Lynn Legg

Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials.

BACKGROUND Stroke-unit care can be valuable for stroke patients in hospital, but effectiveness of outpatient care is less certain. We aimed to assess the effects of therapy-based rehabilitation services targeted at stroke patients resident in the community within 1 year of stroke onset or discharge from hospital. METHODS We did a systematic review of randomised trials of outpatient services, including physiotherapy, occupational therapy, and multidisciplinary teams. We used Cochrane collaboration methodology. FINDINGS We identified a heterogeneous group of 14 trials (1617 patients). Therapy-based rehabilitation services for stroke patients living at home reduced the odds of deteriorating in personal activities of daily living (odds ratio 0.72 [95% CI 0.57-0.92], p=0.009) and increased ability of patients to do personal activities of daily living (standardised mean difference 0.14 [95% CI 0.02-0.25], p=0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, seven (95% CI 2-11) would not deteriorate. INTERPRETATION Therapy-based rehabilitation services targeted at selected patients resident in the community after stroke improve ability to undertake personal activities of daily living and reduce risk of deterioration in ability. These findings should be considered in future service planning.

Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomised trials

Objective To determine whether occupational therapy focused specifically on personal activities of daily living improves recovery for patients after stroke. Design Systematic review and meta-analysis. Data sources The Cochrane stroke group trials register, the Cochrane central register of controlled trials, Medline, Embase, CINAHL, PsycLIT, AMED, Wilson Social Sciences Abstracts, Science Citation Index, Social Science Citation, Arts and Humanities Citation Index, Dissertations Abstracts register, Occupational Therapy Research Index, scanning reference lists, personal communication with authors, and hand searching. Review methods Trials were included if they evaluated the effect of occupational therapy focused on practice of personal activities of daily living or where performance in such activities was the target of the occupational therapy intervention in a stroke population. Original data were sought from trialists. Two reviewers independently reviewed each trial for methodological quality. Disagreements were resolved by consensus. Results Nine randomised controlled trials including 1258 participants met the inclusion criteria. Occupational therapy delivered to patients after stroke and targeted towards personal activities of daily living increased performance scores (standardised mean difference 0.18, 95% confidence interval 0.04 to 0.32, P=0.01) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio 0.67, 95% confidence interval 0.51 to 0.87, P=0.003). For every 100 people who received occupational therapy focused on personal activities of daily living, 11 (95% confidence interval 7 to 30) would be spared a poor outcome. Conclusions Occupational therapy focused on improving personal activities of daily living after stroke can improve performance and reduce the risk of deterioration in these abilities. Focused occupational therapy should be available to everyone who has had a stroke.

Barriers to achieving evidence-based stroke rehabilitation

Objective: To determine the perceived barriers to evidence-based practice by health professionals working within the field of stroke rehabilitation. Design: Focus groups were carried out to identify the perceived barriers; these were followed by a postal questionnaire that asked stroke rehabilitation professionals to rate their agreement with the perceived barriers. Subjects: One hundred and five stroke rehabilitation professionals participated in the focus groups and were sent the postal questionnaire. Eighty-six responses were returned, from 27 physiotherapists, 26 occupational therapists, 22 nurses, 6 speech and language therapists, and 5 other professionals. Main outcome measures: Proportion of subjects rating their level of agreement with statements as 1 ‘agree’, 2, 3, 4 or 5 ‘disagree’. Scores of 1 or 2 were classified as ‘agreement’, and scores of 4 or 5 were classified as ‘disagreement’: the percentages of subjects agreeing or disagreeing with each statement were calculated. Results: Twenty barriers were identified, classified under the headings ‘ability’, ‘opportunity’ and ‘implementation’. Seventy-nine (92%) of all respondents agreed that keeping up to date with research findings was important to them, but only 7 (8%) were happy with the time that they had to do this. Fifty-eight (67%) perceived a need for further training. Only 4 (5%) agreed that it was easy to transfer research findings into their daily practice. A number of significant differences were found between the perceived barriers of different disciplines.

