Anne Forster

Incidence and consequences of falls due to stroke: a systematic inquiry.

Abstract Objective: To undertake a systematic inquiry into the incidence and consequences of falls in a cohort of elderly patients with stroke after discharge from hospital. Design: Administration of a questionnaire to patients and main carers at discharge from hospital and eight weeks and six months later. Setting: Bradford Metropolitan District. Subjects: 108 patients recruited to the Bradford community stroke trial. Patients were recruited to the trial if they were 60 years or over and resident at home with some residual disability. Main outcome measures: Number of falls, motor club assessment, Barthel index, Frenchay activities index, and Nottingham health profile. Stress in carers was indicated by the general health questionnaire. Results: Of 108 patients, 79 (73%) fell in the six months after discharge from hospital with a total of 270 falls reported. Patients who fell in hospital were significantly more likely to fall at least twice at home after discharge (x2=8.16; P=0.004). “Fallers” (two or more falls) were less socially active at six months and more had depressed mood. Carers of these patients were significantly more stressed at six months (53% v 18%; x2=8.5; P=0.003). Conclusion: Stroke is associated with a risk of falling at home and affects the lives of patients with stroke and their carers. Falling and fear of falling is an important issue which needs to be dealt with by the multidisciplinary team.

Specialist nurse support for patients with stroke in the community: a randomised controlled trial

Abstract Objective: To evaluate whether specialist nurse visits enhance the social integration and perceived health of patients with stroke or alleviate stress in carers in longer term stroke care. Design: Stratified randomised controlled trial; both groups assessed at time of recruitment and at 3, 6, and 12 months. Setting: Patients with disability related to new stroke who lived in their own homes in the Bradford Metropolitan District. Subjects: 240 patients aged 60 years or over, randomly allocated to control group (n = 120) or intervention group (n = 120). Intervention: Visits by specialist outreach nurses over 12 months to provide information, advice, and support; minimum of six visits during the first six months. The control group received no visits. Main outcome measures: The Barthel index (functional ability), the Frenchay activities index (social activity), the Nottingham health profile (perceived health status). Stress among carers was indicated by the general health questionnaire-28 (28 items). The nurses recorded their interventions in trial diaries. Results: There were no significant differences in perceived health, social activities, or stress among carers between the treatment and control groups at any of the assessments points. A subgroup of mildly disabled patients with stroke (Barthel index 15-19) had an improved social outcome at six months (Frenchay activities index, median difference 3 (95% confidence interval 0 to 6; P = 0.03)) and for the full 12 months of follow up (analysis of covariance P = 0.01) compared with the control group. Conclusions: The specialist nurse intervention resulted in a small improvement in social activities only for the mildly disabled patients. No proved strategy yet exists that can be recommended to address the psychosocial difficulties of patients with stroke and their families. Key messages This randomised controlled trial using specialist nurses in an intervention strategy found that no significant differences were seen at one year follow up between the two groups of patients in wellbeing or social activities and no reduction in stress among carers A significant but small increase in social activities was reported by a subgroup of mildly disabled patients with stroke No proved strategy yet exists to address the psychosocial difficulties of patients with stroke and their families

Hemiplegic shoulder pain (HSP): Natural history and investigation of associated features

The prevalence of hemiplegic shoulder pain (HSP) and associated factors was studied in patients with a stroke followed for 6 months after discharge from hospital. A questionnaire was used to evaluate shoulder symptoms and an examination of the shoulder and arm was carried out three times over 6 months. A total of 108 patients were studied with a mean age of 71 years. Sixty-nine patients (63.8%) developed HSP at some time during the study period. The number with HSP was 39 at discharge from hospital, 59 at 8 weeks post-discharge and 36 at 6 months. Nine carers reported lifting the patient by pulling on the hemiplegic arm, even though six of them had received advice about correct lifting techniques. Reduced shoulder shrug was associated with HSP at all times and reduced pinch grip was also associated with HSP at discharge from hospital. Patients who required help with transfers were more likely to suffer with HSP. There was no difference in the prevalence of HSP in patients treated at the day hospital compared to those who received domiciliary physiotherapy. It is concluded that HSP is common after a stroke and the prevalence increases in the first weeks after discharge from hospital. Stroke patients and their carers need advice about correct handling of the hemiplegic arm, and more work is required to ensure that correct handling occurs after discharge in patients at high risk of this unpleasant complication.

