Caroline L Watkins

An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial

Objective To evaluate the clinical efficacy of an established programme of occupational therapy in maintaining functional activity and reducing further health risks from inactivity in care home residents living with stroke sequelae. Design Pragmatic, parallel group, cluster randomised controlled trial. Setting 228 care homes (>10 beds each), both with and without the provision of nursing care, local to 11 trial administrative centres across the United Kingdom. Participants 1042 care home residents with a history of stroke or transient ischaemic attack, including those with language and cognitive impairments, not receiving end of life care. 114 homes (n=568 residents, 64% from homes providing nursing care) were allocated to the intervention arm and 114 homes (n=474 residents, 65% from homes providing nursing care) to standard care (control arm). Participating care homes were randomised between May 2010 and March 2012. Intervention Targeted three month programme of occupational therapy, delivered by qualified occupational therapists and assistants, involving patient centred goal setting, education of care home staff, and adaptations to the environment. Main outcome measures Primary outcome at the participant level: scores on the Barthel index of activities of daily living at three months post-randomisation. Secondary outcome measures at the participant level: Barthel index scores at six and 12 months post-randomisation, and scores on the Rivermead mobility index, geriatric depression scale-15, and EuroQol EQ-5D-3L questionnaire, at all time points. Results 64% of the participants were women and 93% were white, with a mean age of 82.9 years. Baseline characteristics were similar between groups for all measures, personal characteristics, and diagnostic tests. Overall, 2538 occupational therapy visits were made to 498 participants in the intervention arm (mean 5.1 visits per participant). No adverse events attributable to the intervention were recorded. 162 (11%) died before the primary outcome time point, and 313 (30%) died over the 12 months of the trial. The primary outcome measure did not differ significantly between the treatment arms. The adjusted mean difference in Barthel index score at three months was 0.19 points higher in the intervention arm (95% confidence interval −0.33 to 0.70, P=0.48). Secondary outcome measures also showed no significant differences at all time points. Conclusions This large phase III study provided no evidence of benefit for the provision of a routine occupational therapy service, including staff training, for care home residents living with stroke related disabilities. The established three month individualised course of occupational therapy targeting stroke related disabilities did not have an impact on measures of functional activity, mobility, mood, or health related quality of life, at all observational time points. Providing and targeting ameliorative care in this clinically complex population requires alternative strategies. Trial registration Current Controlled Trials ISRCTN00757750.

Repetitive task training after stroke: A Cochrane review [Abstract no.116]

