When stroke survivors' self-ratings are inconsistent with the ratings of others: a cohort study examining biopsychosocial factors associated with impaired self-awareness of functional abilities

Background Stroke survivors' self-ratings of functional abilities are often inconsistent with ratings assigned by others (e.g. clinicians), a phenomenon referred to as 'impaired self-awareness' (ISA). There is limited knowledge of the biopsychosocial contributors and consequences of post-stroke ISA measured across the rehabilitation journey. This multi-site cohort study explored biopsychosocial correlates of ISA during subacute rehabilitation (inpatient) and at 4 months post-discharge (community-dwelling).Methods Forty-five subacute stroke survivors participated (Age M (s.d.) = 71.5 (15.6), 56% female), and 38 were successfully followed-up. Self-assessments were compared to those of an independent rater (occupational therapist, close other) to calculate ISA at both time points. Survivors and raters completed additional cognitive, psychological and functional measures.Results Multivariate regression (multiple outcomes) identified associations between ISA during inpatient admission and poorer outcomes at follow-up, including poorer functional cognition, participation restriction, caregiver burden, and close other depression and anxiety. Regression models applied cross-sectionally, including one intended for correlated predictors, indicated associations between ISA during inpatient admission and younger age, male sex, poorer functional cognition, poorer rehabilitation engagement and less frequent use of non-productive coping (adjusted R2 = 0.60). ISA at community follow-up was associated with poorer functional cognition and close other anxiety (adjusted R2 = 0.66).Conclusions Associations between ISA and poorer outcomes across the rehabilitation journey highlight the clinical importance of ISA and the value of assessment and management approaches that consider the potential influence of numerous biological and psychosocial factors on ISA. Future studies should use larger sample sizes to confirm these results and determine the causal mechanisms of these relationships. Stroke survivors often disagree with others (e.g. clinicians) regarding the nature and extent of their post-stroke impairments - a phenomenon termed 'impaired self-awareness' (ISA). Using 45 stroke survivors, this study examined biological, psychological and social factors associated with ISA at two time points during rehabilitation. ISA was associated with a number of biopsychosocial markers of poorer outcomes across the rehabilitation journey. Results highlighted the clinical importance of ISA and suggested there may be value in biopsychosocial-informed assessment and management approaches.