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HPQ0010.1177/1359105315595117Journal of Health PsychologyLo Buono et al.

Review Article

Journal of Health Psychology

Coping strategies and


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© The Author(s) 2015
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DOI: 10.1177/1359105315595117
life after stroke hpq.sagepub.com

Viviana Lo Buono1, Francesco Corallo1,


Placido Bramanti1 and Silvia Marino1,2

Abstract
Cerebral stroke causes a significant worsening of health-related quality of life. This review was conducted
on studies investigating whether the levels of quality of life were influenced by the coping strategies used
by stroke patients. We searched on PubMed and Web of Science databases and screening references of
included studies and review articles for additional citations. From initial 389 publications, we included only
6 studies that met search criteria and described the association between coping and quality of life. Results
showed that patients who prefer accommodative or active coping strategies had a better quality of life after
stroke when compared with patients who adopted assimilative coping.

Keywords
coping, disability, quality of life, stroke

Introduction
Stroke is the third leading cause of death in the impairment of physical, psychological, and
Western countries. The rate of stroke occur- social function, compromising the capacity to
rence is estimated around 75 percent in patients carry out activities of daily living (McGrath
aged 65 years (Truelsen et al., 2000). Stroke et al., 2009; Martin et al., 2002). Physical limi-
patients have high risk of death during the first tations include deficit of movement, sensory
weeks after the event, and between 20 and disturbance, vision, swallowing, and communi-
50 percent die within the first month depending cative disorders (Perry and McLaren, 2003).
on type and severity, age, comorbidity, and Psychological problems include depression and
severity of complications (Truelsen et al.,
2003). The pathological background for stroke
1IRCCS Centro Neurolesi “Bonino Pulejo,” Italy
may be due to either ischemic or hemorrhagic 2Department of Biomedical Sciences and Morphological
disturbances of the cerebral blood circulation and Functional Imaging, University of Messina, Italy
(Truelsen et al., 2000), with consequences that
cause changes in people’s life, for both the Corresponding author:
Viviana Lo Buono, IRCCS Centro Neurolesi “Bonino
long-term disability and the emotional aspects Pulejo,” S.S. 113 Via Palermo, C/da Casazza, 98124
(World Health Organization, 2006). A stroke Messina, Italy.
event can leave an individual with residual Email: viv.lobuono@gmail.com

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2 Journal of Health Psychology 

anxiety, in some cases post-traumatic stress dis- direct to the source of stress; (d) avoidant cop-
order, which negatively affects the social func- ing, which represents an escape of emotional
tion and post-stroke recovery (Sinyor et al., and cognitive events; (e) accommodative
1986). Other categories of social consequences coping, which is direct to a change in the per-
of stroke included negative impact on family sonal goal standards in accordance with per-
relationships as divorce or separation and the ceived deficits; and (f) assimilative coping,
inability to maintain one’s own social role which involves active attempts to alter unsatis-
(Thompson and Ryan, 2009). Physical, social, factory life circumstances and situational con-
and cognitive impairment following a stroke straints in accordance with personal preferences
may constitute a serious problem to the quality (Aspinwall and Taylor, 1992; Brandtstädter and
of life (QoL). About 25 percent of patients, Renner, 1990; Donnellan et al., 2006; Lazarus
indeed, reported a decrease in QoL in the first and Folkman, 1987; Suls and Flechter, 1985).
3 months after stroke associated with a decrease The predominance of one type of strategy is
in the general state of health and a reduction of determined by personal style and cognitive
vitality (Kauhanen, 2000; Leach et al., 2011). appraisal of the stressful event (Ferguson,
The concept of QoL is related to the person’s 2001). Coping strategies are determinant on the
physical health, psychological state, level of HRQoL after stroke since they affect both
independence, social relationship, person recovery and adaptation to disability, even if the
beliefs, and relationship with the environment research on QoL and coping is still lacking.
(World Health Organization, 1997). Health- Only in recent years, the studies on stroke are
related quality of life (HRQoL) evaluates how beginning to focus attention on psychological
the individual’s well-being might get affected outcomes such as QoL and subjective well-
over time by disease, disability, or disorder being in survival, in addition to functional out-
(Centers for Disease Control and Prevention, comes. This descriptive review focused on the
2000). HRQoL is, therefore, the study of QoL studies that investigated which coping strate-
related to health disease that is defined by com- gies were adopted by patients after stroke and
plicated subjective indicators, related to the per- how these influenced their QoL.
ceived well-being. An important psychosocial
factor that influences QoL after stroke is coping
style, used by individuals to deal with disease Methods
state. Coping strategies are cognitive and
behavioral modalities employed to manage the
Search strategy
negative impact of stressful situations (Lazarus A descriptive review was conducted on the meas-
and Folkman, 1984). Depending on the success ures of coping and QoL used by the stroke
or failure of this process, coping may be defined patients. Studies were identified by searching on
as functional (adaptation) or dysfunctional PubMed (1982, year of the first-related published
(increased stress). Coping is a dynamic process, article–July 2014) and Web of Science databases
constituted by a series of reciprocal responses, (1988–August 2014). The search combined the
through which individual and environment following terms: “stroke AND coping AND
influence each other reciprocally. There are quality of life” (“stroke”[MeSH Terms] OR
different definitions of coping strategies in the “stroke”[All Fields]) AND (“adaptation, psycho-
literature. Several coping styles can be distin- logical” [MeSH Terms] OR (“adaptation”
guished such as (a) emotional-focused coping, [All Fields] AND “psychological”[All Fields])
which refers to the ability to regulate negative OR “psychological adaptation”[All Fields] OR
emotions; (b) problem-focused coping, which “coping”[All Fields]) AND (“quality of life”
includes strategies and actions to reduce the [MeSH Terms] OR (“quality”[All Fields] AND
negative impact of the situation through an “life”[All Fields]) OR “quality of life”[All
external change; (c) active coping, which is Fields]).