DOES REPETITIVE TASK TRAINING IMPROVE FUNCTIONAL ACTIVITY AFTER STROKE? A COCHRANE SYSTEMATIC REVIEW AND META-ANALYSIS

OBJECTIVE To determine if repetitive task training after stroke improves functional activity. DESIGN Systematic review and meta-analysis of trials comparing repetitive task training with attention control or usual care. DATA SOURCES The Cochrane Stroke Trials Register, electronic databases of published, unpublished and non-English language papers; conference proceedings, reference lists, and trial authors. REVIEW METHODS Included studies were randomized/quasi-randomized trials in adults after stroke where an active motor sequence aiming to improve functional activity was performed repetitively within a single training session. We used Cochrane Collaboration methods, resources, and software. RESULTS We included 14 trials with 17 intervention-control pairs and 659 participants. Results were statistically significant for walking distance (mean difference 54.6, 95% confidence interval (95% CI) 17.5, 91.7); walking speed (standardized mean difference (SMD) 0.29, 95% CI 0.04, 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13, 0.56), and activities of daily living: SMD 0.29, 95% CI 0.07, 0.51; and of borderline statistical significance for measures of walking ability (SMD 0.25, 95% CI 0.00, 0.51), and global motor function (SMD 0.32, 95% CI -0.01, 0.66). There were no statistically significant differences for hand/arm functional activity, lower limb functional activity scales, or sitting/standing balance/reach. CONCLUSION Repetitive task training resulted in modest improvement across a range of lower limb outcome measures, but not upper limb outcome measures. Training may be sufficient to have a small impact on activities of daily living. Interventions involving elements of repetition and task training are diverse and difficult to classify: the results presented are specific to trials where both elements are clearly present in the intervention, without major confounding by other potential mechanisms of action.

Reliability of gait speed measured by a timed walking test in patients one year after stroke

Objective: To assess the reliability of gait speed in late-stage stroke patients. Design: Test–retest reliability of three timed walks to 10 metres repeated during two assessments one week apart. Setting: The patients home. Subjects: Twenty-two stroke patients with mobility problems more than one year after stroke. Main outcome measure: Gait speed measured in seconds taken to walk 10 metres. Statistical analysis: Intraclass correlations (ICCs) with 95% con”dence interval (CI) and the Bland and Altman method for assessing agreement by calculating the mean difference between measurements (d–); the 95% CI for d–; the standard deviation of the difference (SDdiff); a reliability coef”cient and the 95% limits of agreement. Results: There was a trend for decreased times taken to walk 10 metres both within each assessment and between assessments. ICCs for within assessment reliability were 0.95–0.99. The d– (SDdiff) for the second and third walks for assessment 1 was –1.00 (2.63) seconds and for assessment 2 was –0.70 (1.58) seconds. The reliability coef”cient was 5.26 for assessment 1 and 3.17 for assessment 2. ICCs for between-assessment reliability were 0.87–0.88. The d – (SDdiff) for the comparison of the third walks at assessment 1 and assessment 2 was –0.90 (5.01) seconds. The reliability coef”cient was 10.02 and the 95% limits of agreement were –10.92 to +9.12 seconds. Conclusion: Within-assessment gait speed measured at home is highly reliable. The between-assessment reliability of gait speed measurement is less reliable but comparable with other studies.

Review of stroke rehabilitation

Stroke causes an estimated 5.54 million deaths worldwide each year.1 The burden of stroke is set to rise over future decades because of demographic transitions of populations, particularly in developing countries.w1 Despite a meagre research investmentw2 important progress has been made, reflected in various guideline initiatives.2 3 4 These guidelines relate mainly to stroke services in developed countries. The main burden of stroke to individuals and to societies is as a leading cause for disability—about 40% of stroke survivors are left with some degree of functional impairment. Reducing this burden requires optimising stroke prevention and improving acute care, but rehabilitation is equally essential. The many definitions of rehabilitation, most of which apply well to stroke, can be confusing. However, a clear consensus exists that the purpose of rehabilitation is to limit the impact of stroke related brain damage on daily life by using a mixture of therapeutic and problem solving approaches (see box 1).2 3 4 The high incidence and prevalence of stroke imply that stroke rehabilitation should be a major component of health service provision. In England, for example, the healthcare costs associated with stroke have been estimated at £2.8bn (€4.1bn;

Systematic review of day hospital care for elderly people

5.5bn) a year.w3 A stroke is not simply a brain disease but affects the whole person and the family. There are few other conditions of such complexity that require the challenge of providing highly individualised, complex treatments to large numbers of patients. #### Box 1: What is rehabilitation?w33 Rehabilitation is a complex set of processes usually involving several professional disciplines and aimed at improving quality of life for people facing daily living difficulties caused by chronic disease. Most people (and their carers) after a stroke will require help from a specialist team of doctors, nurses, therapists, social service staff, and psychologists. Each person will need careful assessment by …

A randomized trial to evaluate an education programme for patients and carers after stroke

