Christine McAlpine

Can augmented physiotherapy input enhance recovery of mobility after stroke? A randomized controlled trial

Objective: To discover if the provision of additional inpatient physiotherapy after stroke speeds the recovery of mobility. Design: A multisite single-blind randomized controlled trial (RCT) comparing the effects of augmented physiotherapy input with normal input on the recovery of mobility after stroke. Setting: Three rehabilitation hospitals in North Glasgow, Scotland. Subjects: Patients admitted to hospital with a clinical diagnosis of stroke, who were able to tolerate and benefit from mobility rehabilitation. Intervention: We aimed to provide double the amount of physiotherapy to the augmented group. Main measures: Primary outcomes were mobility milestones (ability to stand, step and walk), Rivermead Mobility Index (RMI) and walking speed. Results: Seventy patients were recruited. The augmented therapy group received more direct contact with a physiotherapist (62 versus 35 minutes per weekday) and were more active (8.0% versus 4.8% time standing or walking) than normal therapy controls. The augmented group tended to achieve independent walking earlier (hazard ratio 1.48, 95% confidence interval 0.90–2.43; p=0.12) and had higher Rivermead Mobility Index scores at three months (mean difference 1.6; 0.1 to 3.3; p=0.068) but these differences did not reach statistical significance. There was no significant difference in any other outcome. Conclusions: A modest augmented physiotherapy programme resulted in patients having more direct physiotherapy time and being more active. The inability to show statistically significant changes in outcome measures could indicate either that this intervention is ineffective or that our study could not detect modest changes.

Does behaviour modification affect post-stroke risk factor control? Three-year follow-up of a randomized controlled trial:

Objective: Little is known about the long-term effectiveness after stroke of interventions for behaviour modification and ensuring concordance with therapies. We describe a follow-up study of a previous randomized controlled trial of a brief period of behaviour modification. The aim of this study was to determine outcomes three years after the initial intervention. Design: Survivors of the original cohort were contacted and asked to attend for follow-up interview, within a geriatric day hospital. This study was carried out in the Geriatric Day Hospital at Stobhill Hospital, Balornock Road, Glasgow. Interventions: Details of risk factor control, including blood pressure, cholesterol levels and diabetic control, were assessed. Questionnaires used in the initial study were repeated including the Geriatric Depression Scale score, Euroqol Perceived Health Status and Stroke Services Satisfaction Questionnaire. Main measures: Primary outcome was collective risk factor control. Clinical outcomes including recurrent cerebrovascular events, medication persistence and perceived health status were also recorded. Results: Mean length of follow-up was 3.6 years (SD 0.43). Of the 205 patients enrolled in the initial study, 102 patients attended for repeat interview (49 intervention/53 control). There were no significant differences in the percentage of controlled risk factors between groups (intervention 51.7% versus control 55.9%, P = 0.53). Similarities were observed in the number of recurrent clinical events and medication persistence between groups. No overall difference was observed in perceived health status, satisfaction with care or depression scores. Conclusions: Brief intervention with respect to behaviour modification and risk factor control does not appear to have any long-term benefit. These results must be cautiously interpreted in light of the small study number and further research is required.

Associations with anticoagulation: a cross-sectional registry-based analysis of stroke survivors with atrial fibrillation

Objective To describe vitamin K antagonist (VKA) anticoagulation prescribing patterns in stroke survivors with atrial fibrillation (AF), with particular emphasis on sociodemographic associations with VKA prescription. Methods We conducted a cross-sectional analysis of city-wide Glasgow primary care data held as part of the Local Enhanced Services (LES) for the year 2010. We collated clinical and sociodemographic data of community-dwelling ischaemic stroke survivors with AF, including risk factors; comorbidity; socioeconomic status and prescribing. We described stroke risk and bleeding risk using recommended stratification tools (CHA2DS2-VASC and HAS-BLED). Univariate and multivariate associations with anticoagulant prescription were described by ORs and corresponding 95% CI. Results We identified 3429 community-dwelling, ischaemic stroke survivors with AF; median age 78 (IQR 72–84); 1699 (49%) male. Median CHA2DS2-VASC score was 5 (IQR 4–6). VKA was prescribed in 1165 (34%). On univariate analysis, higher CHA2DS2-VASC was associated with fewer VKA prescriptions (OR 0.90, 95% CI 0.45 to 0.95). On multivariate analysis, older age (OR 0.97, 95% CI 0.96 to 0.98) and higher deprivation scores (OR 0.59, 95% CI 0.57 to 0.76) were independently associated with non-prescription of VKA. Conclusions Anticoagulation was underused in this high-risk population, and those at highest risk were less likely to be treated. Strategies need to be developed to improve prescription of anticoagulation treatment.

