Lois Helene Thomas

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 DATA SOURCES The Cochrane Stroke Trials Register, electronic databases of published, unpublished and non-English language papers; conference proceedings, reference lists, and trial authors.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.

What can management theories offer evidence-based practice? A comparative analysis of measurement tools for organisational context

BackgroundGiven the current emphasis on networks as vehicles for innovation and change in health service delivery, the ability to conceptualise and measure organisational enablers for the social construction of knowledge merits attention. This study aimed to develop a composite tool to measure the organisational context for evidence-based practice (EBP) in healthcare.MethodsA structured search of the major healthcare and management databases for measurement tools from four domains: research utilisation (RU), research activity (RA), knowledge management (KM), and organisational learning (OL). Included studies were reports of the development or use of measurement tools that included organisational factors. Tools were appraised for face and content validity, plus development and testing methods. Measurement tool items were extracted, merged across the four domains, and categorised within a constructed framework describing the absorptive and receptive capacities of organisations.ResultsThirty measurement tools were identified and appraised. Eighteen tools from the four domains were selected for item extraction and analysis. The constructed framework consists of seven categories relating to three core organisational attributes of vision, leadership, and a learning culture, and four stages of knowledge need, acquisition of new knowledge, knowledge sharing, and knowledge use. Measurement tools from RA or RU domains had more items relating to the categories of leadership, and acquisition of new knowledge; while tools from KM or learning organisation domains had more items relating to vision, learning culture, knowledge need, and knowledge sharing. There was equal emphasis on knowledge use in the different domains.ConclusionIf the translation of evidence into knowledge is viewed as socially mediated, tools to measure the organisational context of EBP in healthcare could be enhanced by consideration of related concepts from the organisational and management sciences. Comparison of measurement tools across domains suggests that there is scope within EBP for supplementing the current emphasis on human and technical resources to support information uptake and use by individuals. Consideration of measurement tools from the fields of KM and OL shows more content related to social mechanisms to facilitate knowledge recognition, translation, and transfer between individuals and groups.

Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial

BackgroundUrinary incontinence (UI) affects half of patients hospitalised after stroke and is often poorly managed. Cochrane systematic reviews have shown some positive impact of conservative interventions (such as bladder training) in reducing UI, but their effectiveness has not been demonstrated with stroke patients.MethodsWe conducted a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP) for the management of UI after stroke. Stroke services were randomised to receive SVP (n = 4), SVP plus supported implementation (SVP+, n = 4), or usual care (UC, n = 4).Feasibility outcomes were participant recruitment and retention. The main effectiveness outcome was presence or absence of UI at six and 12 weeks post-stroke. Additional effectiveness outcomes included were the effect of the intervention on different types of UI, continence status at discharge, UI severity, functional ability, quality of life, and death.ResultsIt was possible to recruit patients (413; 164 SVP, 125 SVP+, and 124 UC) and participant retention was acceptable (85% and 88% at six and 12 weeks, respectively). There was no suggestion of a beneficial effect on the main outcome at six (SVP versus UC: odds ratio (OR) 0.94, 95% CI: 0.46 to 1.94; SVP+ versus UC: OR: 0.62, 95% CI: 0.28 to 1.37) or 12 weeks (SVP versus UC: OR: 1.02, 95% CI: 0.54 to 1.93; SVP+ versus UC: OR: 1.06, 95% CI: 0.54 to 2.09).No secondary outcomes showed a strong suggestion of clinically meaningful improvement in SVP and/or SVP+ arms relative to UC at six or 12 weeks. However, at 12 weeks both intervention arms had higher estimated odds of continence than UC for patients with urge incontinence.ConclusionsThe trial has met feasibility outcomes of participant recruitment and retention. It was not powered to demonstrate effectiveness, but there is some evidence of a potential reduction in the odds of specific types of incontinence. A full trial should now be considered.Trial registrationISRCTN Registry, ISRCTN08609907, date of registration: 7 July 2010.

