Esme Worthington

Fatigue after stroke: frequency and effect on daily life

Purpose: An audit was conducted to assess the frequency of fatigue after stroke, to determine the impact on daily life, and whether it was discussed with clinicians. Method: Patients were recruited from Nottingham University Hospitals NHS Trust stroke service. Patients were interviewed about their fatigue, and the Fatigue Severity Subscale (FSS-FAI), Brief Assessment Schedule for Depression Cards (BASDEC), Barthel Index and Nottingham Extended Activities of Daily Living (EADL) Scale were administered. Results: 64 patients were recruited, with a mean age 73.5 years (SD 14.0, range 37–94 years), 37 (58%) as in-patients and 27 (42%) as outpatients. There were 41 (64%) who reported significant levels of fatigue and 31 (48%) with significant fatigue on the Fatigue Severity Scale. Demographic and clinical variables were not significantly related to fatigue (p > 0.05), apart from gender, with women reporting significantly more fatigue than men (p = 0.006). There was a moderate correlation between the BASDEC and FSS (rs = 0.41, p = 0.002). Of the 41 participants who reported fatigue, 33 (81%) had not discussed this with their clinician. Conclusions: Fatigue was a common problem after stroke. There was a lack of awareness in both patients and clinicians and little advice being given to patients with fatigue. Implications for Rehabilitation Fatigue was reported to be a common problem in a group of patients recruited through a stroke service. Despite this, few patients had discussed fatigue with clinical team members, suggesting it is under-recognised. Rehabilitation staff need to be aware that patients may suffer from significant levels of fatigue which could affect their progress.

Validation of Mood Measures for People with Multiple Sclerosis

BACKGROUND Valid assessments are needed in order to identify anxiety and depression in people with multiple sclerosis (MS). The objective of this study was to assess the validity of questionnaire measures of mood in people with MS. METHODS People with MS were recruited from a clinic database and asked to complete and return a questionnaire containing the Beck Anxiety Inventory (BAI), Beck Depression Inventory-II (BDI-II), and Hospital Anxiety and Depression Scale (HADS). Those who returned the questionnaire were invited to complete a structured clinical interview, which was blind to the results of the questionnaire. RESULTS The BDI-II and HADS were both found to be valid measures to detect depression and anxiety in people with MS. An optimum cutoff score of 23 for the BDI-II yielded high sensitivity (85%) and high specificity (76%). An optimum cutoff score of 11 for the HADS demonstrated high sensitivity and specificity for both the Anxiety subscale (sensitivity 90%, specificity 92%) and the Depression subscale (sensitivity 77%, specificity 81%). The BAI had high sensitivity (80%) but poor specificity (46%) for detecting anxiety. CONCLUSION The BDI-II and HADS can be used to identify mood disorders in people with MS.

Interventions to reduce dependency in personal activities of daily living in community dwelling adults who use homecare services: a systematic review

Objectives: To identify interventions that aim to reduce dependency in activities of daily living (ADL) in homecare service users. To determine: content; effectiveness in improving ability to perform ADL; and whether delivery by qualified occupational therapists influences effectiveness. Data sources: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, OTseeker, PEDro, Web of Science, CIRRIE, and ASSIA. Review methods: We included: randomised controlled trials, non-randomised controlled trials and controlled before and after studies. Two reviewers independently screened studies for inclusion, assessed risk of bias and extracted data. A narrative synthesis of the findings was conducted. Results: Thirteen studies were included, totalling 4975 participants. Ten (77%) were judged to have risk of bias. Interventions were categorised as those termed ‘re-ablement’ or ‘restorative homecare’ (n=5/13); and those involving separate components which were not described using this terminology (n=8/13). Content of the intervention and level of health professional input varied within and between studies. Effectiveness on ADL: eight studies included an ADL outcome, five favoured the intervention group, only two with statistical significance, both these were controlled before and after studies judged at high risk of bias. ADL outcome was reported using seven different measures. Occupational therapy: there was insufficient evidence to determine whether involvement of qualified occupational therapists influenced effectiveness. Conclusion: There is limited evidence that interventions targeted at personal ADL can reduce homecare service users’ dependency with activities, the content of evaluated interventions varies greatly.

