David Gillespie

Interventions for treating anxiety after stroke

BACKGROUNDnApproximately 20% of stroke patients experience clinically significant levels of anxiety at some point after stroke. Physicians can treat these patients with antidepressants or other anxiety-reducing drugs, or both, or they can provide psychological therapy. This review looks at available evidence for these interventions. This is an update of the review first published in October 2011.nnnOBJECTIVESnThe primary objective was to assess the effectiveness of pharmaceutical, psychological, complementary, or alternative therapeutic interventions in treating stroke patients with anxiety disorders or symptoms. The secondary objective was to identify whether any of these interventions for anxiety had an effect on quality of life, disability, depression, social participation, caregiver burden, or risk of death.nnnSEARCH METHODSnWe searched the trials register of the Cochrane Stroke Group (January 2017). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2017, Issue 1: searched January 2017); MEDLINE (1966 to January 2017) in Ovid; Embase (1980 to January 2017) in Ovid; the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1937 to January 2017) in EBSCO; and PsycINFO (1800 to January 2017) in Ovid. We conducted backward citation searches of reviews identified through database searches and forward citation searches of included studies. We contacted researchers known to be involved in related trials, and we searched clinical trials registers for ongoing studies.nnnSELECTION CRITERIAnWe included randomised trials including participants with a diagnosis of both stroke and anxiety for which treatment was intended to reduce anxiety. Two review authors independently screened and selected titles and abstracts for inclusion.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently extracted data and assessed risk of bias. We performed a narrative review. We planned to do a meta-analysis but were unable to do so as included studies were not sufficiently comparable.nnnMAIN RESULTSnWe included three trials (four interventions) involving 196 participants with stroke and co-morbid anxiety. One trial (described as a pilot study) randomised 21 community-dwelling stroke survivors to four-week use of a relaxation CD or to wait list control. This trial assessed anxiety using the Hospital Anxiety and Depression Scale and reported a reduction in anxiety at three months among participants who had used the relaxation CD (mean (standard deviation (SD) 6.9 (± 4.9) and 11.0 (± 3.9)), Cohens d = 0.926, P value = 0.001; 19 participants analysed).The second trial randomised 81 participants with co-morbid anxiety and depression to paroxetine, paroxetine plus psychotherapy, or standard care. Mean levels of anxiety severity scores based on the Hamilton Anxiety Scale (HAM-A) at follow-up were 5.4 (SD ± 1.7), 3.8 (SD ± 1.8), and 12.8 (SD ± 1.9), respectively (P value < 0.01).The third trial randomised 94 stroke patients, also with co-morbid anxiety and depression, to receive buspirone hydrochloride or standard care. At follow-up, the mean levels of anxiety based on the HAM-A were 6.5 (SD ± 3.1) and 12.6 (SD ± 3.4) in the two groups, respectively, which represents a significant difference (P value < 0.01). Half of the participants receiving paroxetine experienced adverse events that included nausea, vomiting, or dizziness; however, only 14% of those receiving buspirone experienced nausea or palpitations. Trial authors provided no information about the duration of symptoms associated with adverse events. The trial of relaxation therapy reported no adverse events.The quality of the evidence was very low. Each study included a small number of participants, particularly the study of relaxation therapy. Studies of pharmacological agents presented details too limited to allow judgement of selection, performance, and detection bias and lack of placebo treatment in control groups. Although the study of relaxation therapy had allocated participants to treatment using an adequate method of randomisation, study recruitment methods might have introduced bias, and drop-outs in the intervention group may have influenced results.nnnAUTHORS CONCLUSIONSnEvidence is insufficient to guide the treatment of anxiety after stroke. Further well-conducted randomised controlled trials (using placebo or attention controls) are required to assess pharmacological agents and psychological therapies.

Post‐stroke depression: the case for augmented, individually tailored cognitive behavioural therapy

In this review, we begin by considering why post-stroke depression (PSD) is so prevalent. We then examine the current evidence base to support cognitive behavioural therapy (CBT) as a treatment approach for the condition. While there is limited evidence currently, we demonstrate that much remains to be established with regard to PSD and the efficacy of CBT. We argue there is every reason to believe CBT should be an effective treatment, but that clinicians must augment and individually tailor this approach to ensure effectiveness. We set out our rationale for a novel augmented, individually tailored CBT protocol, and describe five key components that we believe once incorporated, and tested using randomized controlled methods, should enhance treatment outcome of PSD.

