关键词: 康复；疾病管理；脑卒中；慢性疾病轨迹；干预性研究

Abstract: Objective: To evaluate the effects of a rehabilitation management program based on chronic disease trajectory patterns in stroke patients. Methods: Stroke patients who were hospitalized at a rehabilitation hospital in Shanghai from September 1, 2022 to October 31, 2023 were randomly divided into the control group (63 cases) and the observational group (65 cases) using a random number table method. Patients in the control group and observational groups were respectively assigned to two wards in the south and north buildings of the hospital. Patients in the control group received routine care, including routine rehabilitation training in the neurology rehabilitation department, health education, disease observation, and telephone follow-up after discharge. On the basis of routine care, patients in the observational group received the rehabilitation management program based on chronic disease trajectory patterns, including establishing a rehabilitation management team, developing rehabilitation management plans based on the psychological characteristics and rehabilitation and care needs of patients at different stages of the chronic disease trajectory, and conducting a three-month rehabilitation management through evaluation, goal setting, planning, implementation, evaluation, and other procedures. The changes in hope level, daily life activity ability, and social participation of the two groups of patients were compared before intervention, 1 month after the intervention, and 3 months after the intervention between the two groups. Results: The Herth Hope Scale scores of the two groups at three time points were 21.87±4.03, 30.60±6.01, 41.30±4.66 in the observational group, and 22.68±3.75, 26.30±5.17, 36.12±4.94 in the control group. The difference between the two groups was statistically significant (Ftime=389.492, P<0.001; Fbetween groups=27.312, P<0.001; Finteraction=14.059, P<0.001). The daily living activity scores of two groups of patients at three time points were 34.02±11.13, 43.17±12.76, 62.68±13.09 in the observational group, and 35.06±11.74, 39.03±13.48, 55.14±13.28 in the control group. The difference between the two groups was statistically significant (Ftime=203.751, P<0.001; Fbetween groups=5.802, P=0.019; Finteraction=6.704, P=0.002). The autonomous participation questionnaire scores of two groups of patients at three time points were 69.57±12.75, 59.51±13.10, 43.10±10.82 in the observational group, and 67.73±14.05, 64.35±11.35, 50.03±11.07 in the control group. The difference between the two groups was statistically significant (Ftime=340.061, P<0.001; Fbetween groups=19.525, P<0.001; Finteraction=7.984, P=0.001). Conclusion: The rehabilitation management program based on chronic disease trajectory patterns can increase the hope of stroke patients for treatment and life, as well as improve their daily life activities and thus increase social participation.

Key words: rehabilitation; disease management; stroke; chronic disease trajectory; interventional research