Charlotte Winward

A Population-Based Study of the Prevalence of Fatigue After Transient Ischemic Attack and Minor Stroke

Background and Purpose— Fatigue is common after stroke and can be attributable to the increased physical effort associated with severe neurological deficits; however, its presence in those with little motor deficit raises the possibility of confounding by other factors, such as comorbidity, anxiety, and medication. To control for such factors and determine the extent of stroke-specific fatigue, we compared patients with minor stroke who had little or no residual neurological deficit with patients with TIA; both groups had undergone similar investigations and treatment. Methods— The prevalence of fatigue 6 months after TIA or minor stroke was assessed in consecutive patients using the Chalder fatigue scale in a population-based incidence study (Oxford Vascular Study). Patients were included if they were independent in self-care Barthel Index (≥18/20) and without major cognitive impairment (Mini-Mental State Examination ≥24/30). Stroke severity at baseline was assessed with the National Institute of Health Stroke Scale (NIHSS). Other potential causes of fatigue were assessed including anxiety, depression, recent life events, medication, and abnormalities in biochemistry or hematologic tests. Results— Seventy-six participants had minor stroke (mean age, 74.1 years; 42 men) and 73 had TIA (mean age, 72.5 years; 40 men). At 6-month follow-up, median Barthel Index score was 20 (interquartile range, 20–20) in both groups. However, fatigue was more common after stroke than TIA (56% vs 29%; OR, 3.14; 95% CI, 1.51–6.57; P=0.0008). This difference was present both in patients with modified Rankin score of 0 at 6 months (23.8% vs 10.3%) and patients with modified Rankin score ≥1 (69.2% vs 48.6%), and remained more frequent in stroke patients after adjustment for potential confounders. Within the group of patients with stroke, the prevalence of fatigue increased with initial stroke severity (87% NIHSS ≥4 vs 48% NIHSS ≤3; P=0.0087); however, stroke patients with initial NIHSS of 0 were still more fatigued than patients with TIA (57% vs 29%; P=0.015). Conclusions— The prevalence of fatigue after minor stroke is higher than after TIA, suggesting that it is not simply a consequence of the stress of a recent acute cerebral event, comorbidity, medication, or other potential confounders. The high levels of fatigue in stroke patients without neurological impairment suggest it has a central origin rather than being the result of increased physical effort required after stroke.

The Rivermead Assessment of Somatosensory Performance (RASP): standardization and reliability data

Objective: To develop a standardized, clinically relevant, quantitative assessment of somatosensory performance in patients with stroke. Design: Prospective observational study and test evaluation. Setting: Local Oxford hospitals and a regional neurological rehabilitation centre. Subjects: Stroke patients with a ”rst, lateralized acute stroke in hospital, and age-matched control subjects. Method: Each patient was assessed in a structured way using a new battery of formal tests of somatosensory performance. Results: A total of 100 patients and 50 controls were fully investigated. Control subjects performed at or near ceiling on all tests, but patients showed impaired performance on all tests. The Rivermead Assessment of Somatosensory Performance (RASP) showed good intra-rater and inter-rater reliability for all subtests. There were however only weak relationships between scores of sensory impairment and scores of motor impairment or mobility and dependence. Conclusions: The RASP provides a practical and reliable assessment of sensory loss, which provides the clinician with a comprehensive picture of the patient’s performance and can be used to inform and monitor rehabilitation and recovery.

Current practice and clinical relevance of somatosensory assessment after stroke

Objective: To examine the perceived clinical relevance, current practice and knowledge of somatosensory testing in three professional groups involved in the management and rehabilitation of stroke. Design: Structured postal questionnaire sent to therapists and doctors. Subjects: One hundred and eighty occupational therapists from the National Association of Neurological Occupational Therapists (NANOT), 180 physiotherapists from the Association of Chartered Physiotherapists with an Interest in Neurology (ACPIN) and 360 doctors from the Association of British Neurologists (ABN) and the British Geriatrics Society (BSG). Setting: Hospitals and rehabilitation centres in the UK. Results: Replies were obtained from 84 occupational therapists (47%), 98 physiotherapists (55%) and 78 doctors (22%). Sixty-four occupational therapists (77%), 82 physiotherapists (84%) and 66 doctors (87%) indicated that they routinely performed somatosensory assessment as part of their clinical assessment. The two most commonly used measures were proprioception and light touch. Seventy-eight occupational therapists (93%), 88 physiotherapists (90%) and 67 doctors (91%) regarded sensory assessment as clinically significant in determining prognosis after stroke. Conclusions: Despite published reservations concerning its usefulness and reliability, most therapists and doctors routinely assess somatosensory loss after stroke. All three professions agreed that somatosensory testing presented useful information for prognosis. Furthermore, all professional groups believe somatosensory assessment to be clinically relevant.