Randomised placebo-controlled trials of individualised homeopathic treatment: systematic review and meta-analysis

BackgroundA rigorous and focused systematic review and meta-analysis of randomised controlled trials (RCTs) of individualised homeopathic treatment has not previously been undertaken. We tested the hypothesis that the outcome of an individualised homeopathic treatment approach using homeopathic medicines is distinguishable from that of placebos.MethodsThe review’s methods, including literature search strategy, data extraction, assessment of risk of bias and statistical analysis, were strictly protocol-based. Judgment in seven assessment domains enabled a trial’s risk of bias to be designated as low, unclear or high. A trial was judged to comprise ‘reliable evidence’ if its risk of bias was low or was unclear in one specified domain. ‘Effect size’ was reported as odds ratio (OR), with arithmetic transformation for continuous data carried out as required; OR > 1 signified an effect favouring homeopathy.ResultsThirty-two eligible RCTs studied 24 different medical conditions in total. Twelve trials were classed ‘uncertain risk of bias’, three of which displayed relatively minor uncertainty and were designated reliable evidence; 20 trials were classed ‘high risk of bias’. Twenty-two trials had extractable data and were subjected to meta-analysis; OR = 1.53 (95% confidence interval (CI) 1.22 to 1.91). For the three trials with reliable evidence, sensitivity analysis revealed OR = 1.98 (95% CI 1.16 to 3.38).ConclusionsMedicines prescribed in individualised homeopathy may have small, specific treatment effects. Findings are consistent with sub-group data available in a previous ‘global’ systematic review. The low or unclear overall quality of the evidence prompts caution in interpreting the findings. New high-quality RCT research is necessary to enable more decisive interpretation.

Evidence behind stroke rehabilitation

Stroke is a common and serious condition for which there is no routinely available curative treatment. Because of the high burden of disability and the lack of a widely applicable medical treatment, much of post-stroke care relies upon rehabilitation interventions. This article will discuss the evidence behind stroke rehabilitation interventions. but before doing so we need to define some terminology. Rehabilitation has a rather non-specific definition: “a problem solving process aiming at reducing the disability and handicap resulting from a disease”. In this article we will use a broad definition of rehabilitation, which includes any general aspect of stroke care (generally non-surgical, non-pharmaceutical interventions) that aims to reduce disability and handicap (that is, promote activity and participation). This definition avoids an artificial splitting of early (often termed “acute”) and later (“rehabilitation”) care; rehabilitation interventions are relevant from the onset of symptoms. The main focus will be on evidence about treatments as these are the most common questions posed by clinicians. Conducting methodologically rigorous evaluations of rehabilitation interventions is complex. Firstly, rehabilitation interventions are traditionally tailored by a therapist or nurse to meet the identified needs of an individual patient. As such they can be difficult to define and test within a randomised trial. Secondly, a key strength of the randomised trial can be that both patients and health professionals are blind to the treatment given. In a circumstance where a therapist is applying a manual treatment technique to a patient it is often impossible to achieve such double blinding, although blinding of outcome assessment is usually possible (single blinding). Thirdly, many rehabilitation interventions are targeted at ameliorating a specific body function or promoting a specific activity. It can often be difficult to find a clinically meaningful, reliable, valid measure of outcome that is sensitive to any changes occurring as a …

Is informal caregiving independently associated with poor health? A population-based study

Background Providing informal care has been linked with poor health but has not previously been studied across a whole population. We aimed to study the association between informal care provision and self-reported poor health. Method We used data from the UK 2001 Census. The relationship between informal caregiving and poor health was modelled using logistic regression, adjusting for age, sex, marital status, ethnicity, economic activity and educational attainment. Results We included 44 465 833 individuals free from permanent sickness or disability. 5 451 902 (12.3%) participants reported providing informal care to another person. There was an association between provision of informal caregiving and self-reported poor health; OR 1.100, 95% CI 1.096 to 1.103. This association remained after adjustment for age, sex, ethnic group, marital status, economic activity and educational attainment. The association also increased with the amount of care provided (hours per week). Conclusions Around one in eight of the UK population reports that he or she is an informal caregiver. This activity is associated with poor health, particularly in those providing over 20 h care per week.

