Lynne Turner-Stokes

Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway

Background: Shoulder pain is a common complication of stroke. It can impede rehabilitation and has been associated with poorer outcomes and prolonged hospital stay. This systematic review was undertaken to inform the development of an evidence-based integrated care pathway (ICP) for the management of hemiplegic shoulder pain (HSP). Aims and objectives: 1) To provide a background understanding of the functional anatomy of the shoulder and its changes following stroke. 2) To review the literature describing incidence and causation of HSP and the evidence for factors contributing to its development. 3) To appraise the evidence for effectiveness of different interventions for HSP. Methods: Data sources comprised a computer-aided search of published studies on shoulder pain in stroke or hemiplegia and references to literature used in reviews (total references = 121). Main findings: Although a complex variety of physical changes are associated with HSP, these broadly divide into ‘flaccid’ and ‘spastic’ presentations. Management should vary accordingly; each presentation requiring different approaches to handling, support and intervention. (1) In the ‘accid stage, the shoulder is prone to inferior subluxation and vulnerable to soft-tissue damage. The arm should be supported at all times and functional electrical stimulation may reduce subluxation and enhance return of muscle activity. (2) In the spastic stage, movement is often severely limited. Relieving spasticity and maintaining range requires expert handling; overhead exercise pulleys should never be used. Local steroid injections should be avoided unless there is clear evidence of an in‘ammatory lesion. Conclusions: HSP requires co-ordinated multidisciplinary management to minimize interference with rehabilitation and optimize outcome. Further research is needed to determine effective prophylaxis and document the therapeutic effect of different modalities in the various presentations. Development of an integrated care pathway provides a reasoned approach to management of this complex condition, thus providing a sound basis for prospective evaluation of different interventions in the future.

Goal attainment scaling (GAS) in rehabilitation: a practical guide

Goal attainment scaling is a mathematical technique for quantifying the achievement (or otherwise) of goals set, and it can be used in rehabilitation. Because several different approaches are described in the literature, this article presents a simple practical approach to encourage uniformity in its application. It outlines the process of setting goals appropriately, so that the achievement of each goal can be measured on a 5-point scale ranging from -2 to +2, and then explains a method for quantifying the outcome in a single aggregated goal attainment score. This method gives a numerical T-score which is normally distributed about a mean of 50 (if the goals are achieved precisely) with a standard deviation of around this mean of 10 (if the goals are overachieved or underachieved). If desired, the approach encompasses weighting of goals to reflect the opinion of the patient on the personal importance of the goal and the opinion of the therapist or team on the difficulty of achieving the goal. Some practical tips are offered, as well as a simple spreadsheet (in Microsoft Excel) allowing easy calculation of the T-scores.

Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway. Part 1: Diagnosis, frequency and impact

Background: Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to explore the available evidence on which to base an integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting. It is divided into two parts. Aims and objectives: In part 1 we review the frequency of depression in stroke and its impact on functional recovery. Also the different methods for diagnosis and measurement. Methods: Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews. Main findings: PSD is common and is associated with cognitive, functional and social deficits which potentially limit the outcome from rehabilitation. However, diversity of assessment tools and diagnostic criteria confound assimilation of the available literature. The Beck Depression Inventory (BDI), Hamilton Depression Rating Scale and Zung Self-rating Depression Scale were most commonly used and have demonstrable validity in stroke patients but tend to exclude those with aphasia. Instruments developed specifically to include aphasic patients, such as the Stroke Aphasic Depression Scale, are promising but have yet to be fully evaluated. Conclusions: Further work is required to adapt and evaluate instruments to measure depression in the context of stroke. Development of an integrated care pathway may help to establish a more consistent approach to assessment and diagnosis of PSD.

Does reducing spasticity translate into functional benefit? An exploratory meta-analysis

Background: Spasticity and loss of function in an affected arm are common after stroke. Although botulinum toxin is used to reduce spasticity, its functional benefits are less easily demonstrated. This paper reports an exploratory meta-analysis to investigate the relationship between reduced arm spasticity and improved arm function. Method: Individual data from stroke patients in two randomised controlled trials of intra-muscular botulinum toxin were pooled. The Modified Ashworth Scale (elbow, wrist, fingers) was used to calculate a “Composite Spasticity Index”. Data from the arm section of the Barthel Activities of Daily Living Index (dressing, grooming, and feeding) and three subjective measures (putting arm through sleeve, cleaning palm, cutting fingernails) were summed to give a “Composite Functional Index”. Change scores and the time of maximum change were also calculated. Results: Maximum changes in both composite measures occurred concurrently in 47 patients. In 26 patients the improvement in spasticity preceded the improvement in function with 18 showing the reverse. There was a definite relationship between the maximum change in spasticity and the maximum change in arm function, independent of treatment (ρ = −0.2822, p = 0.0008, n = 137). There was a clear relationship between the changes in spasticity and in arm function in patients treated with botulinum toxin (Dysport) at 500 or 1000 units (ρ = −0.5679, p = 0.0090, n = 22; ρ = −0.4430, p = 0.0018, n = 47), but not in those treated with placebo or 1500 units. Conclusions: Using a targeted meta-analytic approach, it is possible to demonstrate that reducing spasticity in the arm is associated with a significant improvement in arm function.