Cognitive Rehabilitation for Memory Deficits After Stroke: An Updated Review.

Memory problems are common after a stroke, leading to difficulties in everyday life. Memory rehabilitation aims to help retrain lost functions or to teach patients strategies to compensate for them. Although some studies have reported positive outcomes after memory rehabilitation, reviews have provided inconclusive evidence for effectiveness. This is an update of a Cochrane review first published in 2000 and subsequently updated in 2007. The objective of this review1 was to determine whether participants who have received cognitive rehabilitation for memory problems after a stroke had better outcomes in relation to memory function, functional ability, mood, and quality of life, than those given no treatment or a placebo control. For this update, we used …

The Nottingham Fatigue after Stroke (NotFAST) study: factors associated with severity of fatigue in stroke patients without depression:

Objective: To identify factors associated with post-stroke fatigue in a sample of stroke survivors without depression. Design: Cross-sectional cohort study. Setting: Recruitment was from four stroke units in the UK. Subjects: Participants were assessed within four to six weeks of first stroke; those with high levels of depressive symptoms (score ⩾7 Brief Assessment Schedule Depression Cards) were excluded. Main measures: Participants were assessed after stroke on the Fatigue Severity Scale of the Fatigue Assessment Inventory, the Rivermead Mobility Index, Nottingham Extended Activities of Daily Living scale, Beck Anxiety Index, Sleep Hygiene Index, 6m walk test, and measures of cognitive ability. Results: Of the 371 participants recruited, 103 were excluded and 268 were assessed. Of the latter, the mean age was 67.7 years (SD 13.5) and 168 (63%) were men. The National Institutes of Health Stroke Scale mean score was 4.96 (SD 4.12). Post-stroke fatigue was reported by 115 (43%) of participants, with 71 (62%) reporting this to be a new symptom since their stroke. Multivariate analysis using the Fatigue Severity Scale as the outcome variable found pre-stroke fatigue, having a spouse/partner, lower Rivermead Mobility Index score, and higher scores on both the Brief Assessment Schedule Depression Cards and Beck Anxiety Index were independently associated with post-stroke fatigue, accounting for approximately 47% of the variance in Fatigue Severity Scale scores. Conclusions: Pre-stroke fatigue, lower mood, and poorer mobility were associated with post-stroke fatigue.

Virtually home: Exploring the potential of virtual reality to support patient discharge after stroke

Introduction The level of assessment and intervention received by patients prior to discharge varies widely across stroke services in the United Kingdom. This study aimed to explore the potential value of virtual reality in preparing patients for discharge following stroke. Method Semi-structured interviews were carried out with 13 occupational therapists, eight patients with a stroke and four community stroke survivors. Views were sought of the perceived acceptability, potential utility and limitations of a ‘virtual home’ environment for use in pre-discharge education and assessment. Data were analysed thematically. Findings Interviewees found the virtual home to be an acceptable and visual means of facilitating discussions about discharge. It was perceived as valuable in assessing patient insight into safety risks and exploring the implications of installing assistive equipment at home. Limitations were identified relating to specific software issues and the use of virtual reality with patients with cognitive or perceptual impairments. Conclusion The results demonstrate the potential utility of the virtual home within stroke rehabilitation. Patients and therapists engaged with the virtual home and, moreover, made practical suggestions for future development. Feasibility and pilot testing in a clinical setting is required to compare the use of the virtual home with traditional approaches of pre-discharge assessment.