Introduction: nAphasia affects a third of stroke survivors (~5.6 million worldwide annually). The social and emotional impact of aphasia makes timely and effective rehabilitation vital. Speech and language therapy benefits recovery; however the specific patient, stroke, aphasia and intervention factors which optimise recovery and rehabilitation are unclear. We will explore these uncertainties in our RELEASE study (NIHR HS&DR 14/04/22). In Phase I of this study we aimed to create a large, collaborative, international database of individual patient data (IPD) from pre-existing aphasia research. n nMethod: nEligible datasets included IPD of ≥10 people with stroke-related aphasia, with time poststroke specified and aphasia severity data. Contributions were invited from international, multidisciplinary, aphasia research collaborators via the EU COST funded Collaboration of Aphasia Trialists. We also conducted a systematic search of the literature [Cochrane Stroke Group Trials, MEDLINE, CINAHL, AMED, Cochrane Library Databases (CDSR, DARE, CENTRAL, HTA), EMBASE, LLBA and SpeechBITE from inception to Sept 2015 for additional datasets. Two independent reviewers considered full texts, a third resolved any conflicts. n nResults: nAs of June 2016 our database included 2,531 IPD from 11 countries (33 datasets). Nine were in the public domain. Following the systematic search of 5,272 records (of which 75 duplicates, 2,395 reference titles and 965 abstracts were excluded) further datasets were identified and the investigators of these datasets invited to collaborate. n nConclusion: nWe succeeded in creating a large, collaborative, international aphasia database of preexisting IPD. A systematic search process to identify additional datasets eligible for inclusion supplemented more informal dataset recruitment methods.Introduction: Shortening the time to delivery of IV thrombolysis improves patient outcomes and reduces adverse events. This research aimed to explore patient and service delivery factors that increase or decrease DTN time for thrombolysis. nMethod: We conducted a Service Evaluation from July 2011 to March 2013, using stroke data from SINAP and DASH databases. Data was provided by 6 acute trusts in Lancashire and Cumbria which used telemedicine, and 11 stroke services within the North East of England which instead used face-to-face. Our investigation concentrates on admissions to hospital occurring out of routine working hours, when resources are particularly constrained. Descriptive and inferential analyses, focusing on multivariate Cox regressions models selected using a forward stepwise approach, were then carried out to determine which factors impacted on DTN time, our main outcome variable. Results: After testing alternative specifications, our final model included these potential risk factors: mode of thrombolysis decision-making (either face-to-face or telemedicine); hospital; age; sex. Our results show that DTN time was strongly influenced by patient’s age (p<0.01), with older people receiving thrombolysis more quickly. Among the statistically significant variables, type of hospital (p<0.001) nappeared to affect DTN times, together with patient’s sex (p¼0.01), suggesting that males had shorter DTN times. nConclusion: Older age was associated with shorter DTN times, with this effect being independent of other factors. Therefore, our research suggests that age played a predominant role in the delivery of thrombolysis, rather than solely through the choice of assessing acute strokethrough face-to-face or telemedicine.Introduction: Repetitive task training involves the active practice of task-specific motor activities. We updated our Cochrane Review published in 2007. nMethod: We searched MEDLINE (01/10/2006 – 08/03/2016), EMBASE (01/10/2006 – 07/03/2016) and the Cochrane Stroke Trials Register (04/03/2016). 2 authors independently screened abstracts, extracted data and appraised trials. Quality of evidence within each study and outcome group was determined using the Cochrane Collaboration Risk of Bias Tool (CCRBT) and GRADE criteria. nResults: 29 trials with 1759 participants were included. Results were statistically significant for arm function (standardised mean difference (SMD) 0.25, 95% CI 0.11 to 0.40), hand function (SMD 0.28, 95% CI 0.12 to 0.44), sitting balance/reach (SMD 0.28, 95% CI 0.01 to 0.55), walking distance (MD 38.80, 95% CI 24.75 to 52.86), walking speed (SMD 0.33, 95% CI 0.18 to 0.49), functional ambulation (SMD 0.26, 95% CI 0.08 to 0.43), sit-to-stand (Standardised effect 0.35, 95% CI 0.13 to 0.56), lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48), standing balance/reach (SMD 0.27, 95% CI 0.09 to 0.45) and global motor function (SMD 0.38, 95% CI 0.11 to 0.65). Follow-up measures were significant for both upper and lower limb outcomes up to 6 months post-treatment. nConclusion: Repetitive task training resulted in improvement in upper and lower limb function; improvements were sustained up to 6 months post-treatment. Further research should focus on the type and amount of training, including measuring the number of repetitions performed.

The journey from transient ischaemic attack to clinic: Qualitative study of people's response to symptoms and routes to assessment