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Lo Buono et al. 3

The search terms were identified as title and Darlington et al. (2007) conducted a longitu-
abstract. We selected only English texts. After dinal study on 80 patients with a first-event
duplicates had been removed, all articles were stroke caused by cerebral infarction or intracer-
evaluated based on title, abstract, and text. ebral hematoma to examine the prognostic
Studies that examined the relationship between value of coping strategies and QoL after stroke.
coping strategies and QoL after stroke were The patients were evaluated at four different
included, after they fulfilled the following time points: 1 week before discharge and 2, 5,
criteria: and 12 months after discharge and approxi-
mately 1 year later. QoL was assessed by five-
1. Published peer-reviewed research; dimensional EuroQoL (EQ-5D) self-report
2. The sample population included stroke (The EuroQoL Group, 1990), and coping strate-
patients (ischemic or intracerebral hem- gies were measured through the Assimilative–
orrhagic lesion) in rehabilitative phase Accommodative Coping Scale (AACS;
or at home; Brandtstädter and Renner, 1990), a self-report
3. Studies specifically assessed the rela- questionnaire composed by two subscales:
tionship between coping strategies and Tenacious Goal Pursuit (TGP) and Flexible
QoL after a stroke event; Goal Adjustment (FGA). The results showed
4. Data from an instrument quantifying that the variance in coping after stroke was
coping strategies used of the stroke related to long-term QoL. In particular, a posi-
patients and QoL were reported; tive relationship between FGA and HRQoL was
5. We excluded case studies. found. The coping style, however, was not pre-
dictive for the QoL 2 months after the stroke.
The importance of the relationship between
Results FGA and QoL, indeed, has been proven already
Of the 389 studies identified, 6 studies met the at 5 months after a stroke (Clarke and Black,
inclusion criteria (Figure 1). All studies con- 2005). Immediately after the stroke event, sub-
ducted research on 506 stroke survivors and jective well-being was mainly due to the gen-
examined the association between QoL and eral functioning. It seems that assimilative
coping strategies (Table 1). coping was dominant in the acute phase after
Eight different measures of QoL and three stroke, while accommodative coping gradually
coping measures were identified; one study increased over time.
used an individual report to identify preferred A similar study with 213 patients after chronic
coping strategies of patients (Tables 2 and 3); stroke investigated the influence of coping strat-
two studies included stroke patients and their egies and depression on HRQoL (Visser et al.,
partners. 2014). Coping strategies were measured using
The quality assessment of studies was per- AACS, and depression was assessed with the
formed with the National Institute for Health Center for Epidemiologic Studies–Depression
and Care Excellence (NICE, 2010) guidelines. (CES-D; Radloff, 1977) Scale and QoL through
World Health Organization Quality of Life–
Measures coping strategies and BREF (WHOQOL-BREF; WHOQOL Group,
1998). The results showed that coping strategies
HRQoL in stroke survivors and depression were independently related to
Many data in the literature have focused on psychological health on the domain of flexibility
cognitive and physical disability resulting from and tenacity in the chronic phase. Patients who
stroke. However, only very few studies have used accommodative coping showed higher
investigated whether the way in which the HRQoL scores and fewer depressive symptoms.
patient deals with the post-stroke period affects The data confirmed that accommodative coping
the overall well-being. correlated with a high QoL in chronic phase.

