Aim: The present study used two-step analyses to examine the effect of acceptance of disability or ‘insistence on recovery’ in Japanese stroke patients: first on their functional improvement and second, on their psychological symptoms.
Methods: Disability was assessed using functional independence measurements (FIM), examining the stage of acceptance of disability by observation using Fink's theory (from shock to defensive retreat, acknowledgement, and acceptance/change stage), and estimation of insistence on recovery (on a scale of 1–4) by observation. The differences over time and the effects on the improvement in their FIM were then assessed. Depression was measured using the Zung Self-rating Depression Scale (SDS); apathy was measured using the Apathy Scale (AS), and the correlation with the acceptance stage or insistence on recovery was analyzed.
Results: The acceptance stage and functional improvement progressed significantly, but insistence on recovery did not change significantly during hospitalization. Multiple regression indicated that the insistence on recovery score (but not the acceptance stage) was a good predictor of the degree of improvement in FIM (FIM gain per week) in the elderly group. Post-hoc testing showed that the SDS or AS score decreased from the first stage to the fourth stage (but increased at the third stage) of acceptance; whereas for insistence on recovery score, the SDS and AS scores decreased as insistence on recovery score changed from 1 to 3, and then increased as insistence on recovery score changed from 3 to 4.
Conclusions: The appropriate level of insistence on recovery reduced depression and apathy, resulting in enhanced improvement of disability after a stroke in elderly stroke patients.
STROKE HAS BEEN described as a condition with a unique epidemiological profile, with high incidence and mortality rates, and in which a large proportion of survivors have significant but varying degrees of residual disability.1,2 There are two types of improvement that occur after a stroke: neurological improvement and improvement in functional abilities or performance.1 Neurological recovery depends upon the mechanism of the stroke and the location of the lesion. By contrast, the improvement of functional abilities, such as activities of daily living (ADL), depends upon the environment in which the stroke patient is placed and how much training and motivation there is for the patient to learn to become independent again in terms of self-care and mobility. The ability to perform ADL can improve through acceptance and training in the presence or absence of natural neurological recovery.1–4 Stroke rehabilitation must therefore restore optimal physical, psychological, social, and vocational function to enable the patient to become a productive participant in the community.
Emotional responses to stroke have traditionally been thought to follow a natural course of evolution: an initial state of significant distress or depression that, over time and as a result of some active process of ‘working through’, resolves to a condition of acceptance and relative emotional harmony.5,6 This process was thought to be a mourning process or acceptance of disability. Disabled stroke patients who refuse to accept their impairment, eventually realize they are sick but continue to think that they will soon get well.5,6 They manifested this attitude through direct verbal report or inferred from behavior continuously and repeatedly (this attitude was similar to whining, and we termed this emotional status as ‘insistence on recovery’). Insistence on recovery is thought to be a sign of denial and thus is regarded as an irrational belief. Denial is generally found in psychiatric illness, but it is also found in the mourning process among disabled stroke patients.6 It was traditionally thought that patients with insistence on recovery, whose only goal is recovery, can be motivated to do any work perceived as aiding recovery; but are not motivated to learn to function as a disabled person, and so fail to gain the maximum benefit from rehabilitation services.5–8 Thus insistence on recovery is considered a maladaptive status and is thought to be a target for psychotherapeutic intervention.5–8 We have, however, experienced many stroke disabled patients who say repeatedly that they will recover someday, and who participate in rehabilitation and gain independence in ADL in the rehabilitation service. The question arises whether insistence on recovery is an irrational or rational belief. Although there is much popular and professional literature attesting to the veracity of stages of acceptance of disability, the empirical data do not support such a contention.5 Moreover, insistence on recovery is regarded as counterproductive to maximizing functional abilities and enhancing quality of life,5–8 and no previous paper has examined the nature of ‘insistence on recovery’.
The aim of the present study was to evaluate the effect of the stage of acceptance of disability or insistence on recovery on functional independence in stroke patients. Aging is associated with a high incidence of physical impairment, functional disability and depression.9,10 Therefore, we divided stroke inpatients into two age groups: middle-aged and elderly. Moreover, depression and apathy are common neuropsychiatric consequences of a stroke, and can be examined using self-reported tests: the Zung Self-rating Depression Scale (SDS) and the Apathy Scale (AS). To clarify the psychopathological aspects of insistence on recovery after a stroke, we also examined the correlation between insistence on recovery score and the SDS or AS score.
