Audrey Bowen

Reasons for Variability in the Reported Rate of Occurrence of Unilateral Spatial Neglect After Stroke

BACKGROUND AND PURPOSE We sought to determine the frequency of occurrence of contralesional unilateral spatial neglect (USN) after stroke and to investigate the effect of side of lesion, nature of assessment tool used, and timing of assessment relative to stroke onset. METHODS We performed a systematic review of published reports, identified by a search of electronic databases (MEDLINE 1966-1997, PSYCHLIT 1974-1996, and CINAHL 1982-1997) and by searching reference lists of the reports selected. Excluded were unpublished, non-English language, and nonhuman studies. RESULTS Thirty published reports met the selection criteria, 17 of which directly compared right brain damage (RBD) and left brain damage (LBD). Contralesional USN appeared to occur more frequently after RBD than LBD in 16 of these. Both the assessment tool used and the time of assessment relative to stroke onset affected the reported rate of occurrence, although recovery rate data were inadequate (4 reports). CONCLUSIONS The clinical belief that USN occurs more frequently after RBD than LBD was apparently supported by a systematic review of published data. However, an accurate estimate of the rates of occurrence and recovery after stroke could not be derived. Four reasons for the variability among studies were discussed, including subject selection, lesion localization, and nature and timing of assessment. Different USN disorders may exist, which may require type-specific rehabilitation approaches. This may have implications for epidemiological studies and for the development of new treatments. Theoretically driven epidemiological studies are required before adequately powered randomized controlled trials of rehabilitation can be conducted.

Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial

Objective To assess the effectiveness of enhanced communication therapy in the first four months after stroke compared with an attention control (unstructured social contact). Design Externally randomised, pragmatic, parallel, superiority trial with blinded outcome assessment. Setting Twelve UK hospital and community stroke services. Participants 170 adults (mean age 70 years) randomised within two weeks of admission to hospital with stroke (December 2006 to January 2010) whom speech and language therapists deemed eligible, and 135 carers. Interventions Enhanced, agreed best practice, communication therapy specific to aphasia or dysarthria, offered by speech and language therapists according to participants’ needs for up to four months, with continuity from hospital to community. Comparison was with similarly resourced social contact (without communication therapy) from employed visitors. Outcome measures Primary outcome was blinded, functional communicative ability at six months on the Therapy Outcome Measure (TOM) activity subscale. Secondary outcomes (unblinded, six months): participants’ perceptions on the Communication Outcomes After Stroke scale (COAST); carers’ perceptions of participants from part of the Carer COAST; carers’ wellbeing on Carers of Older People in Europe Index and quality of life items from Carer COAST; and serious adverse events. Results Therapist and visitor contact both had good uptake from service users. An average 22 contacts (intervention or control) over 13 weeks were accepted by users. Impairment focused therapy was the approach most often used by the speech and language therapists. Visitors most often provided general conversation. In total, 81/85 of the intervention group and 72/85 of the control group completed the primary outcome measure. Both groups improved on the TOM activity subscale. The estimated six months group difference was not statistically significant, with 0.25 (95% CI –0.19 to 0.69) points in favour of therapy. Sensitivity analyses that adjusted for chance baseline imbalance further reduced this difference. Per protocol analyses rejected a possible dilution of treatment effect from controls declining their allocation and receiving usual care. There was no added benefit of therapy on secondary outcome measures, subgroup analyses (such as aphasia), or serious adverse events, although the latter were less common after intervention (odds ratio 0.42 (95% CI 0.16 to 1.1)). Conclusions Communication therapy had no added benefit beyond that from everyday communication in the first four months after stroke. Future research should evaluate reorganised services that support functional communication practice early in the stroke pathway. This project was funded by the NIHR Health Technology Assessment programme (project No 02/11/04) and is published in full in Health Technology Assessment 2012;16(26):1-160. Trial registration ISRCTN78617680

Mood disorders following traumatic brain injury: identifying the extent of the problem and the people at risk

The extent of mood disorders following traumatic brain injury (TBI), and the possible risk factors, are investigated. New data are presented from a prospective study of consecutive hospital admissions. Six months post-TBI, 99 adults completed a standardized assessment of emotional state, the Wimbledon Self-Report Scale. Cognitive performance and the impact of the injury on everyday functioning were also assessed. The rate of clinically significant mood disorders (caseness) was 38%. Of the demographic or injury characteristics, only pre-injury occupational status predicted post-injury caseness. Those unoccupied pre-injury were more likely to report mood disturbance post-injury. In contrast, post-injury occupational status was not related to caseness either for the whole group or the subgroup of those previously occupied, despite the adverse effects on occupational functioning for a significant proportion of subjects. Associations were found between emotional state and cognitive and everyday functioning 6 months post-injury. Psychosocial disabilities appeared more strongly associated to mood disorders than did physical disabilities. A significant level of unmet need has been highlighted, and possible risk factors identified, which may inform the purchase and provision of TBI rehabilitation services. Follow-up data on these subjects are available and will be reported separately.