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4 Journal of Health Psychology 

PubMed (210) Web of Science (179)

Total (389)

Removed after screening title/abstract (357)

Total (32)

Removed after screening Full-text (21)

Total (11)

Removed because after examination of standardized measures (3)

Total (8)

Removed text not available (1)

Total (7)

Removed study of September 2014 (data no published) (1)

Total (6)

Figure 1.  Search and selection of eligible articles.

Another study focused on eight young stroke deteriorated in 20.1 percent of the patients but
patients (mean age: 47.6 years) and their part- not in their partners. Moreover, patients who
ners (mean age: 44.5 years; Smout et al., 2001). used accommodative coping had a better QoL.
Patients and partners completed the Impact of Coping strategies and QoL are very important
Event Scale (IES) questionnaire (Horowitz outcome measures in rehabilitative phase.
et al., 1979), and they were interviewed to Tramonti et al. (2014) examined the association
obtain information about stroke impact and between functional status and QoL in 29 stroke
coping. QoL was measured by the Schedule for survivors, who were treated with neurorehabili-
Evaluation of Individual Quality of Life tation and included an evaluation of coping strat-
(SEIQoL; McGee et al., 1991), and stroke egies and social support. Test for functional
impact was quantified using the Visual Analog status, HRQoL, individualized QoL, psychologi-
Scales (VASs; Price et al., 1983). QoL was cal distress, coping strategies, and social support

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Table 1.  Studies (n = 6) assessing coping strategies and quality of life after stroke.

References Aim of the study Coping measures QoL measures Socio-demographic Patient group Outcomes
characteristics
Darlington To examine the Assimilative– Five-dimensional 80 stroke patients Time point: Positive relationship
Lo Buono et al.

et al. (2007) prognostic value of Accommodative Coping EuroQoL (EQ-5D) (41 women and 39 discharge between flexible and
coping strategies of Scale (AACS): self- self-report QoL men). Mean age: from hospital. adaptive coping and
stroke patients at the report questionnaire questionnaire 60.9 years. Diagnosis: Rehabilitation QoL
time of discharge on 63 ischemic stroke, center: nursing
QoL (approximately 16 intracerebral home or their
1 year later) hematoma, and 1 home
venus sinus thrombosis
Visser et al. To investigate the AACS: self-report The World Health 213 patients (119 men Home Positive association
(2014) relative associations questionnaire Organization and 94 women) after between
of coping strategy Quality of Life–BREF stroke (>18 months accommodative
and depression on (WHOQOL-BREF), post-onset); mean age: coping and high
health-related QoL in generic HRQoL 59 years QoL in chronic
patients in the chronic questionnaire phase
phase after stroke
Smout et al. To evaluate stroke Semistructured Schedule for 8 stroke patients and Rehabilitation Accommodative
(2001) impact and coping interviews that classified Evaluation of their partners. Mean coping positively to
strategies in QoL in the coping strategies Individual Quality age: 47.6 years in correlate with QoL
younger patients and in two categories: of Life (SEIQoL), patients and 44.5 years in patients and their
in their spouses assimilation and semistructured in partners partners
accommodation coping interview
Tramonti To examine the COPE questionnaire Schedule for 29 stroke patients Hospital Positive correlations
et al. (2014) association among Evaluation of (17 men and 12 neurorehabilitation COPE subscales and

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functional status and Individual Quality women), mean age: unit health-related QoL
measures of QoL in of Life–Direct 63 years. Diagnosis: 18 measures
patients undergoing Weighting (SEIQoL- ischemic stroke and 11
rehabilitative DW); Short-Form hemorrhagic stroke.
programs and to Health Survey 36 Patients were in
consider the role of (SF-36) rehabilitation phase
psychological distress
coping strategies and
social support
5

(Continued)
6

Table 1. (Continued)

