Maggie Lawrence

A systematic review of the benefits of mindfulness-based interventions following transient ischemic attack and stroke.

Background Recent epidemiological studies have demonstrated an association between perceived psychological stress and ischemic stroke. A feature of stroke is recurrence; 30–40% within five-years following first transient ischemic attack/stroke. Equipping patients with skills and coping strategies to help reduce or manage perceived psychological stress may represent an important secondary prevention intervention. Mindfulness-based interventions are structured, group-based self-management programmes with potential to help people with long-term conditions cope better with physical, psychological, or emotional distress. Review evidence suggests significant benefits across a range of physical and mental health problems. However, we could find no evidence synthesis relating specifically to the benefits of mindfulness-based interventions following transient ischemic attack/stroke. Aim The review aims to evaluate the benefits of mindfulness-based interventions following transient ischemic attack/stroke. Methods Six major databases were searched using subject headings and key words. Papers were screened using review-specific criteria. Critical appraisal and data extraction were conducted independently by two reviewers. Statistical meta-analysis was not possible; therefore findings are presented in narrative form. Results Four studies involving 160 participants were reviewed. Three papers reported mindfulness-based interventions delivered to groups; one paper reported a mindfulness-based intervention which was delivered one to one. The results demonstrate a positive trend in favor of the benefits of mindfulness-based interventions across a range of psychological, physiological, and psychosocial outcomes including anxiety, depression, mental fatigue, blood pressure, perceived health, and quality of life. No evidence of harm was found. Conclusion Following transient ischemic attack/stroke, people may derive a range of benefits from mindfulness-based interventions; however, further methodologically robust trials are required.

Defining and measuring patient-centred care: an example from a mixed-methods systematic review of the stroke literature

Background  Involving patients in the determination of their care is increasingly important, and health‐care professionals worldwide have recognized a need for clinical outcome measures and interventions that facilitate patient‐centred care delivery in a range of settings.

Systematic review of reviews of behavioural HIV prevention interventions among men who have sex with men

Abstract Men who have sex with men (MSM) remain one of the groups most at risk of HIV. The growing evidence-base on behavioural HIV prevention interventions includes systematic review-level evidence, including reviews specific to MSM populations. Here, we provide an up-to-date review of these systematic reviews in which we examined the effectiveness of behavioural HIV prevention interventions among MSM. A systematic search of electronic databases, including MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, PsycInfo, from January 2000 to October 2010, along with hand searches of the reference lists of retrieved documents were conducted. Inclusion criteria included: study design limited to systematic reviews and meta-analyses; methodological quality; and review to focus on MSM and behavioural interventions. A narrative synthesis was conducted. Across the four included meta-analyses (102 studies; 52 independent studies), there was strong and consistent evidence for group- and community-level interventions being associated with reductions in UAI (27–30% and 30%, respectively) and increases in condom use amongst MSM, but inconsistent evidence for the effectiveness of individual-level interventions. Skills-building, trained professionals delivering the training and theory-based interventions were also consistently effective. The inherent limitations of the review of review method within a changing health domain meant it was difficult to develop contemporary and directly transferable guidance to HIV prevention policy development. However, the analysis does demonstrate a need for a step change in the kinds of data that are collated in the development of future systematic reviews of HIV prevention interventions among MSM.

Tobacco and alcohol-related interventions for people with mild/moderate intellectual disabilities: a systematic review of the literature.