The UK FIM+FAM: development and evaluation

Background and aims: The aim of this study was to develop and evaluate the UK version of the Functional Assessment Measure (UK FIM+FAM). Design: Before and after evaluation of inter-rater reliability. Development: Ten ‘troublesome’ items in the original FIM+FAM were identified as being particularly difficult to score reliably. Revised decision trees were developed and tested for these items over a period of two years to produce the UK FIM+FAM. Evaluation: A multicentre study was undertaken to test agreement between raters for the UK FIM+FAM, in comparison with the original version, by assessing accuracy of scoring for standard vignettes. Methods: Baseline testing of the original FIM+FAM was undertaken at the start of the project in 1995. Thirty-seven rehabilitation professionals (11 teams) each rated the same three sets of vignettes – first individually and then as part of a multidisciplinary team. Accuracy was assessed in relation to the agreed ‘correct’ answers, both for individual and for team scores. Following development of the UK version, the same vignettes (with minimal adaptation to place them in context with the revised version) were rated by 28 individuals (nine teams). Results: Taking all 30 items together, the accuracy for scoring by individuals improved from 74.7% to 77.1% with the UK version, and team scores improved from 83.7% to 86.5%. When the 10 troublesome items were taken together, accuracy of individual raters improved from 69.5% to 74.6% with the UK version (p<0.001), and team scores improved from 78.2% to 84.1% (N/S). For both versions, team ratings were significantly more accurate than individual ratings (p<0.01). Kappa values for team scoring of the troublesome items were all above 0.65 in the UK version. Conclusion: The UK FIM+FAM compares favourably with the original version for scoring accuracy and ease of use, and is now sufficiently well-developed for wider dissemination.

BOTULINUM TOXIN A FOR TREATMENT OF UPPER LIMB SPASTICITY FOLLOWING STROKE: A MULTI-CENTRE RANDOMIZED PLACEBO- CONTROLLED STUDY OF THE EFFECTS ON QUALITY OF LIFE AND OTHER PERSON-CENTRED OUTCOMES

OBJECTIVE Botulinum toxin is known to relieve upper limb spasticity, which is a disabling complication of stroke. We examined its effect on quality of life and other person-centred perspectives. DESIGN A multi-centre, randomized, double-blind, placebo-controlled study. PATIENTS Ninety-six patients were randomized (mean age 59.5 years) at least 6 months post-stroke. Mean time since stroke was 5.9 years. METHODS Patients received either botulinum toxin type A or placebo into the affected distal upper limb muscles on 2 occasions, 12 weeks apart. Assessment was undertaken at baseline, 8, 12, 20 and 24 weeks. The primary outcome measure was the Assessment of Quality of Life scale (AQoL). Secondary outcome assessments included Goal Attainment Scaling (GAS), pain, mood, global benefit, Modified Ashworth Scale (MAS), disability and carer burden. RESULTS The groups did not differ significantly with respect to quality of life, pain, mood, disability or carer burden. However, patients treated with botulinum toxin type A had significantly greater reduction in spasticity (MAS) (p < 0.001), which translated into higher GAS scores (p < 0.01) and greater global benefit (p < 0.01). CONCLUSION Although no change in quality of life was demonstrated using the AQoL, botulinum toxin type A was found to be safe and efficacious in reducing upper limb spasticity and improving the ability to achieve personal goals.

Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: international consensus statement

Upper limb spasticity affecting elbow, wrist, and finger flexors can be safely and effectively reduced with injections of botulinum toxin type‐A (BoNT‐A). It has been best studied in adults in the context of post‐stroke spasticity. The clinical benefits include reduction in pain and deformity, improvement in washing and dressing the upper limb, and a reduction in caregiver burden (Class I evidence, recommendation level A). Some patients show improvement in function performed by active movement of the affected upper limb (Class III evidence, recommendation C), but predicting and measuring this is difficult, and further research is needed. An individually based approach to treatment and outcome measurement is preferred (Class IV, recommendation U). More research is needed to resolve many unknown issues of assessment and treatment, using research methods appropriate to the question.