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.

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.

Non-pharmacological interventions for perceptual disorders following stroke and other adult-acquired, non-progressive brain injury

BACKGROUNDnStroke and other adult-acquired brain injury may impair perception leading to distress and increased dependence on others. Perceptual rehabilitation includes functional training, sensory stimulation, strategy training and task repetition.nnnOBJECTIVESnTo examine the evidence for improvement in activities of daily living (ADL) six months post randomisation for active intervention versus placebo or no treatment.nnnSEARCH STRATEGYnWe searched the trials registers of the Cochrane Stroke Group and the Cochrane Infectious Diseases Group (May 2009) but not the Injuries Group, the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 3), MEDLINE (1950 to August 2009), EMBASE (1980 to August 2009), CINAHL (1982 to August 2009), PsycINFO (1974 to August 2009), REHABDATA and PsycBITE (May to June 2009). We also searched trials and research registers, handsearched journals, searched reference lists and contacted authors.nnnSELECTION CRITERIAnRandomised controlled trials of adult stroke or acquired brain injury. Our definition of perception excluded visual field deficits, neglect/inattention and apraxia.nnnDATA COLLECTION AND ANALYSISnOne review author assessed titles, abstracts and keywords for eligibility. At least two review authors independently extracted data. We requested unclear or missing information from corresponding authors.nnnMAIN RESULTSnWe included six single-site trials in rehabilitation settings, involving 338 participants. Four trials included people with only stroke. All studies provided sensory stimulation, sometimes with another intervention. Sensory stimulation typically involved practising tasks that required visuo-perceptual processing with occupational therapist assistance. Repetition was never used and only one study included functional training. No trials provided data on longer term improvement in ADL scores. Only three trials provided any data suitable for analysis. Two of these trials compared active to placebo intervention. There was no evidence of a difference in ADL scores at the scheduled end of intervention: mean difference (95% confidence interval (CI))xa0was 0.9 (-1.6 to 3.5) points on a self-care ADL scale in one study and odds ratio (95% CI) was 1.3 (0.56 to 3.1) for passing a driving test in the other, both in favour of active intervention. The trial that compared two active interventions did not findxa0evidence of difference in any of the review outcomes.nnnAUTHORS CONCLUSIONSnThere is insufficient evidence to support or refute the view that perceptual interventions are effective. Future studies should be sufficiently large, include a standard care comparison and measure longer term functional outcomes. People with impaired perception problems should continue to receive neurorehabilitation according to clinical guidelines.

Performance of older adults on tests of cognitive estimation.

This study provides performance data for older adults on two existing tests of cognitive estimation ability (Cognitive Estimation Test [CET] and Temporal Judgement Test [TJT]) and a novel set of estimation questions (n-EQ) that make reference to familiar, everyday objects. It explores the relations between each of the three tests of estimation and verbal intelligence. The sample comprises 101 adults aged 55 years and over. Neither n-EQ nor TJT scores were associated with verbal IQ, but scores on the more established CET were. As well as providing performance data for older adults, this study confirms the limitations of existing measures of cognitive estimation. It is proposed that the novel questions devised for this study show promise as an assessment tool, and warrant further validation.