This study consisted of two parts: first, the changes in ‘acceptance of disability’ and ‘insistence on recovery’ over time were estimated, and we examined the effect of these factors on functional recovery after a stroke. Second, we examined the psychopathological symptoms (depression and apathy) using self-reporting scales, and estimated the association between depression and ‘acceptance of disability’ or ‘insistence on recovery’ after a stroke.
The approval of institutional ethics committees was obtained for this prospective study. Informed consent for functional or psychological measurements, including acceptance of disability, was obtained on admission from all patients or from those authorized to give consent on their behalf. The subjects for the first study were 231 patients with hemorrhagic and occlusive stroke without subarachnoid hemorrhage, diagnosed on computed tomography (CT) and/or magnetic resonance imaging (MRI), who were admitted to the Nishi-Hiroshima Rehabilitation Hospital <3 months after suffering a stroke (range, 10–109 days; mean, 44 ± 21 days), and who were hospitalized for more than 1 month. The patients were divided into two age groups at admission: the middle-aged group (95 patients, age 40–65 years); and the elderly group (136 patients, aged ≥66 years).
For the second study the subjects, who completed the SDS and AS scales, included 237 patients after excluding patients with (i) a history of major psychiatric illness, such as major depression, bipolar disorder, schizophrenia, or schizoaffective disorder; (ii) subarachnoid hemorrhage; (iii) emergency discharge because of medical illness; or (iv) medications, medical illness, physical disability, or cognitive dysfunction (Mini-Mental State Examination score <15) affecting their ability to perform the self-reporting test or to provide consent.
Data were gathered from a subset of the subjects of a previous study, which was a research project on depression and lesion location, or depression/apathy and functional outcome, or sitting balance among stroke rehabilitation patients.11–13 Patients were not selected on the basis of the results of the previous study.
The unit at Nishi-Hiroshima Rehabilitation Hospital provides intensive multidisciplinary goal-oriented inpatient rehabilitation. Every 1 or 2 weeks, the staff, including medical doctors, nurses, care workers (CW), physical therapists (PT), occupational therapists (OT), speech therapists (ST), medical social counselors (MSW) and clinical psychologist (CP), assemble in the conference room and make arrangements regarding the physical, psychological, or social problems of each inpatient, and review the patient rehabilitation programs.
CT scanning was carried out for all patients on admission; a follow-up CT scan was performed every 1–3 months after admission to measure the infarction/hemorrhage site and volume (cubic centimeters) according to the formula 0.5 × A × B × C, where A and B represent the largest perpendicular diameters through the hypodense area on the CT scan, and C is the thickness of the infarction area.11–13
The Functional Independence Measurement (FIM; version 3.0) is an observer-rated multi-item summed rating scale used to evaluate disability in terms of dependency, and is widely used as a measure of disability in stroke patients.12–15 The maximum total FIM score is 126; the lower the score, the greater the disability. All patients were examined for disability using the FIM (Japanese version) within 1 week after admission and at 1–2-week intervals during hospitalization.
The improvement in FIM score per week during hospitalization was calculated as follows: [(FIM score on discharge) − (FIM score on admission)]/[period of hospitalization (weeks)].
Motor impairment in hemiplegic stroke patients was measured by the stage on the Brunnstrom Recovery Scale (BRS), in which movement patterns are evaluated and motor function is rated according to stages of motor recovery.12,13,16 The BRS scale defines recovery only in broad categories; these categories correlate with progressive functional recovery.
Psychological assessments: process of acceptance of disability and insistence on recovery
Inpatient psychological status (acceptance stage and insistence on recovery) was assessed by observation of the behavior of patients under the guidance of clinical psychologists. Information relating to patients' psychological complaints varies among staff members, because the patient usually does not convey his or her real feelings equally to all staff. The acceptance stage and insistence on recovery were therefore estimated on the basis of statements by every doctor, nurse, CW, PT, OT, ST, MSW and CP.