Introduction: nAphasia affects a third of stroke survivors (~5.6 million worldwide annually). The social and emotional impact of aphasia makes timely and effective rehabilitation vital. Speech and language therapy benefits recovery; however the specific patient, stroke, aphasia and intervention factors which optimise recovery and rehabilitation are unclear. We will explore these uncertainties in our RELEASE study (NIHR HS&DR 14/04/22). In Phase I of this study we aimed to create a large, collaborative, international database of individual patient data (IPD) from pre-existing aphasia research. n nMethod: nEligible datasets included IPD of ≥10 people with stroke-related aphasia, with time poststroke specified and aphasia severity data. Contributions were invited from international, multidisciplinary, aphasia research collaborators via the EU COST funded Collaboration of Aphasia Trialists. We also conducted a systematic search of the literature [Cochrane Stroke Group Trials, MEDLINE, CINAHL, AMED, Cochrane Library Databases (CDSR, DARE, CENTRAL, HTA), EMBASE, LLBA and SpeechBITE from inception to Sept 2015 for additional datasets. Two independent reviewers considered full texts, a third resolved any conflicts. n nResults: nAs of June 2016 our database included 2,531 IPD from 11 countries (33 datasets). Nine were in the public domain. Following the systematic search of 5,272 records (of which 75 duplicates, 2,395 reference titles and 965 abstracts were excluded) further datasets were identified and the investigators of these datasets invited to collaborate. n nConclusion: nWe succeeded in creating a large, collaborative, international aphasia database of preexisting IPD. A systematic search process to identify additional datasets eligible for inclusion supplemented more informal dataset recruitment methods.Introduction: Shortening the time to delivery of IV thrombolysis improves patient outcomes and reduces adverse events. This research aimed to explore patient and service delivery factors that increase or decrease DTN time for thrombolysis. nMethod: We conducted a Service Evaluation from July 2011 to March 2013, using stroke data from SINAP and DASH databases. Data was provided by 6 acute trusts in Lancashire and Cumbria which used telemedicine, and 11 stroke services within the North East of England which instead used face-to-face. Our investigation concentrates on admissions to hospital occurring out of routine working hours, when resources are particularly constrained. Descriptive and inferential analyses, focusing on multivariate Cox regressions models selected using a forward stepwise approach, were then carried out to determine which factors impacted on DTN time, our main outcome variable. Results: After testing alternative specifications, our final model included these potential risk factors: mode of thrombolysis decision-making (either face-to-face or telemedicine); hospital; age; sex. Our results show that DTN time was strongly influenced by patient’s age (p<0.01), with older people receiving thrombolysis more quickly. Among the statistically significant variables, type of hospital (p<0.001) nappeared to affect DTN times, together with patient’s sex (p¼0.01), suggesting that males had shorter DTN times. nConclusion: Older age was associated with shorter DTN times, with this effect being independent of other factors. Therefore, our research suggests that age played a predominant role in the delivery of thrombolysis, rather than solely through the choice of assessing acute strokethrough face-to-face or telemedicine.Introduction: Repetitive task training involves the active practice of task-specific motor activities. We updated our Cochrane Review published in 2007. nMethod: We searched MEDLINE (01/10/2006 – 08/03/2016), EMBASE (01/10/2006 – 07/03/2016) and the Cochrane Stroke Trials Register (04/03/2016). 2 authors independently screened abstracts, extracted data and appraised trials. Quality of evidence within each study and outcome group was determined using the Cochrane Collaboration Risk of Bias Tool (CCRBT) and GRADE criteria. nResults: 29 trials with 1759 participants were included. Results were statistically significant for arm function (standardised mean difference (SMD) 0.25, 95% CI 0.11 to 0.40), hand function (SMD 0.28, 95% CI 0.12 to 0.44), sitting balance/reach (SMD 0.28, 95% CI 0.01 to 0.55), walking distance (MD 38.80, 95% CI 24.75 to 52.86), walking speed (SMD 0.33, 95% CI 0.18 to 0.49), functional ambulation (SMD 0.26, 95% CI 0.08 to 0.43), sit-to-stand (Standardised effect 0.35, 95% CI 0.13 to 0.56), lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48), standing balance/reach (SMD 0.27, 95% CI 0.09 to 0.45) and global motor function (SMD 0.38, 95% CI 0.11 to 0.65). Follow-up measures were significant for both upper and lower limb outcomes up to 6 months post-treatment. nConclusion: Repetitive task training resulted in improvement in upper and lower limb function; improvements were sustained up to 6 months post-treatment. Further research should focus on the type and amount of training, including measuring the number of repetitions performed.