References Aim of the study Coping measures QoL measures Socio-demographic Patient group Outcomes
characteristics
Elmståhl To explore Individual reports Life satisfaction 66 stroke patients: Rehabilitation Active coping
et al. (1996) relationship and QoL were 25 men, mean age: strategies are
between personality measured by Lund 75.6 ± 7.4 years, and related with an
characteristics and Gerontology 41 women, mean age improvement
functional recovery Center’s 81.1 ± 8.3 years. They activity life and QoL
after stroke Life Quality were examined 3 years (at 1 and 3 years
Questionnaire after a primary stroke after stroke)
(LGC)
Tielemans To investigate Proactive Competence Stroke-Specific 106 stroke patients Home Proactive coping to
et al. (2014) the capacity of Inventory (PCI): self- Quality-of-Life and their partners. influence HRQoL in
self-management report measure (SSQoL) Scale Aged 18 years stroke patients
intervention based on for physical and or over. Patients
the proactive coping psychosocial were recruited
to increase social domains; six- by rehabilitation
participation and dimensional physicians and nurse
HRQoL EuroQoL (EQ-6D) practitioners in 10
Dutch hospitals and

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rehabilitation centers

QoL: quality of life.


Journal of Health Psychology 
Lo Buono et al.

Table 2.  Coping measures.

Coping scale Coping domains and strategies Items Scales Focus


AACS (Brandtstädter 2 independent scales: Tenacious Goal Pursuit (TGP) and Flexible 15 items 5-point Inclination to use assimilative and
and Renner, 1990) Goal Adjustment (FGA) Likert scale accommodative coping strategies
COPE questionnaire 14 scales: Active Coping, Planning, Suppressing Competing 53 items 4-Point scale To assess which particular process
(Carver et al., 1989) Activities, Restraint Coping, Seeking Social Support for Instrumental of coping the patient will use in
Reasons, Seeking Social Support for Emotional Reasons, Positive difficult or stressful situations
Reinterpretation and Growth, Acceptance, Religion, Focusing on
the Venting Emotion, Denial, Behavioral Disengagement, Mental
Disengagement, and Alcohol–Drug Disengagement
PCI (Greenglass 7 scales: Proactive Coping Scale, Reflective Coping Scale, Strategic 55 items 4-Point self- Integration of processes of
et al., 1999) Planning, Preventive Coping, Instrumental Support Seeking, report scale personal quality of life management
Emotional Support Seeking, and Avoidance Coping with those of self-regulatory
Individual report Questions: how individually chosen difficult life events have been Identification of active, passive,
handled emotional, and avoiding behaviors

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AACS: Assimilative–Accommodative Coping Scale; PCI: Proactive Competence Inventory.
7
8
Table 3.  Quality of life measures.

QoL scale Domains and strategies Items Scales Focus


EQ-5D (The 5 dimensions: mobility, self-care, usual activities, pain or 5 items 5-point scale Generic measure widely
EuroQoL Group, discomfort, and anxiety or depression used for the assessment
1990) of health status
WHOQOL-BREF 4 domains: physical health, psychological health, social 26 items 5-Point Likert scale Subjective perception
(WHOQOL Group, relationships, and environment of the individual’s health
1998) status
SEIQoL (McGee 3 elements of QoL: life considered by the individual to 46 items Visual Analog Scale, To assess QoL from the
et al., 1991) be crucial to his or her QoL are elicited by means of a 0–100 individual’s perspective
structured interview; current functioning or satisfaction with
each aspect is rated by the individual; the relative importance
of each aspect of QoL is measured by deriving the weight the
individual assigns to each in judging overall QoL
SEIQoL-DW Brief measure of SEIQoL 15 items Visual Analog Scale, To assess QoL from the
(LeVasseur et al., 0–100 individual’s perspective
2005) (derived from SEIQoL)
SF-36 (Ware and 8 different subscores (physical and social functioning, physical 36 questions 5- or 6-point or Subjective perception of
Sherbourne, 1992) and emotional role limitations, mental health, energy, pain, 2- or 3-point Likert the health-related QoL
and general health perceptions) scale
LGC (Nordbeck, 10 dimensions: present QoL, psychological well-being, life 51 items 4- or 5-point scale Life satisfaction and life
1996) span quality, satisfaction with living conditions, economy, quality
relations to neighbors, social relations, close relations,
activities, and view of life
EQ-6D (The 6 dimensions: mobility, self-care, usual activities (work, study, 6 items 5-point scale Generic measure widely

