinism of QOL by investigating its association with several series of variables, pertaining to all QOL-relevant categories: demographic (gender, age, level of education, employment status, marital status, number of children), clinical (comorbidities, time interval from stroke onset to hospital admission, stroke severity, hospitalization days, and stroke recovery), psychological (resilience), and psychiatric (anxiety, depression). Through exposing and discussing the comparative importance of all these categories of variables, the study offers valuable information for the design and implementation of specific interventions aiming toward the functional recovery of stroke patients.
At the methodological level, the study has two major strengths which make it intrinsically valuable. Firstly, it has a longitudinal design, offering an overview of perceived QOL during hospitalization, as well as during the early and late recovery periods (1, 3, and 6 months after the stroke). This kind of assessment is important not only for highlighting the significance of cause–effect relationships between study variables but also of their dynamics. Secondly, the study design takes into account the specific clinical particularities of stroke patients which could prevent them from accurately responding to questions referring to rather complex constructs, such as resilience and QOL. From this point of view, ensuring the flexibility of study interviews played a major role in improving the percentage of responsiveness and in increasing the validity of the collected answers. This procedure also indirectly addressed the delicate ethical dilemmas stemming from the nature of this particular study sample.
The instruments used in the study were appropriate for fulfilling its aim and comprised largely used standardized questionnaires, displaying high validity and reliability (Stroke Scale Quality of Life, Hospital Anxiety and Depression Scale, Connor–Davidson Resilience Scale, the National Institutes of Health Stroke Scale, and modified Rankin Scale). The statistical analysis is comprehensive and adequate, with multilevel model analysis acting as a good measure of changes in resilience, QOL, neurological function, anxiety and depression, and as a viable procedure to identify QOL predictors. Post hoc analysis was run via paired t-tests.
The study results argue in favor of resilience representing a major contributor to predicting QOL in patients with first-ever ischemic stroke. Resilience ranked third, in terms of influence on QOL, after neurological function and depression; however, its impact on QOL remained stable over time, as opposed to the other two abovementioned predictors, whose impact had a tendency to decrease over time. Other factors contributing to increased QOL were milder stroke, longer hospitalization days, less anxiety, and less depression.
QOL scores were globally higher compared to other similar studies and tended to improve in a time frame of 6 months post-stroke. However, this trend did not apply to the emotional and personality dimensions of QOL. Considering that resilience has been conceptualized as including both cognitive and emotional components, this finding requires additional research, especially regarding the possible direct or indirect influence of resilience on emotional QOL, a correlation which has been previously reported in literature (Schwartz etal., Reference Schwartz, Michael and Rapkin2017). Future investigations could focus on confirming or disproving the hypothesis that, in stroke, similarly to other debilitating medical conditions (Koelmel etal., Reference Koelmel, Hughes, Alschuler and Ehde2016; Wang etal., Reference Wang, Zhao, Xie, Wang, Chen and Xia2019), resilience acts as a mediator for patients’ request and use of social support, as well as on gaining a better understanding of the relationship between social support and QOL.
The study has a number of limitations, many of which were self-reported by the authors of the paper. For example, patients with serious communication disorders, cognitive dysfunction or severe comorbidities, such as organ dysfunction and cancer, were excluded from the study to conserve methodological accuracy; however, these categories of patients could be relevant in terms of the association between QOL and resilience. Also, the follow-up period, limited to 6 months, may have not been sufficient to explore the entirety of post-stroke QOL dynamics and its predictors. The majority of the study participants were men; thus, a follow-up study with a more balanced gender ratio could be the next logical phase toward confirming these findings and possibly providing additional information.
Despite these limitations, the conclusions of the paper are interesting, and, as a whole, it could represent a significant step forward in elucidating the QOL predictors in stroke, with a clear emphasis on resilience. As this is a psychological characteristic that can be modified through psychotherapeutic intervention, there are numerous practical implications for increasing self-perceived QOL in stroke, both in the short and long run. In terms of screening for resilience, this information could be useful in the early identification of patients who are at risk for low QOL, allowing medical staff to address this issue, by providing them with the necessary tools to restore their adaptive skills, thus better preparing them to face adversity.
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Resilience defines a person’s capacity to successfully remain physically healthy, psychologically positive, and socially active when facing significant adversity or cumulative risks and stressors (Stewart and Yuen, Reference Stewart and Yuen2011). The concept of resilience has gained a great deal of interest in the last few decades, on account of being a dynamic construct, tightly connected to numerous other protective factors acting as buffers against emotional distress.
