Caroline Leigh Watkins

Prevalence of spasticity post stroke

Objectives: To establish the prevalence of spasticity 12 months after stroke and examine its relationship with functional ability. Design: A cohort study of prevalence of spasticity at 12 months post stroke. Setting: Initially hospitalized but subsequently community-dwelling stroke survivors in Liverpool, UK. Subjects: One hundred and six consecutively presenting stroke patients surviving to 12 months. Main outcome measures: Muscle tone measured at the elbow using the Modi”ed Ashworth Scale and at several joints, in the arms and legs, using the Tone Assessment Scale; functional ability using the modi”ed Barthel Index. Results: Increased muscle tone (spasticity) was present in 29 (27%) and 38 (36%) of the 106 patients when measured using the Modi”ed Ashworth Scale and Tone Assessment Scale respectively. Combining the results from both scales produced a prevalence of 40 (38%). Those with spasticity had signi”cantly lower Barthel scores at 12 months (p < 0.0001). Conclusion: When estimating the prevalence of spasticity it is essential to assess both arms and legs, using both scales. Despite measuring tone at several joints, spasticity was demonstrated in only 40 (38%) patients, lower than previous estimates.

Reliability of the tone assessment scale and the modified ashworth scale as clinical tools for assessing poststroke spasticity

OBJECTIVES To establish reliability of the Tone Assessment Scale and modified Ashworth scale in acute stroke patients. SETTING A North Liverpool university hospital. PATIENTS Eighteen men and 14 women admitted with acute stroke and still in hospital at the study start date (median age, 74 yrs; median Barthel score, 8). MAIN OUTCOME MEASURES The modified Ashworth scale and the Tone Assessment Scale. STUDY DESIGN The 32 patients were examined with both scales on the same occasion by two raters (interrater comparison) and on two occasions by one rater (intrarater comparison). RESULTS The reliability of the modified Ashworth scale was very good (kappa = .84 for interrater and .83 for intrarater comparisons). The reliability of the Tone Assessment Scale was not as strong as the modified Ashworth scale, with marked variability in the assessment of posture (kappa = .22 to .50 for interrater and .29 to .55 for intrarater comparisons) and associated reaction (kappa/kappaW = -.05 to .79 for interrater and .19 to .83 for intrarater comparisons). However, those aspects of the Tone Assessment Scale that addressed response to passive movement and that are scored similarly to the modified Ashworth scale showed good to very good interrater reliability (kappaW = .79 to .92) and good to very good intrarater reliability (kappaW = .72 to .86), except for the question related to movement at the ankle where agreement was only moderate (kappaW = .59). CONCLUSIONS The modified Ashworth scale is reliable. The section of the Tone Assessment Scale relating to response to passive movement is reliable at various joints, except the ankle. It may assist in studies on the prevalence of spasticity after stroke and the relationship between tone and function. Further development of a measure of spasticity at the ankle is required. The Tone Assessment Scale is not reliable for measuring posture and associated reactions.

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

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.

Stroke knowledge and awareness: an integrative review of the evidence

BACKGROUND the recognition of stroke symptoms by the public and activation of the emergency medical services (EMS) are the most important factors in instigating pre-hospital stroke care. Studies have suggested that poor recognition of the warning signs of stroke is the main cause of delay in accessing the EMS. METHODS an integrative review of published studies about stroke knowledge and awareness was performed by searching online bibliographic databases, using keywords, from 1966 to 2008. Studies were included in the review if they focussed on risk factors, signs and symptoms, action and information. Each study was reviewed by two researchers (SJ and MJ). RESULTS we identified 169 studies of which 39 were included in the review. The ability to name one risk factor for stroke varied between studies, ranging from 18% to 94% when asked open-ended questions and from 42% to 97% when asked closed questions. The ability to name one symptom ranged from 25% to 72% when asked open-ended questions and from 95% to 100% when asked closed questions. When asked what action people would take if they thought they were having a stroke, between 53% and 98% replied that they would call the EMS. People generally obtained information about stroke from family and friends. Older members of the population, ethnic minority groups and those with lower levels of education had consistently poor levels of stroke knowledge. CONCLUSIONS generally, levels of knowledge about recognising and preventing stroke were poor. Nevertheless, most participants stated they would contact the EMS at the onset of stroke symptoms.