Somatosensory recovery: A longitudinal study of the first 6 months after unilateral stroke

Purpose. The aim of this study was to characterize the recovery pattern of stroke patients in the first 6 months following stroke. Method. Using the Rivermead Assessment of Somatosensory Performance (RASP), the Motricity index and the Barthel Activities of Daily Living (ADL) index, a case series of serial somatosensory and motor measurements was made on 18 patients with a diagnosis of a first ever stroke. Patients comprised 2 distinct groups, acute and subacute. The acute group were seen weekly for the first month post onset and the subacute group were seen monthly for 6 months. Participants were seen at hospital, regional rehabilitation unit and/or the participants home. Standard local rehabilitation was given. Results. The somatosensory subtest of proprioception demonstrated the greatest level of recovery. No patient achieved full recovery on all somatosensory subtests. Motor and functional recovery demonstrated continual improvement over time, somatosensory recovery showed marked variation in subtests both within and between patients. Conclusion. Of the 18 patients tested there were no consistent, generalizable, recognizable patterns of sensory recovery demonstrated.

Pedometer step counts in individuals with neurological conditions

Objective: To examine the accuracy of measuring step counts using a pedometer in participants with neurological conditions and healthy volunteers in relation to a manual step count tally. Setting: Oxford Centre for Enablement, Nuffield Orthopaedic Centre NHS Trust, Oxford, UK. Subjects: Healthy adults (n = 13, age: mean 29, SD = 12) and adults with neurological conditions (n=20 stroke, n=16 multiple sclerosis, n=5 muscular dystrophy, n=1 spinal cord injury, n=1 traumatic brain injury; age: mean 54, SD=13). Main measures: Individuals walked for 2 minutes at self-selected walking speeds (SSWS) wearing a pedometer. Healthy individuals were then asked to walk at slow walking speeds (SWS). Step counts were recorded manually and using a pedometer. Results: In healthy individuals there was no difference between manually measured and pedometer counts during walking (P>0.05). In adults with neurological conditions the pedometers undercounted (P = 0.003); bias (random error): 27 (111); percentage variability 30% and intraclass correlation coefficient (ICC) 0.66. In neurological adults, from regression analysis the relationship between error and walking speed was cubic, with walking speed accounting for 29% of pedometer error. Healthy individuals showed greater variability and undercounting at SWS bias (random error): 10 (31), percentage variability 8% and ICC 0.73, compared with SSWS bias (random error): —3 (13), percentage variability 3% and ICC 0.84. Conclusions: Pedometers may undercount when used for people with neurological conditions. There may be variability in pedometer accuracy but this was not strongly related to walking speed. The suitability of pedometer use for exercise monitoring should be individually determined.

Interventions for fatigue in Parkinson's disease: A systematic review and meta-analysis

The authors sought to review the efficacy of interventions for fatigue in Parkinsons disease. A search was conducted of PubMed, Cinahl, Psychinfo, EMBASE, and Web of Knowledge up to November 2013. Methodological quality was assessed using the PEDro scale. For meta‐analyses, studies were weighted on variance. Effect sizes were calculated with 95% confidence interval (CI); overall effect was presented by means of a Z‐score; heterogeneity was investigated using the I2. Fourteen articles (n = 1,890) investigating drugs and behavioral therapy were eligible. Ten studies demonstrated excellent, three good, and one fair methodological quality. Three articles (investigating amphetamines) were appropriate for meta‐analysis, which was performed according to scales used: Multidimensional Fatigue Inventory: mean difference, –6.13 (95%CI: –14.63‐2.37, Z = 1.41, P = 0.16; I2 = 0); Fatigue Severity Scale: mean difference, –4.00 (95%CI: –8.72‐0.72, Z = 1.66, P = 0.10; I2 = 0). Currently insufficient evidence exists to support the treatment of fatigue in PD with any drug or nondrug treatment. Further study is required.

Weekly exercise does not improve fatigue levels in Parkinson's disease.

Fatigue is one of the most disabling non‐motor symptoms for people with Parkinsons disease. Exercise may modify fatigue. This study examines prescribed exercise effects on physical activity levels, well‐being, and fatigue in Parkinsons disease.