Study protocol: ICONS: Identifying continence options after stroke: A randomised trial

BackgroundUrinary incontinence following acute stroke is common, affecting between 40%-60% of people in hospital after a stroke. Despite the availability of clinical guidelines for urinary incontinence and urinary incontinence after stroke, national audit data suggest incontinence is often poorly managed. Conservative interventions (e.g. bladder training, pelvic floor muscle training and prompted voiding) have been shown to have some effect with participants in Cochrane systematic reviews, but have not had their effectiveness demonstrated with stroke patients.Methods/DesignA cluster randomised controlled pilot trial designed to assess the feasibility of a full-scale cluster randomised trial and to provide preliminary evidence of the effectiveness and cost-effectiveness of a systematic voiding programme for the management of continence after stroke. Stroke services will be randomised to receive the systematic voiding programme, the systematic voiding programme plus supported implementation, or usual care. The trial aims to recruit at least 780 participants in 12 stroke services (4 per arm). The primary outcome is presence/absence of incontinence at six weeks post-stroke. Secondary outcomes include frequency and severity of incontinence, quality of life and cost-utility. Outcomes will be measured at six weeks, three months and (for participants recruited in the first three months) twelve months after stroke. Process data will include rates of recruitment and retention and fidelity of intervention delivery. An integrated qualitative evaluation will be conducted in order to describe implementation and assist in explaining the potential mediators and modifiers of the process.Trial RegistrationISRCTN: ISRCTN08609907

Repetitive Task Training for Improving Functional Ability After Stroke: A Major Update of a Cochrane Review

Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation.1 Primary objective is to determine whether RTT improves upper limb function/reach and lower limb function/balance in adults after stroke. Secondary objectives are (1) to determine the effect of RTT on secondary outcome measures, including activities of daily living, global motor function, quality of life/health status, and adverse events, (2) to determine the factors that could influence primary and secondary outcome measures, including the effect of dose of task practice, type of task (whole therapy, mixed, or single task), and timing of the intervention and type of intervention. We searched the Cochrane Stroke Group …

Icons: identifying continence options after stroke trial: utility of a logic model in the design and implementation of a process evaluation

Background: ICONS is a cluster randomised controlled pilot trial designed to provide preliminary evidence of the effectiveness of a systematic voiding programme (SVP) for the management of continence after stroke. Stroke services were randomised to receive the SVP, the SVP plus supported implementation, or usual care. Process evaluations are designed to evaluate fidelity and provide explanatory evidence around trial outcomes; these need to be underpinned by a theoretical framework to explain linkages between intervention processes and outcomes. Process evaluation: We conducted an evaluation to describe SVP implementation and assist in explaining intervention outcomes. Reflecting best practice in complex intervention research, we developed a logic model to underpin the evaluation representing practitioners’ implementation activities. To increase explanatory power of the model, we synthesised principles from theoretical frameworks underpinning the study (e.g. the Normalisation Process Model) into mechanisms of action to explain conditions necessary for activities to impact on outcomes. Mechanisms were: • Understanding and agreeing: conceptual work associated with the SVP, e.g. increasing awareness. • Driving and aligning: organising systems or processes to align and drive new practice. • Building and supporting: enacting the SVP. • Learning and evaluation: reflecting on performance and progress. Findings: We will discuss the utility of the logic model in explaining conditions necessary for the intervention to work, the success of implementation strategies adopted and variations in patient outcome across trial arms. We will also consider the challenges of synthesising across multiple data sources to understand variation in intervention delivery, maintenance and outcome in cluster trials.

Determining the sample size for a cluster-randomised trial: Bayesian hierarchical modelling of the ICC estimate