Very Early Rehabilitation or Intensive Telemetry after Stroke: A Pilot Randomised Trial

Background: Stroke patients are more likely to make a good recovery if they receive care in a well-organised stroke unit. However, there are uncertainties about how best to provide such care. We studied 2 key aspects of early stroke unit care: early active mobilisation (EM) and automated monitoring (AM) for physiological complications such as hypoxia. Methods: This was an observer-blinded, factorial (2 × 2) pilot randomised controlled trial recruiting stroke patients within 36 h of symptom onset. The patients were randomised to 1 of 4 nurse-led treatment protocols: (a) standard stroke unit care, (b) EM, (c) AM or (d) combined EM and AM. The primary outcome was the Rankin score at 3 months. We also report the data on feasibility and safety. Results: We randomised 32 patients (mean age = 65 years; mean baseline modified NIH score = 6). On unadjusted comparisons, the EM patients were significantly (p < 0.05) more likely to mobilise very early (within 1 h of randomisation) and to achieve walking by day 5 and were less likely to develop complications of immobility. The AM group was significantly (p < 0.05) more likely to have pre-defined physiological complication events detected. All these associations remained, but were less statistically significant, after correcting for age, baseline NIH score and co-interventions. There were no significant safety concerns. Discussion: We have demonstrated the feasibility of implementing EM and AM for physiological complications in a randomised controlled trial. Larger trials are warranted to determine whether these interventions have clinical benefits.

“Do none of you talk to each other?”: the challenges facing the implementation of interprofessional education

There is a growing interest internationally in the development of interprofessional education (IPE), with the potential goal of achieving more effective healthcare delivery. The aim of this study is to explore the feasibility of introducing IPE within undergraduate health professional programmes, using a systematic review of the evidence and focus-group interviews. This paper reports findings from the focus-group interviews. Three focus-group interviews, each lasting two hours, were conducted. Participants (n = 34) were drawn from the clinical and academic environments, from health service consumers and from health professional students. Two areas were explored: (1) the feasibility of IPE and (2) perceptions of its effects. Each focus group had a primary facilitator who led the group discussion and a second facilitator audiotaping discussions and writing observational notes. Three main themes emerged: the advantages of IPE, the challenges of initiating IPE, and the role of IPE in the creation of professional identification. There was consensus in the view that IPE had much potential in breaking down traditional barriers to team working, including professional ‘tribalism’. It is important for IPE to be integrated with interprofessional experiences in clinical practice. Further empirical work, focusing on student and patient outcomes in IPE, is needed.

Predicting spasticity after stroke in those surviving to 12 months

Objective: To measure muscle tone in a cohort of patients 12 months after stroke and develop a preliminary model, using data recorded routinely after stroke, to predict who will develop spasticity. Design: A cohort study. Setting: Initially hospitalized but subsequently community-dwelling stroke survivors in Liverpool, United Kingdom. Subjects: One hundred and six consecutively presenting stroke patients surviving to 12 months. Main outcome measures: Spasticity measured at a range of joints using the Tone Assessment Scale. Results: The Tone Assessment Scale revealed spasticity in 38 (36%) patients and more severe spasticity in 21 (20%) of the 106 patients. Logistic regression analysis revealed that lower day 7 Barthel Index score and early arm or leg weakness were significant predictors of abnormal muscle tone; and lower day 7 Barthel Index score, left-sided weakness and ever smoked to be significant predictors of more severe muscle tone. Conclusions: Using the models, it may be possible to predict whether or not spasticity will develop in patients 12 months after stroke. The utility of the models is aided by their use of predictor variables that are routinely collected as part of stroke care in hospital and which are easy to measure. The models need testing prospectively in a new cohort of patients in order to test their validity, reliability and utility and to determine if other data could improve their efficiency.

Post-stroke dysphagia: A review and design considerations for future trials

Post-stroke dysphagia (a difficulty in swallowing after a stroke) is a common and expensive complication of acute stroke and is associated with increased mortality, morbidity, and institutionalization due in part to aspiration, pneumonia, and malnutrition. Although most patients recover swallowing spontaneously, a significant minority still have dysphagia at six months. Although multiple advances have been made in the hyperacute treatment of stroke and secondary prevention, the management of dysphagia post-stroke remains a neglected area of research, and its optimal management, including diagnosis, investigation and treatment, have still to be defined.

Hi4D-ADSIP 3-D dynamic facial articulation database

The face is an important medium used by humans to communicate, and facial articulation also reflects a persons emotional and awareness states, cognitive activity, personality or wellbeing. With the advances in 3-D imaging technology and ever increasing computing power, automatic analysis of facial articulation using 3-D sequences is becoming viable. This paper describes Hi4D-ADSIP - a comprehensive 3-D dynamic facial articulation database, containing scans with high spatial and temporal resolution. The database is designed not only to facilitate studies on facial expression analysis, but also to aid research into clinical diagnosis of facial dysfunctions. The database currently contains 3360 facial sequences captured from 80 healthy volunteers (control subjects) of various age, gender and ethnicity. The database has been validated using psychophysical experiments used to formally evaluate the accuracy of the recorded expressions. The results of baseline automatic facial expression recognition methods using Eigen- and Fisher-faces are also presented alongside some initial results obtained for clinical cases. This database is believed to be one of the most comprehensive repositories of facial 3-D dynamic articulations to date. The extension of this database is currently under construction aiming at building a comprehensive repository of representative facial dysfunctions exhibited by patients with stroke, Bells palsy and Parkinsons disease.