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EuroQoL Group, household activities, and recreational activities), pain or other used for the assessment
1990) discomfort, anxiety or depression, and cognition (such as of health status (derived
memory and concentration) from EQ-5D)
SSQoL (Post et al., 12 domains: mobility, energy, upper extremity function, work 49 items 5-point Guttman- Disease-specific quality-
2011) and productivity, mood, self-care, social roles, family roles, type scale of-life measures
vision, language, thinking, and personality

QoL: quality of life; EQ-5D: five-dimensional EuroQoL; WHOQOL-BREF: World Health Organization Quality of Life–BREF; SEIQoL: Schedule for Evaluation of Individual
Quality of Life; SEIQoL-DW: Schedule for Evaluation of Individual Quality of Life–Direct Weighting; SF-36: Short-Form Health Survey 36; LGC: Lund Gerontology Center’s Life
Quality Questionnaire; EQ-6D: six-dimensional EuroQoL; SSQoL: Stroke-Specific Quality-of-Life.
Journal of Health Psychology 
Lo Buono et al. 9

were administered. Barthel Index (BI) was used Tielemans et al. (2014) compared the effec-
for functional status (Mahoney and Barthel, tiveness of a 10-week group self-management
1965), Short-Form Health Survey 36 (SF-36; intervention with educational intervention in 106
Ware and Sherbourne, 1992) and the Schedule stroke patients and their partners. The groups
for Evaluation of Individual Quality of Life– were focalized on the learning of proactive cop-
Direct Weighting (SEIQoL-DW) were used to ing strategies. The BI was used to assess stroke
measure QoL (LeVasseur et al., 2005), Hospital severity in terms of basic activities of daily living,
Anxiety and Depression Scale (HADS; Zigmond and the Checklist for Cognitive and Emotional
and Snaith, 1983) was used to assess psychologi- Consequences was administered (Van Heugten
cal distress, COPE questionnaire (Carver et al., et al., 2007). The proactive coping competencies
1989) was used for coping strategies, and were measured with the Proactive Competence
Multidimensional Scale of Perceived Social Inventory (PCI; Thoolen et al., 2009), and partici-
Support (MSPSS; Zimet et al., 1988) was used pation restrictions were measured by the Utrecht
for evaluation of social support. The data from Scale for Evaluation of Rehabilitation (USER)–
this study highlighted the positive impact of Participation Restrictions Scale (Van der Zee
active coping strategies on the QoL and clinical et al., 2010). HRQoL was assessed with short ver-
implication on the relationships between coping sion of the Stroke-Specific Quality-of-Life
and social support. In particular, the support (SSQoL) Scale and six-dimensional EuroQoL
received by family and relatives was related to (EQ-6D; Krabbe et al., 1999; Post et al., 2011). In
adaptive and active coping strategies, while the this study, the authors considered proactive cop-
support received by the primary caregiver was ing as a psychological variable influencing
related to QoL. Coping strategies were strictly HRQoL of the stroke patients and social partici-
correlated with HRQoL and mood status. pation as a primary outcome of a self-manage-
Especially, adaptive coping, such as the research ment intervention.
of support social, was associated with lower lev-
els of depressive mood and a better QoL.
Discussion
Elmståhl et al. (1996) explored the relation-
ship between personality characteristics, func- After stroke, many patients report a reduction in
tional recovery, and coping strategies. They the QoL and consequently to physical, emo-
conducted an interview with 66 patients, tional, and cognitive disabilities (Clarke et al.,
3 years after stroke, about the coping strategies 2002; Viitanen et al., 1988). Physical well-
used to manage difficult events. Personal and being seems to be the most affected component
mental statuses were assessed by Eysenck of HRQoL, and the psychological health tends
Personality Inventory Scale (Eysenck, 1987) to decrease after an acute episode (Sturm et al.,
and the Comprehensive Psychopathological 2004). Emotional consequences of stroke
Rating Scale (CPRS; Asberg et al., 1978). Life including sense of loss, disappointment of
satisfaction and QoL were measured using unmet recovery expectations, and difficulty in
Lund Gerontology Center’s Life Quality coping with dependency are associated with
Questionnaire (LGC; Hagberg, 1995). Coping bad outcomes, including poorer QoL, increased
strategies, defined in more information seek- risk of a second stroke, and death (Crowe et al.,
ing, participation in therapy, problem solving, 2015). There is not always a direct correlation
and engagement in helpful activities, were between functional disability and subjective
identified with individual report of patients. QoL. Indeed, psychological factors may alter
Survivors who used active coping strategy and the perception of individual well-being regard-
presented characteristics of extroversion and less of disability degree. Previous studies on the
neurotic personality showed an improvement stroke consequences confirmed the importance
in activity daily life scores and in QoL 1 and of psychological variables, highlighting the
3 years after stroke event. positive impact of active- and task-oriented