Awareness of Dysphagia by Patients Following Stroke Predicts Swallowing Performance

Patients’ awareness of their disability after stroke represents an important aspect of functional recovery. Our study aimed to assess whether patient awareness of the clinical indicators of dysphagia, used routinely in clinical assessment, related to an appreciation of “a swallowing problem” and how this awareness influenced swallowing performance and outcome in dysphagic stroke patients. Seventy patients were studied 72 h post hemispheric stroke. Patients were screened for dysphagia by clinical assessment, followed by a timed water swallow test to examine swallowing performance. Patient awareness of dysphagia and its significance were determined by detailed question-based assessment. Medical records were examined at three months. Dysphagia was identified in 27 patients, 16 of whom had poor awareness of their dysphagic symptoms. Dysphagic patients with poor awareness drank water more quickly (5 ml/s vs. <1 ml/s, p = 0.03) and took larger volumes per swallow (10 ml vs. 6 ml, p = 0.04) than patients with good awareness. By comparison, neither patients with good awareness or poor awareness perceived they had a swallowing problem. Patients with poor awareness experienced numerically more complications at three months. Stroke patients with good awareness of the clinical indicators of dysphagia modify the way they drink by taking smaller volumes per swallow and drink more slowly than those with poor awareness. Dysphagic stroke patients, regardless of good or poor awareness of the clinical indicators of dysphagia, rarely perceive they have a swallowing problem. These findings may have implications for longer-term outcome, patient compliance, and treatment of dysphagia after stroke.

Development of a reliable self-report outcome measure for pragmatic trials of communication therapy following stroke: the Communication Outcome after Stroke (COAST) scale

Objective: To develop and validate a clinically feasible measure of communication effectiveness for people with any type of communication problem following stroke. Design: Cross-sectional, interview-based, psychometric study, building on the development phase for construction of the Communication Outcome after Stroke (COAST) scale. Setting: A community sample from the northwest of England, UK. Subjects: One hundred and two people with communication problems (aphasia and/or dysarthria) following a stroke, within the previous 4—12 months. Interventions: Administration of the COAST scale, on two occasions, within a two-week period, and collection of demographic and other data relating to disability, degree of aphasia (where appropriate) and hospital diagnosis of aphasia/dysarthria. Main measures: Acceptability (missing values), reliability (internal consistency and test—retest reliability) and item analysis (item redundancy). Results: Ninety-seven (visit 1) and 98 (visit 2) respondents provided usable data for the psychometric analysis. The 29-item COAST scale showed good acceptability (few missing values, sample spread 28—100%), internal consistency and test—retest reliability for the scale (α = 0.95; ICC = 0.90) and its subscales (α = 0.65—0.93; ICC = 0.72—0.88), but possible item redundancy. A revised scale of 20 items was produced, demonstrating good internal consistency and test—retest reliability (α = 0.83—92; ICC = 0.72—0.88). Conclusions: The COAST is a patient-centred, practical and reliable measure that can be used to assess self-perceived communication effectiveness for people with aphasia and/or dysarthria. Further testing on construct validity and responsiveness to change is needed before the measure can be firmly recommended for use within clinical practice and research.

Communication outcome after stroke: a new measure of the carer’s perspective:

Objective: To validate a measure of the carer’s perspective of a stroke survivor’s communication in everyday life. Design: Cross-sectional, interview-based, psychometric study. Setting: A community sample from the northwest of England, UK. Subjects: Fifty-eight carers and 58 stroke survivors with communication problems (aphasia and/or dysarthria) following a stroke within the previous 4—12 months. Interventions: Administration of the 20-item Carer Communication Outcome after Stroke (Carer COAST) scale, on two occasions, within a two-week period; the 15-item Carers of Older People in Europe (COPE) Index, the patient Communication Outcome after Stroke (COAST) Scale, and collection of demographic and other data relating to the stroke survivor’s disability (Barthel Index), degree of aphasia (Frenchay Aphasia Screening Test) and hospital diagnosis of aphasia/dysarthria. Main measures: Acceptability (missing values), reliability (internal consistency and test—retest reliability) and construct validity. Results: Carer COAST showed good acceptability (no incomplete items, sample spread 24—100%), internal consistency and test—retest reliability for the scale (a = 0.94; intraclass correlation (ICC) = 0.91) and its subscales (a = 0.78—0.90; ICC = 0.75—0.87), and indicative evidence on construct validity (Carer COAST, COPE subscales and COAST). There were statistically significant correlations between the communication items of Carer COAST and the negative impact of caregiving (rs = —0.29) and the financial difficulties of caregiving (rs = —0.38). Conclusions: The Carer COAST scale has considerable potential as a reliable and valid measure of the carer’s perspective on the communication effectiveness of stroke survivors. Intercorrelations with COPE provide specific evidence of the impact of caring for a person with communication difficulties following a stroke.