BACKGROUND The behavioural determinants of health among people with mild/moderate intellectual disabilities (ID) are of increasing concern. With the closure of long-stay institutions, more people with ID are living in the community. As they lead more ordinary and less restricted lives, people with ID may be exposed to social and environmental pressures that encourage them to adopt behaviours that impact negatively on their health. Levels of smoking and alcohol consumption in this client group are of particular concern. METHODS We undertook a mixed method review of the literature, aiming to assess the Feasibility, Appropriateness, Meaningfulness and Effectiveness (FAME) of interventions designed to address the use of tobacco and/or alcohol in people with mild/moderate ID. Key electronic databases were searched (e.g., Medline, Cochrane Register of Controlled Trials, PsycINFO) from 1996 to 2011. The search was developed using appropriate subject headings and key words (e.g., intellectual disability, tobacco use, alcohol drinking, health promotion). On completion of the database searches, inclusion/exclusion criteria, based on an adaptation of the PICO framework (Population, Intervention, Comparison, Outcomes), were applied. Methodological quality was assessed using a seven-point rating scale. RESULTS Database searches identified 501 unique records, of which nine satisfied the inclusion criteria. Four focused on tobacco, three on alcohol and two on both tobacco and alcohol. Located in the U.K., the U.S.A. and Australia, the studies aimed to increase knowledge levels and/or change behaviour (e.g., to encourage smoking cessation). One was a randomised controlled trial, one a quasi-experiment and the others were before and after studies and/or case studies. Methodological quality was poor or moderate. The combined studies had a sample size of 341, with ages ranging from 14 to 54 years. The interventions were delivered by professionals (e.g., in health, social care, education) during sessions that spanned a period of three weeks to one academic year. The studies highlighted a number of important issues linked to the appropriateness of interventions for this client group (e.g., use of pictures, quizzes, role play, incentives); however, in the majority of cases the interventions appeared to lack a theoretical framework (e.g., behaviour change theory). The appropriateness of the outcome measures for use with this client group was not tested. One study discussed feasibility (teachers delivering lessons on alcohol and tobacco) and only one was informative in terms of effectiveness, i.e., increasing knowledge of the health and social dangers of smoking and excessive alcohol consumption. CONCLUSIONS This review is the first to systematically collate evidence on tobacco and alcohol-related interventions for people with ID. While there is currently little evidence to guide practice, the review delivers clear insights for the development of interventions and presents a strong case for more robust research methods. In particular there is a need to test the effectiveness of interventions in large-scale, well-designed trials and to ensure that outcome measures are developed/tailored appropriately for this client group.

The effectiveness of secondary prevention lifestyle interventions designed to change lifestyle behavior following stroke: summary of a systematic review

Background A feature of stroke is that it recurs (25% within five-years). Risk factors for stroke and recurrent stroke include smoking, alcohol consumption, poor diet, and physical inactivity. Aim To evaluate the effectiveness of secondary prevention lifestyle interventions designed to change lifestyle behavior following stroke. This short paper presents a summary of the systematic review process and findings. Methods Ten major databases were searched using subject headings and key words. Papers were screened using review-specific criteria. Critical appraisal and data extraction were conducted independently by two reviewers. Data were pooled in statistical meta-analysis; where this was not possible findings were presented in narrative form. Results Three studies involving 581 participants were reviewed. Two models of intervention delivery were reported: shared care and nurse-led. Interventions were delivered to groups or in one-to-one consultations. Metaanalyses of the pooled lifestyle data favored the interventions (2P = 0.02). In terms of physiological outcomes, while overall treatment effect was not significant, pooled results did approach statistical significance (2P = 0.08), however the test of heterogeneity was significant, suggesting differences in the variables that were pooled. Pooled secondary outcomes, including perceived health status and stroke knowledge, favored the interventions (2P #< 0.00001), however, the test for heterogeneity was highly significant. Conclusion Stroke secondary prevention lifestyle interventions are effective in terms of effecting positive change in lifestyle behaviors and secondary outcomes, and appear promising in relation to physiological outcomes. There was insufficient evidence to determine the effect of intervention on incidence of stroke recurrence.

Multimodal Secondary Prevention Behavioral Interventions for TIA and Stroke: A Systematic Review and Meta-Analysis