In common with many cluster-randomised trials, it was difficult to determine the appropriate sample size for the planned trial of the effectiveness of a systematic voiding programme for post-stroke incontinence due to the lack of a robust estimate of the intra-cluster correlation coefficient (ICC). One approach to overcome this problem is a method of combining ICC values in the Bayesian framework (Turner et al. 2005). We adopted this approach and used Bayesian hierarchical modelling to estimate the ICC. To obtain the ICCs to combine in the model, we performed a literature search and identified a number of relevant studies with ICC estimates. To allow for uncertainty in ICC estimates, the Bayesian hierarchical model includes separate weights for each study and each outcome: study weights represent the degree of relevance to study population and intervention, and outcome weights are similarly related to the planned trial’s primary outcome (frequency of urinary incontinence). Assigning weights is rather subjective and is a source of uncertainty in the model. To minimise this subjectivity, we performed an exercise by which a team of expert reviewers with a range of relevant expertise assigned weights for each trial and each outcome. These weights were incorporated into the model to combine the individual ICC estimates and construct a distribution of a targeted ICC estimate to inform the sample size. This approach should provide a more robust estimate of an ICC for determining the sample size for a cluster-randomised trial as it combines relevant ICCs in Bayesian framework.

Interventions to improve patient access to and utilisation of genetic and genomic counselling services

This is the protocol for a review and there is no abstract. The objectives are as follows. PRIMARY OBJECTIVE The primary objective is to assess the effectiveness of interventions to improve patient identification, access to and utilisation of genetic and genomic counselling services when compared to: No intervention;Usual or current practice; andOther active intervention. SECONDARY OBJECTIVE The secondary objective is to explore the resource use and costs associated with interventions aimed at improving patient identification, access to and utilisation of genetic and genomic counselling services from studies meeting the eligibility criteria. We will report on factors that may explain variation in the effectiveness of interventions aimed at improving patient identification, access to and utilisation of genetic and genomic counselling services from studies meeting the eligibility criteria. Another secondary objective is to explore how interventions which target improved patient identification, access to and utilisation of genetic and genomic counselling services affect the subsequent appropriate use of health services for the prevention or early detection of disease. It is also possible that the genetic counselling interaction itself will contribute to the possible use of preventative services.

Assessing fidelity to complex interventions: the icons experience

Background Assessing fidelity to complex healthcare interventions in clinical trials is a challenging area. ‘ICONS’ is a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP), incorporating bladder training and prompted voiding, to promote post-stroke continence. Here we describe feasibility of one aspect of fidelity assessment: the day-to-day implementation of the SVP through analysis of clinical logs. Methods Nurses completed clinical logs daily, which included documenting: the toileting interval, proposed toileting times and times toileted. Clinical logs were sampled across trial sites. The original intention was to assess fidelity by exploring the degree of concordance between proposed times and times toileted. Initial analysis revealed the unfeasibility of this method due to documentation errors in toileting intervals and proposed times. Consequently, the planned method was changed to identification of key ‘quality indicators’ (QIs) for documentation of practice. Results The need to revise the method of measurement demonstrates the difficulty in assessing fidelity. Assessment of clinical logs revealed low levels of adherence to key quality indicators. However, it is unclear whether this indicates poor fidelity or an imprecise method of fidelity assessment. Conclusion

Abstracts; The views of African people towards cancer: a literature review

BACKGROUND: The World Health Organisation reports that cancer mortality rates in developing African countries are rising because late diagnosis limits treatment options. In the UK there is evidence of inequalities in the delivery of cancer services to black and minority ethnic groups contributing to deaths from late diagnoses. UK studies of the African population are limited and focus on the African Caribbean community. Hence, UK cancer prevention strategies may not account for the African population’s cultural beliefs or attitudes towards cancer; this may affect awareness of the signs and symptoms. AIM: To identify evidence-based information about African immigrants’ views regarding cancer. METHODS: Six databases were searched: Academic Search Complete, AMED, CINAHL, MEDLINE, PsycInfo, and Soc Index. The literature search was extended to include grey literature and a search of reference lists of relevant studies. Publications not written in English were excluded. RESULTS: Six qualitative, nine quantitative, and one mixed method study were identified; all except two were conducted in the USA. The majority indicated that African people had low levels of knowledge about cancer risk factors, signs and symptoms. Misconceptions, cultural and religious belief and fear appear to influence African people’s views towards cancer; this may affects their behaviour in terms of seeking treatment. CONCLUSION: This review demonstrates a need for UK based studies to determine the relevance of review findings towards, and fill the gaps in knowledge about, the growing UK based African population.