Early research conducted on resilience focused mainly on children and adolescents who were at risk of mental illness due to various external factors, such as absent or poor parenting or impoverished living conditions (Johnson and Wiechelt, Reference Johnson and Wiechelt2004). As the study of resilience broadened, research parameters expanded to include several other categories of individuals, including those with chronic illness (Cal etal., Reference Cal, Ribeiro de Sa, Glustak and Barreto Santiago2015), which also comprised stroke patients (Carod-Artal, Reference Carod-Artal2012). Regardless of the medical condition being investigated, resilience was found to have a general positive effect on the psychological functioning of affected individuals. Resilience was especially linked to higher levels of self-esteem, self-efficacy, internal locus of control, optimism, mastery, hardiness, hope, self-empowerment, acceptance of illness, and self-determination, all of which could be improved by using interventions based on social support, spirituality, and benefit-finding (Stewart and Yuen, Reference Stewart and Yuen2011; De Santis etal., Reference De Santis, Florom-Smith, Vermeesch, Barroso and DeLeon2013; Tan-Kristanto and Kiropoulos, Reference Tan-Kristanto and Kiropoulos2015). In the case of highly prevalent diseases with a significant public impact, such as cardiovascular diseases, diabetes mellitus, Parkinson’s disease, or multiple sclerosis, resilience has been demonstrated to significantly improve patients’ psychosocial adjustment to their illness (Stewart and Yuen, Reference Stewart and Yuen2011). Furthermore, cancer patients with higher levels of resilience reported significant resilience-related benefits in coping with their disease (Armando etal., Reference Armando, da Motta, Pinto, Matiello, Da Silva and Ferreira Filho2010), as well as more efficient use of their social support networks (Costa etal., Reference Costa, Heitkemper, Alencar, Damiani, Da Silva and Jarrett2016). In long-term survivors of chronic illness, interventions targeting resilience have been proven to successfully facilitate mental adaptation, reduce emotional and physical burden, and increase patients’ overall quality of life (QOL) during the treatment and rehabilitation process (Guccione, Reference Guccione2014). Still, when considering the efficacy of resilience in association with other variables, the current literature is inconclusive; several studies have identified resilience as being an independent, stand-alone predictor of QOL (Liu etal., Reference Liu, Zhou, Zhang and Zhou2019), while other studies have asserted that it is only a mediator between social support and QOL (Wu etal., Reference Wu2017).
In the case of patients affected by stroke, resilience is particularly challenged, as this disease typically generates a wide range of long-term consequences; common complaints include physical impairment, changes in patients’ daily activities, and social roles, as well as uncertainty about the future. This sudden undesired situation threatening patients’ lifestyle and having great potential to cause emotional imbalance may favor, along with other factors, the development of psychiatric diseases, such as anxiety and depression, in these individuals (Liu etal., Reference Liu, Zhou, Zhang and Zhou2019). However, the exact role of resilience in stroke remains a topic of debate, since few studies have been conducted on this subject and there is no widely accepted methodological approach available to researchers (Ungar, Reference Ungar2011). In this respect, knowing more about the distinct contribution of resilience toward helping stroke patients could be very useful for clinicians, especially since resilience may be addressed through psychotherapeutic intervention. Resilience could alleviate the impact of other negative predictors in stroke, which are more difficult or impossible to modify (age, gender or disease-related characteristics) (Liu etal., Reference Liu, Zhou, Zhang and Zhou2019). Moreover, it could represent a key variable to address when designing, adjusting or implementing better, more successful protocols of psychotherapeutic assistance for patients affected by stroke.
Previous studies have revealed several significant factors which could be used to predict low QOL in stroke patients. These include demographic factors (age, gender, marital status, and low educational level), severity of neurological deficit, specific physical conditions (e.g. dysphagia, chronic pain, and post-stroke sexual dysfunction), functional disability, and psychosocial factors (anxiety, depression, maladaptive coping styles, dysfunctional family, low social support, and perceived economic burden) (Carod-Artal, Reference Carod-Artal2012). Despite the previously mentioned indisputable benefits of resilience in chronic disease patients in general, its precise role in the context of these numerous factors negatively impacting QOL in stroke patients remains unclear.
So far, very few theoretical and empirical studies specifically focusing on providing in-depth insight about resilience in stroke patients (Ungar, Reference Ungar2011) or its relationship to QOL in these individuals have been conducted. This could be due to a plethora of reasons, including methodological reasons, as these patients are difficult to properly select and approach, or difficulty in obtaining reliable self-reports on QOL in stroke. One of the studies published on this topic, conducted by De Lima etal. (Reference De Lima2016), comprised an integrative literature review using the limited number of studies available; however, they encountered some difficulties in the selection process, as papers about resilience and stroke were very scarce. Nevertheless, they concluded that resilience is a primordial factor related to improved QOL and welfare, in the case of stroke patients. Similarly, a paper by Michael (Reference Michael2014) explained, from a theoretical perspective, the rationale for addressing resilience in the rehabilitation process of patients with stroke; the paper suggested that resilience is crucial in the process of developing patients’ ability to be independent, thus increasing their QOL. Michael (Reference Michael2014) also recommended additional empirical testing related to the efficacy of current specific interventions in stroke, in order to maximize the physical and psychological benefits of resilience in these patients. Sadler etal. (Reference Sadler, Sarre, Tinker, Bhalla and McKevitt2016) elaborated a mixed methods design study of a novel intervention promoting resilience after stroke, with the aim of improving patients’ mental health and QOL. They demonstrated that a range of resilience practices to promote adjustment after stroke can be targeted in a theoretically and empirically robust intervention; however, the assessment of the intervention’s feasibility was conducted on a small sample of participants. Numerous cross-sectional studies, performed on larger samples, also focused on the investigation of the relationship between resilience and QOL in stroke patients. Liu etal. (Reference Liu, Zhou, Zhang and Zhou2019) confirmed that resilience is an extremely important predictor of QOL in patients with early ischemic stroke, while Ajayi etal. (Reference Ajayi, Salawu and Ayodele2020) also provided evidence that resilience is a powerful predictor of stroke patients’ QOL. Up to this point, to our knowledge, no longitudinal research has been conducted pertaining to the direct impact of resilience on QOL in stroke patients.