Patients' needs following transient ischaemic attack: A mixed methods study of patients’ carers’ and healthcare professionals’ views

Introduction: nAphasia affects a third of stroke survivors (~5.6 million worldwide annually). The social and emotional impact of aphasia makes timely and effective rehabilitation vital. Speech and language therapy benefits recovery; however the specific patient, stroke, aphasia and intervention factors which optimise recovery and rehabilitation are unclear. We will explore these uncertainties in our RELEASE study (NIHR HS&DR 14/04/22). In Phase I of this study we aimed to create a large, collaborative, international database of individual patient data (IPD) from pre-existing aphasia research. n nMethod: nEligible datasets included IPD of ≥10 people with stroke-related aphasia, with time poststroke specified and aphasia severity data. Contributions were invited from international, multidisciplinary, aphasia research collaborators via the EU COST funded Collaboration of Aphasia Trialists. We also conducted a systematic search of the literature [Cochrane Stroke Group Trials, MEDLINE, CINAHL, AMED, Cochrane Library Databases (CDSR, DARE, CENTRAL, HTA), EMBASE, LLBA and SpeechBITE from inception to Sept 2015 for additional datasets. Two independent reviewers considered full texts, a third resolved any conflicts. n nResults: nAs of June 2016 our database included 2,531 IPD from 11 countries (33 datasets). Nine were in the public domain. Following the systematic search of 5,272 records (of which 75 duplicates, 2,395 reference titles and 965 abstracts were excluded) further datasets were identified and the investigators of these datasets invited to collaborate. n nConclusion: nWe succeeded in creating a large, collaborative, international aphasia database of preexisting IPD. A systematic search process to identify additional datasets eligible for inclusion supplemented more informal dataset recruitment methods.Introduction: Shortening the time to delivery of IV thrombolysis improves patient outcomes and reduces adverse events. This research aimed to explore patient and service delivery factors that increase or decrease DTN time for thrombolysis. nMethod: We conducted a Service Evaluation from July 2011 to March 2013, using stroke data from SINAP and DASH databases. Data was provided by 6 acute trusts in Lancashire and Cumbria which used telemedicine, and 11 stroke services within the North East of England which instead used face-to-face. Our investigation concentrates on admissions to hospital occurring out of routine working hours, when resources are particularly constrained. Descriptive and inferential analyses, focusing on multivariate Cox regressions models selected using a forward stepwise approach, were then carried out to determine which factors impacted on DTN time, our main outcome variable. Results: After testing alternative specifications, our final model included these potential risk factors: mode of thrombolysis decision-making (either face-to-face or telemedicine); hospital; age; sex. Our results show that DTN time was strongly influenced by patient’s age (p<0.01), with older people receiving thrombolysis more quickly. Among the statistically significant variables, type of hospital (p<0.001) nappeared to affect DTN times, together with patient’s sex (p¼0.01), suggesting that males had shorter DTN times. nConclusion: Older age was associated with shorter DTN times, with this effect being independent of other factors. Therefore, our research suggests that age played a predominant role in the delivery of thrombolysis, rather than solely through the choice of assessing acute strokethrough face-to-face or telemedicine.Introduction: Repetitive task training involves the active practice of task-specific motor activities. We updated our Cochrane Review published in 2007. nMethod: We searched MEDLINE (01/10/2006 – 08/03/2016), EMBASE (01/10/2006 – 07/03/2016) and the Cochrane Stroke Trials Register (04/03/2016). 2 authors independently screened abstracts, extracted data and appraised trials. Quality of evidence within each study and outcome group was determined using the Cochrane Collaboration Risk of Bias Tool (CCRBT) and GRADE criteria. nResults: 29 trials with 1759 participants were included. Results were statistically significant for arm function (standardised mean difference (SMD) 0.25, 95% CI 0.11 to 0.40), hand function (SMD 0.28, 95% CI 0.12 to 0.44), sitting balance/reach (SMD 0.28, 95% CI 0.01 to 0.55), walking distance (MD 38.80, 95% CI 24.75 to 52.86), walking speed (SMD 0.33, 95% CI 0.18 to 0.49), functional ambulation (SMD 0.26, 95% CI 0.08 to 0.43), sit-to-stand (Standardised effect 0.35, 95% CI 0.13 to 0.56), lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48), standing balance/reach (SMD 0.27, 95% CI 0.09 to 0.45) and global motor function (SMD 0.38, 95% CI 0.11 to 0.65). Follow-up measures were significant for both upper and lower limb outcomes up to 6 months post-treatment. nConclusion: Repetitive task training resulted in improvement in upper and lower limb function; improvements were sustained up to 6 months post-treatment. Further research should focus on the type and amount of training, including measuring the number of repetitions performed.