Elder abuse and neglect

Elderly mistreatment is a hidden, and often ignored problem in society. In the general population many will have heard the phrase ‘Granny Battering’ but will know little more than that, other than perhaps some awareness of problems publicised in television programmes on Care Homes. The term ‘Granny Battering’ dates back to 1975 [1], so this is not a new phenomenon; but in the UK we have been slow to respond to the challenge, with persisting resistance to the idea that such a problem could exist. By the late 1980s every state in the USA had legislation related to elder abuse. In the UK, however, a major catalyst was a multi-disciplinary British Geriatrics Society Conference ‘Abuse of Elderly People: an Unnecessary and Preventable Problem’ [2]. This led to various projects and research; the first British Medical Journal paper about elder abuse, concerning the abuse of older people by their carers, was published in 1990 [3]. Subsequently the charity Action on Elder Abuse was formed in 1993. In 2004 a major House of Commons Health Committee report [4] highlighted a series of problems and made several proposals including improved Care Home inspection, mandatory training in elder abuse recognition for professionals working with older people, mandatory local availability of multi-agency guidelines and better regulation of care staff. Action on Elder Abuse developed a definition which was later adopted by the World Health Organisation : ‘elder abuse is a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’. There has been debate about prevalence figures since the syndrome was first recognised. Cooper et al. in their systematic review [5] of international elder abuse prevalence looked at studies where abuse was reported by older people themselves or by family or professional caregivers, and was investigated using objective measures. In their extensive literature search they found only seven studies which fulfilled these criteria: one of these was the first major study in the United Kingdom, by Ogg and Bennett in 1992 [6]. The systematic review of studies found that more than 6% of the general population, a quarter of vulnerable adults and a third of family caregivers reported being involved in significant abuse: this suggests a much larger number of episodes than are known to statutory services. Since Cooper et al. completed their work, Comic Relief with some additional Department of Health funding has sponsored another extensive survey of elder abuse which showed prevalence levels in the United Kingdom of around 4% of older people being abused by family members or acquaintances [7]. These figures suggest that the prevalence of elder abuse is similar in the United Kingdom to other Western societies though prevalence varies considerably worldwide. The main types of elder abuse (neglect, physical, psychological, financial, sexual) were described in the early days of the recognition of the syndrome and will be well known to most geriatricians. Less well known perhaps will be the range of impacts, with individuals often experiencing a range of these: including emotional distress, loss of self-confidence and self-esteem, depression, attempts at suicide and self-harm, social isolation, financial loss and negative impacts on physical health. Barriers for older people seeking help include low self-confidence and selfesteem (perhaps following bereavement or a move into care), fear of the consequences of action (e.g. being blamed in some way, or alienating family and friends) and lack of awareness of the role and remit of services which could help [7]. Everyone involved in the care and support of older people must be aware of the existence of elder abuse and be able to provide advice on how to deal with the situation. The vast majority of caring relationships will never experience the problem but for the minority who do, the problem must be solved and the impact minimised. Government and other agencies have produced a succession of initiatives such as in England ‘No Secrets’ and ‘Safeguarding Adults’, and ‘Breaking the Silence—Elder Abuse’ in Scotland. There is an annual world Elder Abuse Awareness Day and the International Network for the Prevention of Elder Abuse has United Nations and World Health Organisation support. Major voluntary organisations such as Age Concern and Help the Aged have well-organised systems to provide advice and support to older people who may have been abused. Action on Elder Abuse also runs a telephone hotline both for people who may have been abused or for people who have witnessed possible abuse and are uncertain what to do; they also provide advice for health professionals asked to deal with the problem. All doctors working with older people must be alert to the possibility of elder abuse; they must be aware of how to identify it, and should be strongly in support of multi-agency working in both prevention and management of elder abuse to minimise the impact on older people.