The stage of acceptance of disability in each inpatient was estimated using Fink's theory of the acceptance process (first stage, shock; second stage, defensive retreat; third stage, acknowledgement; fourth stage, acceptance and change) as described previously.7 In scoring the acceptance stage, a value of 1–4 was assigned to an observation as follows: shock, 1; defensive retreat, 2; acknowledgement, 3; acceptance and change, 4.
‘Insistence on recovery’ was defined as the patient's direct verbal report or, as inferred from their behavior, that they thought that they would soon get well.8 The assumption of a normal body is implicit in any discussion of future plans. The person is preoccupied with their physical condition and is apt to overestimate the meaning of any small improvement. They say, ‘I know it's taken a long time, but I still haven't given up hope. ‘Insistence on recovery’ was estimated by observation of patient behavior in quantitative terms: the ‘insistence on recovery’ score was constructed on a scale on which complaints that are noted a little of the time, some of the time, much of the time, or most of the time, were scored 1, 2, 3, and 4, respectively.
Self-rating Depression Scale
We used the Japanese version of the SDS to examine the subjective severity of depression.11–13,17 Patients completed the SDS within 1 month after admission. We classified the patients into two groups according to their score: a non-depressed group (SDS score <45 points) and a depressed group (SDS score ≥45 points). The cut-off point was determined on the basis of a previous report on Japanese stroke patients.17
To quantify the apathetic state, we used a Japanese version of the AS.11–13,18–20 Patients completed the AS within 1 month after admission. The AS consists of 14 questions concerning spontaneity, initiation, emotionality, activity level, and interest in hobbies. This scale was self-assessed. The answers to each question were scored as 0–3 and the total score was used for the analysis. We classified the patients into two groups according to their score: a non-apathetic group (AS < 16 points) and an apathetic group (AS ≥ 16 points).
Statistical analyses were based on the assumption that the data were not normally distributed, analysis being performed with non-parametric tests to examine the correlation between the middle-aged and elderly groups; Fisher's exact tests were used to compare categorical variables and the Mann-Whitney U test was used to compare continuous variables.
Differences in the time course of acceptance of disability or FIM score were assessed using Kruskal–Wallis one-way analysis of variance (ANOVA) at admission, 3 months, and 5 months. Post-hoc testing was performed using the Scheffé test.
Multiple regression was used to estimate the independent effects of predictor variables (highest attained acceptance stage, ‘insistence on recovery’ score, age, sex, presence of a history of stroke, BRS, FIM score on admission, period of hospitalization) on improvement in FIM (FIM gain/week).
Different degrees of the acceptance stage or insistence on recovery stage were compared with the SDS or AS score using one-way ANOVA followed by a post-hoc Fisher protected least significant difference test.
Values were considered to be significant at P < 0.05. Stat View 5.0 (SAS Institute, Cary, NC, USA) was used for all analyses.
Baseline patient data
Table 1 lists the baseline data for all patients in the two age groups (middle-aged or elderly). There were no differences in the presence of stroke history, laterality of the stroke, size of CT findings, FIM gain/week, acceptance stage, or insistence on recovery score at admission between the two age groups at baseline. The two age groups were not matched for sex, type of stroke, FIM score, or insistence on recovery score at discharge. The FIM score, insistence on recovery score at discharge, male gender and rate of hemorrhage were much higher in the middle-aged group than in the elderly group.
Table 1. Baseline data for stroke inpatients
Total (n = 231)
Middle-aged (n = 95)
Elderly (n = 136)
Fisher's exact test was used to compare categorical variables; the Mann–Whitney U-test was used to compare continuous variables, and to test correlation between the middle-aged and elderly groups.
FIM, Functional Independence Measurement.