Memory impairment following right hemisphere stroke: A comparative meta-analytic and narrative review

ABSTRACT We examined the evidence for widely held clinical beliefs about memory impairment following right hemisphere stroke (RHS), conducting both narrative and meta-analytic reviews of the literature [MEDLINE (1966-January 2003), PsycINFO (1974-January 2003), and CINAHL (1982-December 2002)]. We sought to determine whether RHS patients experience more problems with non-verbal memory than non-stroke controls (NSCs) and left hemisphere stroke (LHS) patients. Secondarily, we sought to determine whether RHS patients experience more problems with verbal memory than NSCs and fewer verbal memory problems than LHS patients. We also examined the effect of type of memory assessment (recall versus recognition) on reported findings. As regards non-verbal memory, narrative and meta-analytic reviews found that RHS patients had deficits relative to NSCs, on tests of both recall and recognition. The evidence for RHS non-verbal memory deficits relative to LHS was mixed in the narrative review, whereas the meta-analysis found RHS deficits on non-verbal recognition tests, but no difference between RHS and LHS patients on non-verbal recall tests. Deficits on recognition tests imply problems with early encoding of material or possibly its storage. Regarding verbal memory, the narrative review found that RHS patients performed more poorly than NSCs in about half of all studies. The meta-analytic review confirmed poorer RHS performance on tests of verbal recall, but none of the studies that compared RHS and NSCs on verbal recognition could be included in this type of review. The narrative review found mixed evidence as regards the performance of RHS and LHS patients on verbal memory tests, but the meta-analysis pointed to RHS superiority for both verbal recall and recognition. The relative strengths of both types of review are discussed.

Spatial Neglect: Is Rehabilitation Effective?

Section Editor: Graeme J. Hankey MD, FRACP ### Background Unilateral spatial neglect can reduce a person’s ability to look, listen, or make movements toward one half of their environment. Many rehabilitation approaches have been used to reduce the disabling effects of this cognitive deficit following stroke. These approaches have included training in visual scanning and providing tactile cues to draw attention to the affected side. ### Objectives This Cochrane systematic review aimed to determine the effects of cognitive rehabilitation for neglect following stroke as measured on impairment and activity (disability) level assessments, and destination on discharge from hospital. We also aimed to determine whether any effects persisted at follow-up assessment. ### Search Strategy We searched the Cochrane Stroke Group’s Trials …

Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence

Background: Although cognitive impairments are common following stroke, there is considerable uncertainty about the types of interventions that can reduce activity restrictions and improve quality of life. Indeed, a recent project to identify priorities for research into life after stroke determined that the top priority for patients, carers and health professionals was how to improve cognitive impairments. Objective: To provide an overview of the evidence for the effectiveness of cognitive rehabilitation for patients with stroke and to determine the main gaps in the current evidence base. Methods: Evidence was synthesised for the six Cochrane reviews relating to rehabilitation for post-stroke cognitive impairment and any subsequently published randomized controlled trials to February 2012. Results: Data arising from 44 trials involving over 1500 patients was identified. Though there was support for the effectiveness of cognitive rehabilitation for some cognitive impairments, significant gaps were found in the current evidence base. All of the Cochrane reviews identified major limitations within the evidence they identified. Conclusions: There is currently insufficient research evidence, or evidence of insufficient quality, to support clear recommendations for clinical practice. Recommendations are made as to the research required to strengthen the evidence base, and so facilitate the delivery of effective interventions to individuals with cognitive impairment after stroke.

Psychological services for people with stroke: compliance with the UK National Clinical Guidelines:

Background: The UK National Clinical Guidelines for Stroke (2000) include recommendations on psychological services. The third National Sentinel Audit of Stroke was completed in 2001-2002. Objectives: To examine the extent to which UK stroke services complied with the national guidelines. Design: Use of three retrospective case note audits of hospital admissions, covering the period from admission to six months after discharge, and audits of how stroke services were organized. Setting: Hospitals within England, Wales, Northern Ireland, the Channel Islands and the Isle of Man. Subjects: Stroke patients admitted consecutively within a three-month time frame. Main measures: Compliance with the guidelines on mood disorders and cognitive impairments, and changes between audits. Results: The 2001-2002 audit provided data on 60% of possible participants, from 145 hospitals and 5152 patients. Compliance with the guideline to screen for mood disturbance was poor; the median patient compliance rate of hospitals was 50%. More hospitals (88%) had a locally agreed cognitive assessment protocol in 2001-2002 than in 1998 (68%) and in 1999 (82%). However, actual rates of screening for cognitive difficulties were lower than implied by the existence of a local protocol. There were no strong case-mix associates of mood and cognitive screening. Access to clinical psychologists was poor. Mood and cognitive assessment rates were not much better for stroke units with access to clinical psychologists than for units without access (mood: p = 0.6, cognition: p = 0.09). Conclusions: Although compliance with some of the guidelines has improved, many areas in current psychological services for stroke urgently need attention.