The use of standardized outcome measures in rehabilitation centres in the UK

Aim: To identify the standardized outcome measures currently used in routine clinical practice in rehabilitation centres in the UK. Design: Cross-sectional survey by postal questionnaire. Participants: All UK consultant members of the British Society of Rehabilitation Medicine (BSRM) (n = 180). Results: A total of 108 (60%) responses were received, representing 83 different rehabilitation services. Of these, 71 (86%) collected at least one standardized measure. The Barthel Index and the UK Functional Independence Measure and/or Functional Assessment Measure (FIM9 ± FAM) were the most popular global outcome measures: 83% of units measured one or other of these. The Northwick Park Dependency Scale (NPDS) and Care Needs Assessment (NPCNA) (n = 21, 28%) were used for the more dependent patients. Depression and pain scores were more commonly used than general health measures. Sixty (72%) units routinely assessed outcome through the achievement of set goals, but only four transformed data to a goal attainment scale. Outcome measure scores were routinely reported in discharge summaries by 72% of units. Conclusions: The survey demonstrated quite widespread use of outcome assessments in routine clinical rehabilitation within the UK, with an encouraging level of common measurement in some areas of practice. The results have been used to update the BSRM ‘basket of recommended measures’.

GOAL ATTAINMENT SCALING IN THE EVALUATION OF TREATMENT OF UPPER LIMB SPASTICITY WITH BOTULINUM TOXIN: A SECONDARY ANALYSIS FROM A DOUBLE-BLIND PLACEBO-CONTROLLED RANDOMIZED CLINICAL TRIAL

OBJECTIVE To examine goal attainment scaling for evaluation of treatment for upper limb post-stroke spasticity with botulinum toxin-A. DESIGN Secondary analysis of a multi-centre double-blind, placebo-controlled randomized clinical trial. SETTING Six outpatient clinics in Australia. PARTICIPANTS Patients (n=90) completing per protocol 2 cycles of treatment/placebo. Mean age 54.5 (standard deviation 13.2) years. Mean time since stroke 5.9 (standard deviation 10.5) years. INTERVENTIONS Intramuscular botulinum toxin-A (Dysport 500-1000U) or placebo given at 0 and 12 weeks. Measurement points were baseline, 8 and 20 weeks. MAIN OUTCOME MEASURES Individualized goal attainment and its relationship with spasticity and other person-centred measures - pain, mood, quality of life and global benefit. RESULTS A significant treatment effect was observed with respect to goal attainment (Mann-Whitney z=-2.33, p< or = 0.02). Goal-attainment scaling outcome T-scores were highly correlated with reduction in spasticity (rho=0.36, p=0.001) and global benefit (rho=0.45, p<0.001), but not with other outcome measures. Goal-attainment scaling T-scores were lower than expected (median 32.4, interquartile range 29.6-40.6). Goals related to passive tasks were more often achieved than those reflecting active function. Qualitative analysis of goals nevertheless demonstrated change over a wide area of patient experience. CONCLUSION Goal-attainment scaling provided a responsive measure for evaluating focal intervention for upper limb spasticity, identifying outcomes of importance to the individual/carers, not otherwise identifiable using standardized measures.

GOAL ATTAINMENT SCALING: DOES IT PROVIDE ADDED VALUE AS A PERSON-CENTRED MEASURE FOR EVALUATION OF OUTCOME IN NEUROREHABILITATION FOLLOWING ACQUIRED BRAIN INJURY?

OBJECTIVE To compare goal attainment scaling (GAS) and standardized measures in evaluation of person-centred outcomes in neurorehabilitation. DESIGN A prospective cohort analysis from a tertiary inpatient neuro-rehabilitation service for younger adults with complex neurological disability. SUBJECTS/PATIENTS Consecutive patients (n = 164) admitted for rehabilitation following acquired brain injury (any cause) over 3 years. Mean age 44.8 (standard deviation 14.4) years. DIAGNOSIS 66% strokes, 18% trauma, 16% other. Male:female ratio 102:62. METHODS GAS-rated achievement of 1-6 patient-selected goals was compared with the Functional Assessment Measure (UK FIM+FAM), and Barthel Index (BI), rated on admission and discharge. Personal goals were mapped retrospectively to the FIM+FAM and International Classification of Functioning, Disability and Health (ICF). RESULTS Median (interquartile range; IQR) GAS T-scores were 50.0 (44.2-51.8) and moderately correlated with changes in FIM+FAM and BI (both rho 0.38 (p < 0.001)). Standardized response means were 2.2, 1.6 and 1.4 for GAS, FIM+FAM and BI, respectively. Of 667 personal goals set, 495 (74%) were fully achieved. Although 413 (62%) goals were reflected by changes in FIM+FAM, over one-third of goals were set in other areas. CONCLUSION GAS appeared to be more responsive, and captured gains beyond the FIM+FAM, thus providing added value as an adjunct to outcome measurement in patients with complex disability.