Neurocognitive Deficits and Neurocognitive Rehabilitation in Adult Brain Tumors

Opinion statementNeurocognitive deficits are common with brain tumors. If assessed at presentation using detailed neurocognitive tests, problems are detected in 80xa0% of cases. Neurocognition may be affected by the tumor, its treatment, associated medication, mood, fatigue, and insomnia. Interpretation of neurocognitive problems should be considered in the context of these factors. Early post-operative neurocognitive rehabilitation for brain tumor patients will produce rehabilitation outcomes (e.g., quality of life, improved physical function, subjective neurocognition) equivalent to stroke, multiple sclerosis, and head injury, but the effect size and duration of benefit needs further research. In stable patients treated with radiotherapy +/− chemotherapy, the most frequent causes of distress include neurocognitive problems, psychological factors of anxiety, depression, fatigue, and sleep. Exercise, neurocognitive training, neurocognitive behavioral therapy, and medications to treat fatigue, behavior, memory, mood, and removal of drugs that may be associated with neurocognitive side effects (e.g., anti-epileptic drugs) all show promise in helping patients to manage the effects of their neurocognitive impairments better. As these are complex symptoms, multidisciplinary expertise is necessary to evaluate the influence of each variable to plan appropriate support and intervention. Neurocognitive rehabilitation should therefore occur in parallel with disease-centered, medical management from the outset. It should not occur in series, as a restricted phase in a patient’s pathway. It should be considered in the pre- and post-operative period where there are good prospects of recovery, as one would for any brain-injured patient, so that the person may reach their optimal physical, sensory, intellectual, psychological, and social functional level. Yet the identification and selection of patients for early neurological rehabilitation and routine evaluation of cognition is uncommon in neurosurgical wards.

Rehabilitation of patients with stroke: summary of SIGN guidance

Stroke is the third most common cause of death and the most frequent cause of severe adult disability in Scotland.1 Despite considerable advances in organised stroke care over recent years, improvements are still needed,2 because patients have been reported to spend up to 50% of their time in bed3 and only 20% of their time in treatment.4 Since publication of the previous Scottish Intercollegiate Guidelines Network (SIGN) guideline on rehabilitation after stroke (SIGN 64), several small studies have shown the effectiveness of new therapeutic techniques and technologies.5 This guideline supersedes the earlier guideline and summarises the most recent recommendations from SIGN on rehabilitation after stroke.6 It also complements SIGN guidelines 119 and 108 on other aspects of the management of stroke.7 8 nnSIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (figure⇓), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”), based on the clinical experience of the guideline development group, is also indicated (as GPP).nnnnExplanation of SIGN grades of recommendationsnnnn### Arranging appropriate care

Prevalence of Pseudobulbar Affect following Stroke: A Systematic Review and Meta-Analysis

BACKGROUNDnSeveral studies have reported that emotional lability is a common consequence of stroke. However, there is uncertainty about the true prevalence of the condition because, across these studies, patients have been recruited at different stages of recovery, from different settings, and using different diagnostic methods. There have been no systematic reviews of the published evidence to ascertain how the prevalence of poststroke pseudobulbar affect (PBA) might vary according to these factors.nnnMETHODSnA systematic review and meta-analysis of the published literature were undertaken.nnnRESULTSnA total of 15 studies (nu2009=u20093391 participants) met inclusion criteria for the review. Meta-analysis estimated that the prevalence of PBA was 17% (95% confidence interval 12%-24%) acutely (<1u2009month post stroke), 20% (14%-29%) post acutely (1-6u2009months post stroke), and 12% (8%-17%) in the medium to longer term (>6u2009months post stroke). The evidence from the published literature, although limited, is that crying is a more common PBA presentation following stroke than laughter.nnnCONCLUSIONSnPBA is a common condition that affects approximately 1 in 5 stroke survivors at the acute and postacute phases, and 1 in 8 survivors beyond 6 months post stroke. These prevalence data are very important for clinicians and the commissioners of services.

The Assessment of Premorbid Intellectual Ability Following Right-Hemisphere Stroke: Reliability of a Lexical Decision Task

Comparing current with estimated premorbid performance helps identify acquired cognitive deficits after brain injury. Tests of reading pronunciation, often used to measure premorbid ability, are inappropriate for stroke patients with motor speech problems. The Spot-the-Word Test (STWT), a measure of lexical decision, offers an alternative approach for estimating premorbid capacity in those with speech problems. However, little is known about the STWTs reliability. In the present study, a consecutive sample of right-hemisphere stroke (RHS) patients (n = 56) completed the STWT at 4 and 16 weeks poststroke. A control group, individually matched to the patients for age and initial STWT score, also completed the STWT on two occasions. More than 80% of patients had STWT scores at retest within 2 scaled score points of their initial score, suggesting that the STWT is a reliable measure for most individuals with RHS. However, RHS patients had significantly greater score change than controls. Limits of agreement analysis revealed that approximately 1 in 7 patients obtained abnormally large STWT score improvements at retest. It is concluded that although the STWT is a useful assessment tool for stroke clinicians, this instrument may significantly underestimate premorbid level of ability in approximately 14% of stroke patients.