In this context, the recent study authored by Liu etal. (Reference Liu, Zhou, Zhang and Zhou2020) can be considered an important contribution toward investigating the exact role of resilience in improving QOL in first-episode ischemic stroke patients.
At the conceptual level, the study provides interdisciplinary content, which is rarely encountered in the literature of this domain. The authors address the multi-layered determinism of QOL by investigating its association with several series of variables, pertaining to all QOL-relevant categories: demographic (gender, age, level of education, employment status, marital status, number of children), clinical (comorbidities, time interval from stroke onset to hospital admission, stroke severity, hospitalization days, and stroke recovery), psychological (resilience), and psychiatric (anxiety, depression). Through exposing and discussing the comparative importance of all these categories of variables, the study offers valuable information for the design and implementation of specific interventions aiming toward the functional recovery of stroke patients.
At the methodological level, the study has two major strengths which make it intrinsically valuable. Firstly, it has a longitudinal design, offering an overview of perceived QOL during hospitalization, as well as during the early and late recovery periods (1, 3, and 6 months after the stroke). This kind of assessment is important not only for highlighting the significance of cause–effect relationships between study variables but also of their dynamics. Secondly, the study design takes into account the specific clinical particularities of stroke patients which could prevent them from accurately responding to questions referring to rather complex constructs, such as resilience and QOL. From this point of view, ensuring the flexibility of study interviews played a major role in improving the percentage of responsiveness and in increasing the validity of the collected answers. This procedure also indirectly addressed the delicate ethical dilemmas stemming from the nature of this particular study sample.
The instruments used in the study were appropriate for fulfilling its aim and comprised largely used standardized questionnaires, displaying high validity and reliability (Stroke Scale Quality of Life, Hospital Anxiety and Depression Scale, Connor–Davidson Resilience Scale, the National Institutes of Health Stroke Scale, and modified Rankin Scale). The statistical analysis is comprehensive and adequate, with multilevel model analysis acting as a good measure of changes in resilience, QOL, neurological function, anxiety and depression, and as a viable procedure to identify QOL predictors. Post hoc analysis was run via paired t-tests.
The study results argue in favor of resilience representing a major contributor to predicting QOL in patients with first-ever ischemic stroke. Resilience ranked third, in terms of influence on QOL, after neurological function and depression; however, its impact on QOL remained stable over time, as opposed to the other two abovementioned predictors, whose impact had a tendency to decrease over time. Other factors contributing to increased QOL were milder stroke, longer hospitalization days, less anxiety, and less depression.
QOL scores were globally higher compared to other similar studies and tended to improve in a time frame of 6 months post-stroke. However, this trend did not apply to the emotional and personality dimensions of QOL. Considering that resilience has been conceptualized as including both cognitive and emotional components, this finding requires additional research, especially regarding the possible direct or indirect influence of resilience on emotional QOL, a correlation which has been previously reported in literature (Schwartz etal., Reference Schwartz, Michael and Rapkin2017). Future investigations could focus on confirming or disproving the hypothesis that, in stroke, similarly to other debilitating medical conditions (Koelmel etal., Reference Koelmel, Hughes, Alschuler and Ehde2016; Wang etal., Reference Wang, Zhao, Xie, Wang, Chen and Xia2019), resilience acts as a mediator for patients’ request and use of social support, as well as on gaining a better understanding of the relationship between social support and QOL.
The study has a number of limitations, many of which were self-reported by the authors of the paper. For example, patients with serious communication disorders, cognitive dysfunction or severe comorbidities, such as organ dysfunction and cancer, were excluded from the study to conserve methodological accuracy; however, these categories of patients could be relevant in terms of the association between QOL and resilience. Also, the follow-up period, limited to 6 months, may have not been sufficient to explore the entirety of post-stroke QOL dynamics and its predictors. The majority of the study participants were men; thus, a follow-up study with a more balanced gender ratio could be the next logical phase toward confirming these findings and possibly providing additional information.
Despite these limitations, the conclusions of the paper are interesting, and, as a whole, it could represent a significant step forward in elucidating the QOL predictors in stroke, with a clear emphasis on resilience. As this is a psychological characteristic that can be modified through psychotherapeutic intervention, there are numerous practical implications for increasing self-perceived QOL in stroke, both in the short and long run. In terms of screening for resilience, this information could be useful in the early identification of patients who are at risk for low QOL, allowing medical staff to address this issue, by providing them with the necessary tools to restore their adaptive skills, thus better preparing them to face adversity.