66.3 ± 10.2
56.2 ± 6.1
73.4 ± 5.4
Type of stroke: hemorrhage/infarction
Presence of history of stroke, n (%)
Period of hospitalization, days
152.5 ± 51.2
146.8 ± 60.4
160.4 ± 49.7
Side of stroke: right/left/bilateral
Size of CT finding (cm3)
37.9 ± 55.6
38.2 ± 59.0
37.6 ± 53.4
FIM score on admission
64.1 ± 25.0
69.7 ± 25.1
61.1 ± 24.5
FIM score on discharge
84.5 ± 25.5
90.9 ± 22.5
81.1 ± 26.4
0.86 ± 0.56
0.87 ± 0.56
0.84 ± 0.56
Stage of acceptance at admission
1.9 ± 1.0
1.9 ± 1.0
1.8 ± 1.1
Stage of acceptance at discharge
3.0 ± 1.1
3.1 ± 1.1
3.0 ± 1.2
Insistence on recovery score at admission
2.0 ± 0.9
2.2 ± 1.0
1.9 ± 0.9
Insistence on recovery score at discharge
2.1 ± 0.9
2.3 ± 0.9
2.0 ± 0.8
Time course of the acceptance stage, insistence on recovery score and FIM score
Changes in the FIM score, acceptance stage, and insistence on recovery score over time are given in Table 2. In both age groups the acceptance stage progressed and the FIM score increased significantly each month (P < 0.0001, Kruskal–Wallis test). Post-hoc testing (Scheffé) indicated a difference between the acceptance stage at admission and at 3 or 5 months. But we found no significant differences between acceptance stage or FIM score at 3 months or at 5 months (Scheffé). We found no differences in the insistence on recovery score on admission, at 3 months or at 5 months (Kruskal–Wallis test and Scheffé test). Therefore, progression of acceptance stage and functional improvement were evident, especially during the first 3 months after admission, but the insistence on recovery score did not change during hospitalization in either age group.
Table 2. Time course of FIM, stage of acceptance and insistence on recovery score during 5 months after admission
Admission (n = 95)
3 months (n = 76)
5 months (n = 52)
Admission (n = 136)
3 months (n = 118)
5 months (n = 95)
Differences in time course (e.g. at admission, 3 months and 5 months) of acceptance of disability, FIM score, or insistence on recovery were assessed using Kruskal–Wallis one-way ANOVA. Post-hoc tests were done using the Scheffé test.
FIM, functional independence measurement; ND, not determined.
78.2 ± 25.9
86.4 ± 23.0
89.5 ± 20.5
P < 0.0001
65.0 ± 26.4
76.0 ± 27.1
78.2 ± 24.6
P < 0.0001
Admission vs 3 months
P = 0.0007
P = 0.0002
Admission vs 5 months
P < 0.0001
P < 0.0001
3 months vs 5 months
P = 0.1667
P = 0.4095
Acceptance of disability
1 Shock, n (%)
P < 0.0001
P < 0.0001
2 Defensive retreat, n (%)
3 Acknowledgment, n (%)
4 Acceptance and change, n (%)
ND, n (%)
Admission vs 3 months
P < 0.0001
P < 0.0001
Admission vs 5 months
P < 0.0001
P < 0.0001
3 months vs 5 months
P = 0.0690
P = 0.0905
Insistence on recovery'
1, n (%)
P = 0.5259
P = 0.7386
2, n (%)
3, n (%)
4, n (%)
ND, n (%)
Admission vs 3 months
P = 0.6334
P = 0.9393
Admission vs 5 months
P = 0.5732
P = 0.7451
3 months vs 5 months
P = 0.9939
P = 0.9098
Effects of acceptance stage or insistence on recovery score on improvement in FIM after a stroke
To identify predictors of improvement in FIM after a stroke, we performed multiple regression using sex, age, presence of history of stroke, period of hospitalization, FIM at admission, BRS (upper limb, finger, lower limb), acceptance stage and insistence on recovery score as independent variables, with improvement in FIM as the dependent variable (Table 3). In the middle-aged group, no predictors were found. In the elderly group, however, the FIM score on admission, the period of hospitalization, and the insistence on recovery score were correlated significantly with FIM gain/week. It was noteworthy that the insistence on recovery score (but not the acceptance stage) correlated positively with improvement in FIM in the elderly group.
Effects of acceptance stage or insistence on recovery score on depression or apathy after a stroke
To examine the effects of the acceptance stage on depression or apathy, we used ANOVA and post-hoc test (Fig. 1). The SDS score (Fig. 1a) and AS score (Fig. 1c) changed significantly from ‘shock (first) stage’ to ‘acceptance and change (fourth) stage’. Post-hoc testing indicated a difference between first and fourth, second and third, and third and fourth stages for the SDS score and between first and fourth, and third and fourth stages for the AS score. Both SDS and AS scores were highest in the third stage but significantly decreased in the fourth stage.