Background Guidelines recommend implementation of multimodal interventions to help prevent recurrent TIA/stroke. We undertook a systematic review to assess the effectiveness of behavioral secondary prevention interventions. Strategy Searches were conducted in 14 databases, including MEDLINE (1980-January 2014). We included randomized controlled trials (RCTs) testing multimodal interventions against usual care/modified usual care. All review processes were conducted in accordance with Cochrane guidelines. Results Twenty-three papers reporting 20 RCTs (6,373 participants) of a range of multimodal behavioral interventions were included. Methodological quality was generally low. Meta-analyses were possible for physiological, lifestyle, psychosocial and mortality/recurrence outcomes. Note: all reported confidence intervals are 95%. Systolic blood pressure was reduced by 4.21 mmHg (mean) (−6.24 to −2.18, P = 0.01 I2 = 58%, 1,407 participants); diastolic blood pressure by 2.03 mmHg (mean) (−3.19 to −0.87, P = 0.004, I2 = 52%, 1,407 participants). No significant changes were found for HDL, LDL, total cholesterol, fasting blood glucose, high sensitivity-CR, BMI, weight or waist:hip ratio, although there was a significant reduction in waist circumference (−6.69 cm, −11.44 to −1.93, P = 0.006, I2 = 0%, 96 participants). There was no significant difference in smoking continuance, or improved fruit and vegetable consumption. There was a significant difference in compliance with antithrombotic medication (OR 1.45, 1.21 to 1.75, P<0.0001, I2 = 0%, 2,792 participants) and with statins (OR 2.53, 2.15 to 2.97, P< 0.00001, I2 = 0%, 2,636 participants); however, there was no significant difference in compliance with antihypertensives. There was a significant reduction in anxiety (−1.20, −1.77 to −0.63, P<0.0001, I2 = 85%, 143 participants). Although there was no significant difference in odds of death or recurrent TIA/stroke, there was a significant reduction in the odds of cardiac events (OR 0.38, 0.16 to 0.88, P = 0.02, I2 = 0%, 4,053 participants). Conclusions There are benefits to be derived from multimodal secondary prevention interventions. However, the findings are complex and should be interpreted with caution. Further, high quality trials providing comprehensive detail of interventions and outcomes, are required. Review Registration PROSPERO CRD42012002538.

Needs, priorities, and desired rehabilitation outcomes of family members of young adults who have had a stroke: findings from a phenomenological study

Purpose: This study explored the experience of stroke from the perspective of family members of young adults who have had a stroke. Gaining understanding of the short, medium and long-term needs and desired rehabilitation outcomes of family members assisted identification of appropriate family-centred multidisciplinary rehabilitation interventions. Method: A qualitative approach based on Merleau-Ponty’s existential phenomenology enabled exploration of family members’ experience of stroke. Eleven family members, including parents, spouses, children and siblings, participated in 24 interviews over 2 years. A subsequent iterative process of critical reflection was used to identify family-centred needs, priorities and associated rehabilitation outcomes. Results: Within a thematic framework, family members’ experience was conceptualised as Disruption of Temporal Being. Against this overarching theme or (back)ground, figural themes were identified: Uncertainty, Disrupted and Altered Relationships, and Situatedness. In addition, sixteen short, medium and long-term effects of stroke were identified along with associated family-centred needs and rehabilitation outcomes. Conclusion: An empathetic understanding of the experience of stroke from the perspective of family members, combined with research evidence and professional expertise enables the multidisciplinary rehabilitation team to deliver tailored interventions based on identified needs and priorities, and negotiation of mutually agreed goals. Implications for Rehabilitation Following stroke in a young adult, families’ needs, priorities and associated rehabilitation outcomes change over time; rehabilitation services should reflect this dynamic process. To deliver family-centred care, rehabilitation professionals need to develop a deeper understanding of the experience of families affected by stroke, gained from qualitative research findings and from their own reflective practice. Gaining understanding of the experience of family members of young adults who have had a stroke will enable health professionals to consider how they may improve practice and enhance service provision to ensure delivery of effective, family-centred interventions. The table of family-centred needs and outcomes can be used by members of the multidisciplinary stroke rehabilitation team in conjunction with their own knowledge, experience and resources to inform family-centred practice.

A systematic review of the effectiveness of secondary prevention lifestyle interventions designed to change lifestyle behaviour following stroke