A systematic review of the evidence on home care reablement services

Objective: To determine whether publically funded ‘reablement services’ have any effect on patient health or use of services. Design: Systematic review of randomized controlled trials and non-randomized studies in which reablement interventions were compared with no care or usual care in people referred to public-funded personal care services. Data sources included: Cochrane Central Register of Controlled Trials, EPOC register of studies, trials registers, Medline, EMBASE, and CINHAL. Searches were from 2000 up to end February 2015. Setting: Not applicable. Participants: Investigators’ definition of the target population for reablement interventions. Main outcome measures: Use of publically funded personal care services and dependence in personal activities of daily living. Results: We found no studies fulfilling our inclusion criteria that assessed the effectiveness of reablement interventions. We did note the lack of an agreed understanding of the nature of reablement. Conclusions: Reablement is an ill-defined intervention targeted towards an ill-defined and potentially highly heterogeneous population/patient group. There is no evidence to suggest it is effective at either of its goals; increasing personal independence or reducing use of personal care services.

Therapy-Based Rehabilitation for Stroke Patients Living at Home

Stroke unit care is now accepted as an effective service model for hospital care, but the effectiveness of outpatient services are less certain. This review focuses on therapy-based rehabilitation services (defined as input from occupational therapy, physiotherapy, or a multidisciplinary team) targeted at stroke patients living at home. To assess the effects of therapy-based rehabilitation services targeted toward stroke patient resident in the community within 1 year of stroke onset or discharge from hospital following stroke. We searched the Cochrane Stroke Group Specialised …

Randomised, double-blind, placebo-controlled trials of non-individualised homeopathic treatment: systematic review and meta-analysis

BackgroundA rigorous systematic review and meta-analysis focused on randomised controlled trials (RCTs) of non-individualised homeopathic treatment has not previously been reported. We tested the null hypothesis that the main outcome of treatment using a non-individualised (standardised) homeopathic medicine is indistinguishable from that of placebo. An additional aim was to quantify any condition-specific effects of non-individualised homeopathic treatment.MethodsLiterature search strategy, data extraction and statistical analysis all followed the methods described in a pre-published protocol. A trial comprised ‘reliable evidence’ if its risk of bias was low or it was unclear in one specified domain of assessment. ‘Effect size’ was reported as standardised mean difference (SMD), with arithmetic transformation for dichotomous data carried out as required; a negative SMD indicated an effect favouring homeopathy.ResultsForty-eight different clinical conditions were represented in 75 eligible RCTs. Forty-nine trials were classed as ‘high risk of bias’ and 23 as ‘uncertain risk of bias’; the remaining three, clinically heterogeneous, trials displayed sufficiently low risk of bias to be designated reliable evidence. Fifty-four trials had extractable data: pooled SMD was –0.33 (95% confidence interval (CI) –0.44, –0.21), which was attenuated to –0.16 (95% CI –0.31, –0.02) after adjustment for publication bias. The three trials with reliable evidence yielded a non-significant pooled SMD: –0.18 (95% CI –0.46, 0.09). There was no single clinical condition for which meta-analysis included reliable evidence.ConclusionsThe quality of the body of evidence is low. A meta-analysis of all extractable data leads to rejection of our null hypothesis, but analysis of a small sub-group of reliable evidence does not support that rejection. Reliable evidence is lacking in condition-specific meta-analyses, precluding relevant conclusions. Better designed and more rigorous RCTs are needed in order to develop an evidence base that can decisively provide reliable effect estimates of non-individualised homeopathic treatment.

Nonpharmacological Interventions for Caregivers of Stroke Survivors

Providing care may be associated with psychological morbidity in informal caregivers. Because stroke is the leading cause of adult disability, people who provide informal care to stroke survivors are a useful group for studying the effects of interventions. A number of nonpharmacological interventions directed toward caregivers have been studied. We aimed to describe health effects of these interventions in a stroke context using systematic review and meta-analysis. ### Search Strategy We searched the Cochrane Stroke Group Trials Register (last searched March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 4, 2010), MEDLINE (1950–August 2010), EMBASE (1980–December 2010), CINAHL (1982–August 2010), AMED (1985–August 2010), PsycINFO (1967–August 2010) Science Citation Index (1992 to August 2010), and 6 other electronic databases. In an effort …