Therapeutic itinerary of post-stroke patients: the state of the art of Brazilian scientific production

| The study analyzed the qualitative research conducted in Brazil on the rehabilitation itinerary of patients who have suffered a stroke and synthesized its main contributions in search of the underlying senses and meanings. The integrative literature review was based on the question: how are the rehabilitation itineraries of stroke patients described in qualitative studies? BIREME, MEDLINE, LILACS, and SciELO databases were consulted, using the DeCS/MeSH descriptors: “acidente vascular cerebral AND qualitativa”; “reabilitação AND acidente vascular cerebral”; “acidente vascular cerebral”; “pesquisa qualitativa”; “acidente vascular encefálico AND qualitativa”; “reabilitação AND acidente vascular encefálico.” A total of six articles were included, which highlighted the importance of integrality of care, the role of the family in the recovery process, the centralization of services, the difficulty with transportation, and the unavailability of family members and caregivers as obstacles in the rehabilitation itinerary. Such results reinforce the need to improve the pathway of care of the patient who suffered a stroke and the demand for integrality of management.

AND qualitativa"; "reabilitação AND acidente vascular encefálico."A total of six articles were included, which highlighted the importance of integrality of care, the role of the family in the recovery process, the centralization of services, the difficulty with transportation, and the unavailability of family members and caregivers as obstacles in the rehabilitation itinerary.Such results reinforce the need to improve the pathway of care of the patient who suffered a stroke and the demand for integrality of management."reabilitação AND acidente vascular cerebral"; "acidente vascular cerebral"; "pesquisa qualitativa"; "acidente vascular encefálico AND qualitativa"; "reabilitação AND acidente vascular encefálico".Foram incluídos seis artigos, que destacaram a importância da integralidade do cuidado, o papel da família no processo de recuperação, a centralização dos serviços, a dificuldade com transporte e a indisponibilidade dos familiares e cuidadores como obstáculos no itinerário da reabilitação.
Os resultados reforçam a necessidade de implementar melhorias no percurso de cuidado do paciente que sofreu AVC e a demanda pela integralidade do manejo.

INTRODUCTION
Stroke is the second greatest cause of death in the world, accounting for 5.7 million deaths in 2016 1 .According to the Ministry of Health, every five minutes a Brazilian dies because of stroke, resulting in more than 100,000 deaths per year 2 .
Besides deaths, stroke is responsible for producing sequels, as described by the National Survey of Health (PNS)--a household-based epidemiological survey conducted by the Brazilian Ministry of Health in partnership with the Brazilian Institute of Geography and Statistics (IBGE)--which estimates that, in 2013, 570,000 people live with severe disability in Brazil 3 .
Stroke can cause sequelae related to motor, sensory, cognitive, and emotional functions, requiring a multidisciplinary care approach.Late assistance is associated with more severe disability and a longer process of functional recovery 4 .The resulting physical and psychosocial consequences usually require prolonged care 5 .
Difficulties in accessing health services and lack of follow-up services limit the opportunities for patients to obtain support after stroke 6 .Because it is a timedependent condition, the sooner the patient is cared for after a stroke, the better the prognosis.
The success or failure of this initial therapy influences future demands for follow-up in the individuals' rehabilitation process.Thus the importance of reviewing the available knowledge on the therapeutic itinerary (TI) to analyze its state of the art and inform the gaps and opportunities to explore in future studies.The TI is the construction of the trajectory of events and decision-making of an individual or group, with the treatment of the disease as the main objective 7 .
The integrative review aims to gather and synthesize research results on a given theme or issue in a systematic and orderly manner 8 .The objective of this review is to analyze the qualitative studies conducted in Brazil on the rehabilitation itinerary of stroke patients and to synthesize their main contributions, in search of the underlying senses and meanings.

METHODOLOGY
The following steps were followed, according to the referenced method about integrative literature review: selection of the research guiding question; definition of the specific objective; data collection within the previously established inclusion and exclusion criteria; categorization; evaluation of the included studies; analysis of results, and knowledge synthesis 9,10 .
The study started with the following question: how are the rehabilitation itineraries of stroke patients described in qualitative studies?To conduct the study, the following health sciences descriptor terms (DeCS/MeSH) were used: "acidente vascular cerebral AND qualitativa"; "reabilitação AND acidente vascular cerebral"; "acidente vascular cerebral"; "pesquisa qualitativa"; "acidente vascular encefálico AND qualitativa"; "reabilitação AND acidente vascular encefálico."Data was collected from articles published in journals indexed in the Virtual Health Library, comprising BIREME, MEDLINE, LILACS, SciELO, and specific health journals.
The following inclusion criteria were considered: (1) scientific articles conducted in Brazil; (2) articles from qualitative studies; and (3) articles related to the rehabilitation process.Exclusion criteria were: (1) articles conducted outside Brazil; (2) not related to qualitative research; and (3) without reference to the rehabilitation process.No publication cut-offs date were established for the inclusion.
The search for the articles was conducted from February to March 2019.Based on the combination of these descriptors, 729 articles were found; of these, 725 remained after removing duplicates.In the screening, 164 were selected and 561 were excluded, leaving 44 eligible articles; of these, 38 were excluded, and six articles describing qualitative studies conducted in Brazil were included, which provided the corpus of this integrative review (Figure 1).
For extracting the information from the articles, a registration was performed considering the following variables: subjects, methodology, sample size, analysis methods, and concepts employed.