Executive summary Background Each year, approximately 15 million people worldwide have a stroke; of these, five million die and another five million are chronically disabled. Stroke recurs in approximately 25% of patients during the first five years post‐stroke; recurrence may result in death, increased disability or institutionalisation. Modifiable risk factors for recurrent stroke have been identified, and may be addressed by means of behavioural health promotion interventions. Objectives This systematic review sought to establish the effectiveness of secondary prevention behavioural interventions, which address one or more modifiable lifestyle risk factors for recurrent stroke i.e. tobacco use, unhealthy diet, physical inactivity and excessive alcohol consumption. Inclusion criteria Types of participants The review included studies that had recruited adults (aged ≥18 years) who had had a stroke, minor stroke or transient ischaemic attack. Types of intervention The review considered studies that evaluated behavioural lifestyle interventions, designed to address the prevention of recurrent stroke. Types of outcomes Primary outcomes were concerned with lifestyle behaviour change i.e. tobacco use, diet, physical activity and alcohol consumption, and with change in physiological measures e.g. blood pressure, total cholesterol, and Body Mass Index. Secondary outcome measures included psychological outcomes, learning outcomes and incidence of stroke recurrence. Types of studies Experimental and non‐experimental quantitative studies were considered. Search strategy In August 2009, we searched All EMB Reviews, AMED, ASSIA, British Nursing Index and Archive, CINAHL, Conference Proceedings Citation Index ‐ Science, ProQuest dissertation and theses, EMBASE, MEDLINE, PsycINFO, and bibliographies of retrieved papers. Methodological quality and data extraction Two review authors independently assessed methodological quality using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument, and extracted data using a review‐specific data extraction form. Data analysis Where possible, results from the review papers were pooled in statistical meta‐analysis using bespoke software based on the system used by the Early Breast Cancer Trialists Collaborative Group. Where statistical pooling was not possible, findings are presented in narrative form. Results Three studies, two RCTs and one quasi‐experimental study, involving 581 participants (baseline) were included in the review. Two models of service delivery were reported: shared care and nurse‐led. Interventions were delivered to groups or in one‐to‐one consultations. Meta‐analyses of the pooled lifestyle data favoured the interventions (2p=0.02; Note: here and throughout, 2p represents the two‐tailed probability). In terms of physiological outcomes, the pooled data favoured the interventions (2p=0.05), particularly those aiming to reduce blood pressure and cholesterol levels. The pooled secondary outcomes, including perceived health status and stroke knowledge favoured the interventions (2p<0.00001), however, the test for heterogeneity was also highly significant. Conclusions Stroke secondary prevention lifestyle interventions are effective in terms of affecting positive change in relation to lifestyle behaviours, physiological and secondary outcomes. However, there was insufficient evidence to determine the effect of intervention on incidence of stroke recurrence. Implications for practice Clinicians should implement stroke secondary prevention interventions which address lifestyle behaviours, physiological factors, psychological outcomes and stroke knowledge. Implications for research Further large‐scale, well‐designed trials are needed to determine the factors that impact on the effectiveness of secondary prevention interventions.

Top 10 research priorities relating to stroke nursing: a rigorous approach to establish a national nurse‐led research agenda

AIM To determine the top 10 research priorities specific to stroke nursing. BACKGROUND It is important that stroke nurses build their research capability and capacity. This project built on a previous James Lind Alliance prioritization project, which established the shared stroke research priorities of stroke survivors, carers and health professionals. DESIGN Research priority setting project using James Lind Alliance methods; a survey for interim prioritization and a consensus meeting for final priority setting. METHODS Between September - November 2014, stroke nurses were invited to select their top 10 priorities from a previously established list of 226 unique unanswered questions. These data were used to generate a list of shared research priorities (interim priority setting stage). A purposefully selected group of stroke nurses attended a final consensus meeting (April 2015) to determine the top 10 research priorities. RESULTS During the interim prioritization stage, 97 stroke nurses identified 28 shared priority treatment uncertainties. At the final consensus meeting, 27 stroke nurses reached agreement on the top 10 stroke nursing research priorities. Five of the top 10 questions relate to stroke-specific impairments and five relate to rehabilitation and long-term consequences of stroke. CONCLUSIONS The research agenda for stroke nursing has now been clearly defined, facilitating nurses to undertake research, which is of importance to stroke survivors and carers and central to supporting optimal recovery and quality of life after stroke.

The effectiveness of transcutaneous tibial nerve stimulation (TTNS) for adults with overactive bladder syndrome: A systematic review

To evaluate effectiveness of transcutaneous tibial nerve stimulation (TTNS) for treating adults with overactive bladder (OAB) of idiopathic or neurogenic origin, using a systematic review of the literature.