The SDS score (Fig. 1b) and AS score (Fig. 1d) changed significantly as insistence on recovery score changed from 1 to 4. On post-hoc testing there were significant differences between insistence on recovery scores 1 and 3, and insistence on recovery score 3 and 4 for the SDS score, and significant differences between insistence on recovery scores 1 and 2, and insistence on recovery scores 1 and 3 on the AS score. It is noteworthy that both the SDS and AS scores decreased as insistence on recovery score increased from 1 to 3, and then increased for insistence on recovery scores 3–4.
The present results demonstrate that many stroke patients improved in functional disability, proportional to progress in stage of acceptance of disability in the rehabilitation hospital. It is surprising that the presence of insistence on recovery enhanced functional improvement. To our knowledge this is the first stroke study to address the influence of insistence on recovery on functional improvement after a stroke.
Stage of acceptance of disability correlated with FIM improvement
The stage theory of acceptance of disability states that people undergoing a life crisis follow a predictable, orderly path of emotional response. In the present study we examined the effect of acceptance on functional improvement in Japanese stroke patients. The present data demonstrated that acceptance stage progress and FIM scores increased significantly each month, particularly in the first 3 months after hospital admission (Table 2). At the onset of physical disability after a stroke, the individual cannot tolerate the overwhelming chaos accompanying the shock.7,8 In this shock phase, the person feels emotionally numb and experiences a sense of depersonalization. Physical recovery from the acute phase is interpreted as a sign that everything is returning to its former state.7,8 At that time, the acceptance stage progresses from the shock phase to defensive retreat. When the disabled patient gradually begins to experience a physical plateau, the acknowledgement phase occurs.7,8,21,22 The patient no longer finds it possible to escape reality and experiences the loss of their valued self-image. The feeling-state, which accompanies these changes, is one of deep depression as in mourning. Therefore, patients in this acknowledgement stage suffered higher levels of depression and apathy than those in the other acceptance stages (Fig. 1). The patient who has accepted their permanent physical impairment considers the disability to be merely one of their many characteristics.7,8,21,22 Therefore, it was suggested that many stroke patients functionally improved in parallel with progression of the acceptance stage.
Appropriate level of insistence on recovery reduced depression and apathy, resulting in an improvement in the FIM
According to the stage theory of acceptance, insistence on recovery is a sign of denial, and an indicator of poor prognosis in rehabilitation.5–8 But the present data contradicted this; the appropriate level of insistence on recovery reduced depression and apathy, resulting in an improvement in the FIM. The question arises as to the nature of insistence on recovery in the present study.
Changes in physical functioning or appearance must be incorporated into a revised self-image, which can necessitate a change in personal values and lifestyle.23–25 The individual must then prepare for an uncertain future with the threat of permanent physical disabilities, which results in a deep depression, similar to mourning. To cope with this identity crisis, individuals must maintain hope that restoration of function is possible.24 Even when the prognosis is certain, the future is still uncertain; patients think about their physical disability and hope for improvement every day (the so-called ‘insistence on recovery’ in the present study). The disabled stroke patients experience these positive (restoration of function, maintain hope) and negative (disability would continue permanently) feelings toward their disability in turn. The coexistence of both positive and negative feelings is commonly understood as ambivalence,26 and representation of insistence on recovery was thought to be a sign of post-stroke ambivalent state during the mourning process. In the traditional view, ambivalence has been seen as particularly important to the development of complicated grief, but Piper et al reported the opposite result: the more ambivalent the behavior of the patient, the less severe was the grief.26 Defining of their disability is a painful process for the stroke patient. But insistence on recovery (ambivalence) may minimize the seriousness of the crisis (permanent physical disability, identity crisis) and reduce the pain during the process of defining the disability. Therefore, many stroke patients can confront this painful mourning process (defining their disability) gradually, in order to keep the depressive or apathetic symptoms to a minimum, easing the pain with the help of a more optimistic idea (‘insistence on recovery’ or ambivalent feeling). Thus insistence on recovery may be considered as part of the fighting spirit in which patients seek to conquer disease (such as cancer) based on hope, and indicates a good prognosis.27–29 Judging from these observations it is possible that insistence on recovery in the present study may be a favorable prognostic factor for disabled stroke patients.