Characterization of the studies
The articles differed regarding sample size, year of publication, and location in Brazil (Table 1).The samples ranged from 6 11 to 16 12 subjects and were collected in the inland Northeast of Brazil (municipality not specified) 13 ; Florianópolis (SC) 14 ; Sobral (CE) 10 ; Ijuí (RS) 11 ; Casa Nova (BA), Petrolina (PE) and Remanso (BA) 12 ; Belo Horizonte (MG) 15 .Two articles were published in 2007, three in 2016, and one in 2017.Data saturation was the method described for sample closure.Semi-structured interviews were conducted.One study did not present the instrument used for data collection 13 .Patients were interviewed in their households or hospital facilities.The guiding question was described in only two articles.As for the analysis method, three reported using content analysis: one used what was called as "an interpretive analysis of the disease experience," one did not clarify the data analysis method, and the other failed to describe it.Table 2 shows that all articles used different analytical categories, except for one 13 .

Thematic content analysis
Not present The onset of the disease; men and their care network; and therapeutic itineraries.

Characterization of the subjects included in the studies
The average age of the subjects who participated in the studies was 63 years, mostly males, married, with low schooling level, and with an approximate income ranging from 1 to 2 minimum wages.
About the prevalence of stroke in Brazil, Bensenor et al. 3 presents the following: 1.6% in men and 1.4% in women; disability in 29.5% and 21.5% among men and women, respectively; high prevalence rates, especially in older adults with no formal education.These data corroborate the findings of our review.

DISCUSSION
All these articles addressed the rehabilitation process, specially the article by Caetano et al. 10 , in which they clarify the importance of the integrality of care, emphasizing the role of physical therapy, which, according to them, is not always within everyone's reach.Based on the patients' perspective, the findings indicate that drug treatment may be enough for some, and that physical therapy is difficult because they rely on transportation or family members to accompany them, in addition to the fact that public services are centralized, making it difficult to access.
We emphasize that comprehensive rehabilitation does not involve only physical therapy services and that the needs of each patient must be individually analyzed.However, stroke sequelae are most often related to motor impairments, and physical therapy is fundamental to the process of functional recovery.
In Brazil, an ordinance published by the Ministry of Health in 2012 regulated the stroke care strategy, aiming to provide integrated care for these patients, such as universal access to the therapies established in guidelines, while respecting regional differences 16 .
Silva et al. 13 indicate that the offer of physical therapy services by the Brazilian Unified Health System (SUS) is still insufficient, requiring more investments, whether by hiring human resources, expanding the service network, or providing adequate transportation for users.
Individuals who suffered a stroke presented dissatisfaction regarding the access to interventions after hospital discharge, they mention restrictions for continuity of care in the community scenario 1 .The findings show a dissociation between public policy guidelines for the care and rehabilitation of stroke survivors and the reality experienced by these people and their families.Spedo, Pinto, and Tanaka 17 show that the access to specialized services-among them rehabilitation-has been considered one of the main obstacles to the effectiveness of the integrality of SUS.
One of the conclusions of Girardon-Perlini and Faro 18 is that the way each person faces illness and the limitations resulting from it, relates to individual characteristics and the meanings given to the event, as well as the support and encouragement received from the family, the possibility of access to health resources and to professionals whobesides valuing subjective issues-guide and help in recovery, in coping, and/or in adapting to the lost functions.
According to Girondi et al. 14 , the process of falling ill is unique: each affected person has their way of acting, feeling, and signifying the disease, influencing their rehabilitation process.The authors emphasize the role of family and healthcare professionals as motivators in the recovery and coping with the disease by older adults affected by stroke.In this process, a structured health network is indispensable to provide continuous and integral care.
Marques et al. 19 emphasize that family and cultural values play an essential role in the rehabilitation process of stroke patients.However, Bocchi 20 highlights that, for family members to be able to provide this care, is necessary to offer adequate conditions and information about the disease while also offering emotional support to cope with this new condition.
For Amaral et al. 21, family is a nucleus of forces that can interfere in the health-illness process of individuals, with consequences for the overall rehabilitation process and social reintegration.
The study by Fausto et al. 12 observed a lack of adequate orientation at discharge: the referral from the hospital service to the primary health care service did not happen formally.They also mention that the discharge report was sometimes unavailable to the patient, who did not receive explanations on what was being requested.
Although referred for follow-up with a neurologist, cardiologist, and physical therapist, in most cases the patient lacked access to such services, probably because the referral made by the hospital was more a "recommendation" than a guaranteed access to it.
Castro et al. 15 , in a qualitative study conducted with hospitalized men, concluded that the therapeutic itinerary--from the beginning to hospital discharge--is very autonomous for men, and that such logic is caused by social aspects of masculinity, such as being strong, inflexible, unwavering, and provider.
All articles highlight the importance of integrality of care, as well as the role of the family, which is essential for the recovery process.They also stress that the lack of guidance for patients and caregivers by health professionals can be a limiting factor to accessing therapies and adhering to the treatment.The caregivers play a very important role in this process: when well oriented, they become facilitators of the rehabilitation process.

CONCLUSION
This review synthesizes the knowledge produced, within the intended scope, about the rehabilitation itinerary of stroke patients, presenting obstacles and evidencing the scarcity of studies on the subject in Brazil.
These studies highlighted the importance of integrality of care, the role of the family in the recovery process, the centralization of services, the difficulty with transportation, and the unavailability of family members and caregivers as obstacles in the rehabilitation itinerary.Such results reinforce the need to improve the care pathway of the stroke patient and the demand for integrality in their care.
Future investigations that collaborate to understand the process of stroke care, especially from the perspective of those affected regarding access to services, can potentially help management, in accordance with stroke care strategy for a more comprehensive rehabilitation, as recommended by the SUS.

Table 1 .
Sociodemographic data in the articles selected W: women; M: men.

Table 2 .
Studies characteristics