Impact of a clinical pathway on end-of-life care following stroke: A mixed methods study

Background: Death after stroke is common, but little is known about end-of-life care processes in acute stroke units. Aim: (1) To identify family and health-care worker perceptions of an end-of-life care pathway for patients who die after acute stroke. (2) To determine whether patients with fatal stroke judged to require an end-of-life care pathway differ from patients with fatal stroke who die without introduction of such a pathway. Design: Mixed methods study integrating qualitative semistructured interviews with quantitative casenote review. Setting/participants: In four Scottish acute stroke units, 17 relatives of deceased stroke patients and 23 health-care professionals were interviewed. Thematic analysis used a modified grounded theory approach. Multivariate analysis was performed on casenote data, identified prospectively from 100 consecutive stroke deaths. Results: Deciding pathway use was a consultative process, occurring within normal working hours. Families were commonly involved and could veto or trigger aspects of end-of-life care. Families sometimes felt responsible for decisions such as pathway use, resuscitation or hydration. Families were often led to expect their relative’s death early in the post-stroke period. Prolonged dying processes, particularly where patients had severe dysphagia, added to distress for families. Preferences for place of care were discussed infrequently. No link was found between demographic or clinical characteristics and care pathway use. Conclusion: Distressing stroke-related clinical problems dominated relatives’ concerns rather than use of the end-of-life care pathway. At times, relatives felt primarily responsible for key aspects of decision-making. Relatives often felt unprepared for a prolonged dying process after stroke, particularly where patients had persistent major swallowing difficulties.

Accuracy and feasibility of an android-based digital assessment tool for post stroke visual disorders - The StrokeVision App

Background Visual impairment affects up to 70% of stroke survivors. We designed an app (StrokeVision) to facilitate screening for common post stroke visual issues (acuity, visual fields, and visual inattention). We sought to describe the test time, feasibility, acceptability, and accuracy of our app-based digital visual assessments against (a) current methods used for bedside screening and (b) gold standard measures. Methods Patients were prospectively recruited from acute stroke settings. Index tests were app-based assessments of fields and inattention performed by a trained researcher. We compared against usual clinical screening practice of visual fields to confrontation, including inattention assessment (simultaneous stimuli). We also compared app to gold standard assessments of formal kinetic perimetry (Goldman or Octopus Visual Field Assessment); and pencil and paper-based tests of inattention (Albert’s, Star Cancelation, and Line Bisection). Results of inattention and field tests were adjudicated by a specialist Neuro-ophthalmologist. All assessors were masked to each other’s results. Participants and assessors graded acceptability using a bespoke scale that ranged from 0 (completely unacceptable) to 10 (perfect acceptability). Results Of 48 stroke survivors recruited, the complete battery of index and reference tests for fields was successfully completed in 45. Similar acceptability scores were observed for app-based [assessor median score 10 (IQR: 9–10); patient 9 (IQR: 8–10)] and traditional bedside testing [assessor 10 (IQR: 9–10); patient 10 (IQR: 9–10)]. Median test time was longer for app-based testing [combined time to completion of all digital tests 420 s (IQR: 390–588)] when compared with conventional bedside testing [70 s, (IQR: 40–70)], but shorter than gold standard testing [1,260 s, (IQR: 1005–1,620)]. Compared with gold standard assessments, usual screening practice demonstrated 79% sensitivity and 82% specificity for detection of a stroke-related field defect. This compares with 79% sensitivity and 88% specificity for StrokeVision digital assessment. Conclusion StrokeVision shows promise as a screening tool for visual complications in the acute phase of stroke. The app is at least as good as usual screening and offers other functionality that may make it attractive for use in acute stroke. Clinical Trial Registration https://ClinicalTrials.gov/ct2/show/NCT02539381.

Outcomes, experiences and palliative care in major stroke: a multicentre, mixed-method, longitudinal study

BACKGROUND: Case fatality after total anterior circulation stroke is high. Our objective was to describe the experiences and needs of patients and caregivers, and to explore whether, and how, palliative care should be integrated into stroke care. METHODS: From 3 stroke services in Scotland, we recruited a purposive sample of people with total anterior circulation stroke, and conducted serial, qualitative interviews with them and their informal and professional caregivers at 6 weeks, 6 months and 1 year. Interviews were transcribed for thematic and narrative analysis. The Palliative Care Outcome Scale, EuroQol-5D-5L and Caregiver Strain Index questionnaires were completed after interviews. We also conducted a data linkage study of all patients with anterior circulation stroke admitted to the 3 services over 6 months, which included case fatality, place of death and readmissions. RESULTS: Data linkage (n = 219) showed that 57% of patients with total anterior circulation stroke died within 6 months. The questionnaires recorded that the patients experienced immediate and persistent emotional distress and poor quality of life. We conducted 99 interviews with 34 patients and their informal and professional careers. We identified several major themes. Patients and caregivers faced death or a life not worth living. Those who survived felt grief for a former life. Professionals focused on physical rehabilitation rather than preparation for death or limited recovery. Future planning was challenging. “Palliative care” had connotations of treatment withdrawal and imminent death. INTERPRETATION: Major stroke brings likelihood of death but little preparation. Realistic planning with patients and informal caregivers should be offered, raising the possibility of death or survival with disability. Practising the principles of palliative care is needed, but the term “palliative care” should be avoided or reframed.