Severe level of ‘insistence on recovery’ associated with both depression and apathy
Disabled stroke patients with a severe level of insistence on recovery form only a minority of stroke patients, but they suffered severe depression and apathy according to the present data. Insistence on recovery is thought to be a sign of denial. Denial is generally found in cognitive psychological research of psychopathology, and sometimes denial is found in non-psychological patients. Mildly depressed individuals are more balanced in self-perceptions and evince more accurate predictions of control and future outcomes.6 More severe depression often yields negative appraisal tendencies.6 The patients with severe insistence on recovery are thought to be in a severe denial state and therefore simply wait for recovery, and often state that they do not understand the purpose of rehabilitation exercises, resulting in poor participation in rehabilitation therapy.30–32
In a rehabilitation unit many staff feel that these patients are troublesome. Although patients with severe levels of insistence on recovery are only in a minority, their characteristics are conspicuous, and all staff tend to think empirically that the existence of insistence on recovery prevents an improvement in functional disability, irrespective of the degree of severity. This staff tendency was thought to be a countertransference reaction, which generates more negative interactions with patients, leading to worse outcome.33 In practice the majority of patients have an appropriately low level of insistence on recovery, which helps disabled patients to confront the painful acceptance process (reduce depression and apathy). But encouraging the patients to give up insistence on recovery regardless of the possible low level of severity, might also reduce the protection that stroke patients have from depression or apathy, resulting in preventing stroke patients from improving their functioning.
Disparity in functional and psychological states between middle-aged and elderly patients
In the present study, insistence on recovery enhanced functional improvement after a stroke: this trend was statistically significant in the elderly group, but not in the middle-aged group. A question arises regarding the difference between the middle-aged and elderly groups. Once an individual reaches old age, the body starts to lose its autonomy.9,10 As independence and control are challenged, self-esteem and confidence weaken. Most elderly people seem to find themselves, almost involuntarily, thinking about dying and about feeling ill, depressed, and somehow let down.10,34,35 To some extent, these thoughts reflect a desperation that confronts all older people. But most people struggle to counterbalance these associations with thoughts of more optimistic, life-affirming involvement.34,35 These observations suggest that elderly stroke patients hope for recovery from their physical disability, and try to counterbalance desperation with thoughts of more optimistic, life-affirming involvement. Therefore insistence on recovery may encourage elderly stroke patients to participate in a rehabilitation program and gain functional improvement during hospitalization.
The present findings do not suggest that insistence on recovery causes depression and apathy; rather they indicate that insistence on recovery is frequently associated with depression and apathy, and likely interacts with the recovery process. The present findings should be seen in the light of certain methodological limitations. First, the sample size was small and the number of patients with a severe level of insistence on recovery was limited. Therefore the results require replication with a larger sample. Second, no structured personality scale was used; hence personality data might have been influenced by recall bias. Third, there is a possibility that social factors, such as employment and economic problems, might be more strongly influenced than psychological problems in the present study, and thus insistence on recovery might not influence ADL improvement in the middle-aged group. Fourth, the present results refer to national characteristics of Japanese people, and thus are not typical of other countries. Fifth, the psychological measurements in the present report were carried out only within 6–9 months after the onset of stroke, but the process of acceptance or mourning against disability is thought to continue for many years after the onset of stroke. Therefore, further longitudinal study is required to clarify the long-term effect of acceptance or insistence on recovery on the improvement of ADL and social function after the onset of stroke.
Progression of acceptance stages kept pace with improvement in functional disability after a stroke during rehabilitation. A mild level of insistence on recovery is a kind of fighting spirit, a rational belief, which minimizes the seriousness of the integrity of self-image, and accelerates functional improvement. A severe (not mild) level of insistence on recovery, however, is an irrational belief, and leads patients to develop a more severe depressive state. Insistence on recovery was previously believed to be a negative indicator for functional improvement of disabled stroke patients, but the present data contradict this, especially among elderly patients. Thus, the clinician should be aware of the severity of the patient's insistence on recovery in order to facilitate improvement of ADL especially among elderly stroke patients. When caring for patients, especially elderly patients, we should inform them of their prognosis in such a way such that they do not give up hope.
This study was supported in part by the Research on Psychiatric and Neurological Disease and Mental Health, Ministry of Health, Labour and Welfare, Japan.