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10 Journal of Health Psychology 

coping strategies on QoL. In particular, social Our conclusions suggest that subjective
support received and the acceptance of change well-being is related to the ability to actively
of life seem to have a greater impact in the per- manage the consequences of the disease. This
ception of individual well-being. In the result has shown similar findings in other stud-
reviewed studies, the variance in coping strate- ies on different populations where emotion-
gies after stroke was related to long-term oriented coping style has been positively linked,
HRQoL. Flexible or accommodative coping for both men and women, with negative health
was associated with a higher QoL, and a better variables such as anxiety, depression, and poor
global well-being was registered after 5 months recovery from illness (Endler et al., 1993).
from the acute event. As described by Many patients report a long-term negative
Brandtstädter and Renner (1990), accommoda- consequence of stroke on their HRQoL, but this
tive coping involves flexibly adjusting of one’s relationship remains poorly investigated.
goals in response to a persistent problem. The Indeed, as already mentioned, only few works
use of these strategies helped patients to adjust in the literature have investigated the connec-
their goals to accommodate constraints and tion between coping strategies and QoL after
impairments by revising values and priorities, stroke. The data from the present review sug-
constructing a new meaning from the situation, gest that specific coping strategies help to
and potentially transforming personal identity. improve the well-being and could influence the
In addition, active coping strategies, whether recovery. Several active or behavioral strategies
behavioral or emotional, could be good strate- were reported as extremely helpful during
gies to deal with stressful events. Indeed, posi- recovery: information seeking, participation in
tive association between responses designed to rehabilitation, problem solving, and engage-
change the nature of the stressor and improve- ment in activities (Ch’Ng et al., 2008).
ment of daily life activity was found after 1 year. This is a very interesting result since during
Furthermore, both accommodative coping and rehabilitation, the patients should be trained to
active coping were related with a decrease in use active coping strategies. In fact, an appro-
depressive symptoms. priate psychological intervention could modify
Active coping strategies were associated coping strategies in order to optimize HRQoL
with social support and influenced emotional during hospitalization or rehabilitative phase
aspects. The support obtained from family (Van Mierlo et al., 2014). Thus, stroke patients
members was a resource which helps the patient trained to use effective coping strategies could
in the disease management. enhance, for example, the process of accepting
Other factors influencing the coping strate- the consequences of stroke and improve
gies are the individual’s personality traits. In HRQoL (Visser et al., 2014).
particular, extraversion had a positive impact
on some aspects of HRQoL and was correlated Final considerations and clinical
with active coping strategies. Patients may be
trained to use coping strategies in order to
implications
improve HRQoL. This review showed, for This review focused on the lack of studies that
example, the importance of the proactive cop- explore the relationship between QoL and coping
ing that is implemented before any stressful strategies after stroke. A small number of works
events. Aspinwall and Taylor (1997) have were included in this review since only six stud-
emphasized the importance of this coping style ies met the inclusion criteria. Furthermore, only
since it minimizes the total amount of stress that two out of the six reviewed studies employed a
the patient might encounter and increases the longitudinal design, and this is a limitation related
capacity to deal problematic situations. In to cross-sectional design in this research area. A
stroke patients, proactive coping was a psycho- meta-analysis was unable to be performed
logical variable influencing HRQoL. because quantitative information was not reported

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Lo Buono et al. 11

in the included studies. We observed a significant Funding


weakness in the definition of QoL and a method- This research received no specific grant from any
ological variability in the qualitative and quanti- funding agency in the public, commercial, or not-for-
tative measures of HRQoL. However, there is no profit sectors.
consensus about which instrument should be
used to measure coping after stroke (Donnellan References
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comprehensive psychopathological rating scale.
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