An evaluation of treatment integrity in a randomized trial of behavioural therapy for low mood in stroke patients with aphasia

Objective: To assess the treatment integrity of behavioural therapy for low mood in stroke patients with aphasia. Design: Participants were recruited to a multicentre randomized controlled trial (Communication and Low Mood; CALM trial) comparing behavioural therapy with a usual care control group. Subjects: Of the 51 participants randomly allocated to receive behavioural therapy, 44 participants completed treatment. Methods: Participants were assessed on measures of disability, language and mood. The number and length of therapy sessions, and therapist was recorded. Allocation of time to therapy components was compared across three phases of therapy. Associations between levels of disability, aphasia, mood and the therapy patients received were determined. Therapy content was compared between centres and at the beginning and end of the trial. Results: The mean number of therapy sessions was 9.1 (range 3–18, SD 2.6) and the mean duration of sessions was 58 minutes (range 30–89 minutes, SD 10.7). Allocation of time to each therapy component significantly differed across the three phases of therapy (P < 0.05). There were no significant associations (P > 0.05) between the length and number of sessions and patients’ aphasia, mood or disability, suggesting similar levels of therapy were provided regardless of patients’ characteristics. The content of therapy showed some differences between centres (P < 0.01) and there was programme drift in some components of therapy. Conclusions: The results support the ability of the therapists to deliver behavioural therapy according to the treatment manual. However there were differences between centres and over time in some components of therapy.

Virtually home: Feasibility study and pilot randomised controlled trial of a virtual reality intervention to support patient discharge after stroke.

Introduction Virtual reality has the potential to assist occupational therapists in preparing patients for discharge by facilitating discussions and providing education about relevant practical issues and safety concerns. This study aimed to explore the feasibility of using a virtual reality intervention to support patient discharge after stroke and pilot its use. Method Practical aspects of delivering a virtual reality intervention prior to discharge were explored by means of a non-randomised feasibility study and a subsequent pilot randomised controlled trial. Factors considered included eligibility, recruitment, intervention delivery, attrition and suitability of outcome measures. Outcome measures included standardised assessments of stroke severity, mobility, health-related quality of life, functional ability, satisfaction with services and concerns about falling. Results Thirty-three participants were recruited in total: 17 to the feasibility study and 16 to the pilot trial. At 1-month follow-up, 14 participants (82%) were re-assessed in the feasibility study and 12 (75%) in the pilot trial. The main difficulties encountered related to recruitment, particularly regarding post-stroke cognitive impairments, the presence of mild deficits or illness. Conclusion It was feasible to recruit and retain participants, deliver the intervention and collect outcome measures, despite slow recruitment rates. These findings could inform the design of a definitive trial.

The Nottingham Fatigue After Stroke (NotFAST) study: results from follow-up six months after stroke

Abstract Background Post-stroke fatigue is common and disabling. Objectives The aim of NotFAST was to examine factors associated with fatigue in stroke survivors without depression, six months after stroke. Methods Participants were recruited from four UK stroke units. Those with high levels of depressive symptoms (score ≥7 on Brief Assessment Schedule Depression Cards) or aphasia were excluded. Follow-up assessment was conducted at six months after stroke. They were assessed on the Fatigue Severity Scale, Rivermead Mobility Index, Nottingham Extended Activities of Daily Living scale, Barthel Index, Beck Anxiety Index, Brief Assessment Schedule Depression Cards, Impact of Event Scale-Revised, and Sleep Hygiene Index. Results Of the 371 participants recruited, 263 (71%) were contacted at six months after stroke and 213 (57%) returned questionnaires. Approximately half (n = 109, 51%) reported fatigue at six months. Of those reporting fatigue initially (n = 88), 61 (69%) continued to report fatigue. ‘De novo’ (new) fatigue was reported by 48 (38%) of those not fatigued initially. Lower Nottingham Extended Activities of Daily Living scores and higher Beck Anxiety Index scores were independently associated with fatigue at six months. Conclusions Half the stroke survivors reported fatigue at six months post-stroke. Reduced independence in activities of daily living and higher anxiety levels were associated with the level of fatigue. Persistent and delayed onset fatigue may affect independence and participation in rehabilitation, and these findings should be used to inform the development of appropriate interventions.