Supported community exercise in people with long-term neurological conditions: a phase II randomized controlled trial

Objective: Adults with long-term neurological conditions have low levels of participation in physical activities and report many barriers to participation in exercise. This study examines the feasibility and safety of supporting community exercise for people with long-term neurological conditions using a physical activity support system. Design: A phase II randomized controlled trial using computer-generated block randomization, allocation concealment and single blind outcome assessment. Setting: Oxfordshire and Birmingham community Inclusive Fitness Initiative gyms. Subjects: Patients with a long-term neurological condition. Interventions: The intervention group (n = 51) received a 12-week, supported exercise programme. The control group (n = 48) participants received standard care for 12 weeks and were then offered the intervention. Main measures: Physical activity, adherence to exercise, measures of mobility, health and well-being. Results: Forty-eight patients (n = 51) completed the intervention, achieving 14 gym attendances (range 0–39) over the 12 weeks. Overall activity did not increase as measured by the Physical Activity Scale for the Elderly (change score mean 14.31; 95% confidence interval (CI) −8.27 to 36.89) and there were no statistically significant changes in body function and health and well-being measures. Conclusions: People with long-term neurological conditions can safely exercise in community gyms when supported and achieve similar attendance to standard exercise referral schemes, but may reduce other life activities in order to participate at a gym.

Phase II randomised controlled trial of a 6-month self-managed community exercise programme for people with Parkinson's disease.

Background Evidence for longer term exercise delivery for people with Parkinsons disease (PwP) is deficient. Aim Evaluate safety and adherence to a minimally supported community exercise intervention and estimate effect sizes (ES). Methods 2-arm parallel phase II randomised controlled trial with blind assessment. PwP able to walk ≥100 m and with no contraindication to exercise were recruited from the Thames valley, UK, and randomised (1:1) to intervention (exercise) or control (handwriting) groups, via a concealed computer-generated list. Groups received a 6-month, twice weekly programme. Exercise was undertaken in community facilities (30 min aerobic and 30 min resistance) and handwriting at home, both were delivered through workbooks with monthly support visits. Primary outcome was a 2 min walk, with motor symptoms (Movement Disorder Society Unified Parkinsons Disease Rating Scale, MDS-UPDRS III), fitness, health and well-being measured. Results Between December 2011 and August 2013, n=53 (n=54 analysed) were allocated to exercise and n=52 (n=51 analysed) to handwriting. N=37 adhered to the exercise, most attending ≥1 session/week. Aerobic exercise was performed in 99% of attended sessions and resistance in 95%. Attrition and adverse events (AEs) were similar between groups, no serious AEs (n=2 exercise, n=3 handwriting) were related, exercise group-related AEs (n=2) did not discontinue intervention. Largest effects were for motor symptoms (2 min walk ES=0.20 (95% CI −0.44 to 0.45) and MDS-UPDRS III ES=−0.30 (95% CI 0.07 to 0.54)) in favour of exercise over the 12-month follow-up period. Some small effects were observed in fitness and well-being measures (ES>0.1). Conclusions PwP exercised safely and the possible long-term benefits observed support a substantive evaluation of this community programme. Trial registration number NCT01439022.

A long-term self-managed handwriting intervention for people with Parkinson’s disease: results from the control group of a phase II randomized controlled trial

Objective: To report on the control group of a trial primarily designed to investigate exercise for improving mobility in people with Parkinson’s disease (pwP). The control group undertook a handwriting intervention to control for attention and time spent practising a specific activity. Design: Secondary analysis of a two-arm parallel phase II randomized controlled trial with blind assessment. Setting: Community. Participants: PwP able to walk ⩾100 m and with no contraindication to exercise were recruited from the Thames Valley, UK, and randomized (1:1) to exercise or handwriting, via a concealed computer-generated list. Intervention: Handwriting was undertaken at home and exercise in community facilities; both were delivered through workbooks with monthly support visits and involved practice for 1 hour, twice weekly, over a period of six months. Main measures: Handwriting was assessed, at baseline, 3, 6 and 12 months, using a pangram giving writing speed, amplitude (area) and progressive reduction in amplitude (ratio). The Movement Disorder Society (MDS)–Unified Parkinson’s Disease Rating Scale (UPDRS) item 2.7 measured self-reported handwriting deficits. Results: In all, 105 pwP were recruited (analysed: n = 51 handwriting, n = 54 exercise). A total of 40 pwP adhered to the handwriting programme, most completing ⩾1 session/week. Moderate effects were found for amplitude (total area: d = 0.32; 95% confidence interval (CI): −0.11 to 0.7; P = 0.13) in favour of handwriting over a period of12 months; effects for writing speed and ratio parameters were small ≤0.11. Self-reported handwriting difficulties also favoured handwriting (UPDRS 2.7: odds ratio (OR) = 0.55; 95% CI: 0.34 to 0.91; P = 0.02). No adverse effects were reported. Conclusion: PwP generally adhere to self-directed home handwriting which may provide benefit with minimal risk. Encouraging effects were found in writing amplitude and, moreover, perceived ability.