Abstract Objective: To examine the effectiveness of day hospital attendance in prolonging independent living for elderly people. Design: Systematic review of 12 controlled clinical trials (available by January 1997) comparing day hospital care with comprehensive care (five trials), domiciliary care (four trials), or no comprehensive care (three trials). Subjects: 2867 elderly people. Main outcome measures: Death, institutionalisation, disability, global “poor outcome,” and use of resources. Results: Overall, there was no significant difference between day hospitals and alternative services for death, disability, or use of resources. However, compared with subjects receiving no comprehensive care, patients attending day hospitals had a lower odds of death or “poor” outcome (0.72, 95% confidence interval 0.53 to 0.99; P<0.05) and functional deterioration (0.61, 0.38 to 0.97; P<0.05). The day hospital group showed trends towards reductions in hospital bed use and placement in institutional care. Eight trials reported treatment costs, six of which reported that day hospital attendance was more expensive than other care, although only two analyses took into account cost of long term care. Conclusions: Day hospital care seems to be an effective service for elderly people who need rehabilitation but may have no clear advantage over other comprehensive care. Methodological problems limit these conclusions, and further randomised trials are justifiable. Key messages The benefits of geriatric day hospital care have been controversial for many years This systematic review of 12 randomised trials comparing a variety of day hospitals with a range of alternative services found no overall advantage for day hospital care Day hospitals had a possible advantage over no comprehensive care in terms of death or poor outcome, disability, and use of resources The costs of day hospital care may be partly offset by a reduced use of hospital beds and institutional care among survivors

Cochrane review: information provision for stroke patients and their caregivers

Objectives: To evaluate the effectiveness of an education programme for patients and carers recovering from stroke. Design: Randomized controlled trial. Subjects and setting: One hundred and seventy patients admitted to a stroke rehabilitation unit and 97 carers of these patients. Interventions: The intervention group received a specifically designed stroke information manual and were invited to attend education meetings every two weeks with members of their multidisciplinary team. The control group received usual practice. Measures: Primary outcome was knowledge of stroke and stroke services. Secondary outcomes were handicap (London Handicap Scale), physical function (Barthel Index), social function (Frenchay Activities Index), mood (Hospital Anxiety and Depression Scale) and satisfaction (Pound Scale). Carer mood was measured by the General Health Questionnaire-28. Results: There was no statistical evidence for a treatment effect on knowledge but there were trends that favoured the intervention. The education programme was associated with a significantly greater reduction in patient anxiety score at both three months (p=0.034) and six months (p=0.021) and consequently fewer ‘cases’ (Hospital Anxiety and Depression Scale anxiety subscale score ≥ 11). There were no other significant statistical differences between the patient or carer groups for other outcomes, although there were trends in favour of the education programme. Conclusion: An education programme delivered within a stroke unit did not result in improved knowledge about stroke and stroke services but there was a significant reduction in patient anxiety at six months post stroke onset.

Is physical rehabilitation for older people in long-term care effective? Findings from a systematic review

Objective: To assess the effectiveness of information provision strategies in improving the outcome for stroke patients and/or their identified caregivers. Data sources: We searched: the Cochrane Stroke Group Trials Register; the Cochrane Central Register of Controlled Trials; electronic databases MEDLINE; EMBASE; CINAHL; PsycINFO; Science Citation Index and Social Science Citation Index; Assia; Index to UK theses; Dissertation Abstracts; ongoing trials and research registers; bibliographies of retrieved papers, relevant articles, and books; the Journal of Advanced Nursing. We also contacted researchers for additional information. Review methods: Two review authors independently assessed trial eligibility, extracted data and assessed methodological quality. Primary outcomes were knowledge about stroke and impact on mood. Meta-analyses were undertaken for the domains of knowledge, mood, satisfaction, and mortality. Results: Seventeen trials were identified and 11 contributed data to the meta-analyses. There were significant effects in favour of the intervention on patient knowledge (standardized mean difference (SMD) 0.29, 95% confidence interval (CI) 0.12 to 0.46), caregiver knowledge (SMD 0.74 95% CI 0.06 to 1.43), patient depression scores (weighted mean difference (WMD) -0.52, 95% CI -0.93 to -0.10), and one aspect of patient satisfaction (odds ratio (OR) 2.07, 95% CI 1.33 to 3.23). Post-hoc subgroup analyses showed that strategies which actively involved patient and caregivers had a significantly greater effect on patient anxiety (P<0.05) and depression (P<0.02) than passive strategies. Conclusion: There is some evidence to support the routine provision of information to stroke patients and their families. Although the best way to provide information is still not clear, the results of this review suggest that strategies which actively involve patients and caregivers should be used in routine practice.