Is Palliative Care Appropriate for All People After Major Stroke

Background and Aims: Outcomes for stroke patients are improved by reducing time to, and increasing accessibility of, stroke-specialist consultation and treatments (e.g. delivery of thrombolysis). Telemedicine is a way that this can be facilitated, especially outside routine working hours. This study compared the timeliness of treatment and short-term patient outcomes when telemedicine or face-to-face assessment was used as part of the decision process of administering thrombolysis to patients affected by stroke. Method: Stroke data from SINAP and DASH databases between July 2011 and March 2013 was provided from six trusts in Lancashire and Cumbria which used telemedicine for the assessment of acute stroke, and eleven trusts within the North East of England which assessed patients face-to-face. Data was analysed from 220 stroke patients who received thrombolysis; this was restricted to those admitted out-of-hours as this was when telemedicine would normally be used. Results: The results showed that stroke patients assessed via telemedicine had a subsequent longer door-to needle time in comparison to those assessed via traditional face-to-face methods (95%CI: -32.43 to -11.15 minutes). Also, no significant differences were found between telemedicine and face-to-face assessments on patient outcomes such as length of stay in hospital (95%CI: -10.29 to 3.23 days), stay in stroke unit (95%CI: -10.42 to 3.01 days), rate of complications (OR 95%CI: 0.33 to 1.82) or discharge destination (OR 95%CI: 0.30 to 1.11). Conclusion: Patients assessed by telemedicine have a longer door-toneedle time than those assessed face-to-face. However, whether assessment was via telemedicine or face-to-face does not appear to affect short-term patient outcomes.

Decision to insert an indwelling urinary catheter in newly diagnosed stroke patients

Introduction: In recent years new rehabilitation techniques have emerged such as constraint-induced therapy, biofeedback therapy and robot-aided therapy, as alternatives to conventional physical therapies. Robotic techniques allow precise recording of movements and application of forces to the affected limb, making it a valuable tool for motor rehabilitation. In addition, robot-aided therapy can utilise visual cues conveyed on a computer screen to convert repetitive movement practice into an engaging task such as a game. This paper presents the development and evaluation of whole-arm robot-aided therapy, using a purpose designed robotic system for upper limb rehabilitation facilitating selective functional reaching and grasping movements in a reach-grasp-transport-release sequence with a task-oriented paradigm incorporating visual, audio, haptic and performance feedback. Method: A clinical pilot study with a total duration of twelve weeks was conducted with four stroke impaired subjects at the sub-acute phase of recovery. Subjects were exposed to sixteen hours of robotic intervention. Clinical outcome measures were used to assess therapy effectiveness on the recovery of the stroke participants prior to the study, during the study and on study completion. Results: The results obtained from the clinical outcome measures showed substantial gains in favour of the robot-aided intervention. The clinical outcome results show higher gains when compared to other robotic sub-acute studies targeting only proximal arm segments. Conclusion: The study demonstrated the feasibility and potential of reach and grasp therapy for stroke neurorehabilitation in the treatment of patients with upper limb hemiplegia and is a good indicator that this strategy should be pursued.Observational gait analysis is frequently used by clinicians but has been shown to have moderate reliability particularly in relation to joint angles. The siliconCOACH movement analysis software utilises a digital image to determine joint angles, taken from a video. One study to date has investigated the reliability of knee joint angles using siliconCOACH but this was not during walking. The aim of this study was to determine the inter-rater reliability of siliconCOACH dynamic knee joint angles in stroke patients.Knee hyperextension during gait is a common abnormality following stroke. The siliconCOACH movement analysis software has been developed to enable joint angles to be determined from a digital image taken from a video. The aim of this study was to determine the pattern of knee joint angles during the stance phase in stroke patients.