Michael John Leathley

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 DATA SOURCES The Cochrane Stroke Trials Register, electronic databases of published, unpublished and non-English language papers; conference proceedings, reference lists, and trial authors.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

Stroke knowledge and awareness: an integrative review of the evidence

BACKGROUND the recognition of stroke symptoms by the public and activation of the emergency medical services (EMS) are the most important factors in instigating pre-hospital stroke care. Studies have suggested that poor recognition of the warning signs of stroke is the main cause of delay in accessing the EMS. METHODS an integrative review of published studies about stroke knowledge and awareness was performed by searching online bibliographic databases, using keywords, from 1966 to 2008. Studies were included in the review if they focussed on risk factors, signs and symptoms, action and information. Each study was reviewed by two researchers (SJ and MJ). RESULTS we identified 169 studies of which 39 were included in the review. The ability to name one risk factor for stroke varied between studies, ranging from 18% to 94% when asked open-ended questions and from 42% to 97% when asked closed questions. The ability to name one symptom ranged from 25% to 72% when asked open-ended questions and from 95% to 100% when asked closed questions. When asked what action people would take if they thought they were having a stroke, between 53% and 98% replied that they would call the EMS. People generally obtained information about stroke from family and friends. Older members of the population, ethnic minority groups and those with lower levels of education had consistently poor levels of stroke knowledge. CONCLUSIONS generally, levels of knowledge about recognising and preventing stroke were poor. Nevertheless, most participants stated they would contact the EMS at the onset of stroke symptoms.

Predicting spasticity after stroke in those surviving to 12 months

Objective: To measure muscle tone in a cohort of patients 12 months after stroke and develop a preliminary model, using data recorded routinely after stroke, to predict who will develop spasticity. Design: A cohort study. Setting: Initially hospitalized but subsequently community-dwelling stroke survivors in Liverpool, United Kingdom. Subjects: One hundred and six consecutively presenting stroke patients surviving to 12 months. Main outcome measures: Spasticity measured at a range of joints using the Tone Assessment Scale. Results: The Tone Assessment Scale revealed spasticity in 38 (36%) patients and more severe spasticity in 21 (20%) of the 106 patients. Logistic regression analysis revealed that lower day 7 Barthel Index score and early arm or leg weakness were significant predictors of abnormal muscle tone; and lower day 7 Barthel Index score, left-sided weakness and ever smoked to be significant predictors of more severe muscle tone. Conclusions: Using the models, it may be possible to predict whether or not spasticity will develop in patients 12 months after stroke. The utility of the models is aided by their use of predictor variables that are routinely collected as part of stroke care in hospital and which are easy to measure. The models need testing prospectively in a new cohort of patients in order to test their validity, reliability and utility and to determine if other data could improve their efficiency.

Retrospective case note review of acute and inpatient stroke outcomes

The annual incidence of stroke in the community is about 2 per 1000 population,1 whereas among hospital inpatients it is 11 per 1000.2 However, a study that systematically and simultaneously identifies all inpatients experiencing stroke and all patients admitted with stroke does not exist. Previous work on stroke among inpatients has excluded some patients—for example, those with 3 or without 2 obvious iatrogenic predisposing factors. Similarly, although risk factors for stroke have been used as predictors of an event in the context of a study,3 these are often not documented clinically. Secondary prevention is dependenton identification and documentation of risk factors. We compared outcomes and the identification and documentation of known risk factors in a cohort of patients admitted with a stroke or having had a stroke while in hospital (having been admitted to hospital with …

Development and inter-rater reliability of an assessment tool for measuring muscle tone in people with hemiplegia after a stroke

Summary There is no validated method of measuring spasticity per se The most widely accepted clinical scale, the modified Ashworth scale, has been evaluated only at the elbow and does not take account of the possible effects of posture and associated reactions on tone. The aim of this study was to develop a reliable measure which incorporated response to passive movement, resting posture and associated reactions to active effort. The Tone Assessment Scale was constructed and modified, and its reliability tested in 15 patients with stroke. Inter-rater comparisons were made between two physiotherapists examining the reliability of each item of the scale. The six items reflecting response to passive movement were reliable (Kw 0.66 – 0.94), while those relating to posture were not (K 0.12 – 0.49). Only two of the three items relating to associated reactions were reliable (Kw 0.79 and 0.94, K 0.31). The establishment of reliability of measurement of tone at a number of joints should ensure more comprehensive estimates of spasticity and facilitate determination of treatment effects.

The challenges of implementing a telestroke network: a systematic review and case study

BackgroundThe use of telemedicine in acute stroke care can facilitate rapid access to treatment, but the work required to embed any new technology into routine practice is often hidden, and can be challenging. We aimed to collate recommendations and resources to support telestroke implementation.MethodsSystematic search of healthcare databases and the Internet to identify descriptions of the implementation of telestroke projects; interviews with key stakeholders during the development of one UK telestroke network. Supporting documentation from existing projects was analysed to construct a framework of implementation stages and tasks, and a toolkit of documents. Interviews and literature were analysed with other data sources using Normalisation Process Theory as described in the e-Health Implementation Toolkit.Results61 telestroke projects were identified and contacted. Twenty projects provided documents, 13 with published research detailing four stages of telestroke system development, implementation, use, and evaluation. Interviewees identified four main challenges: engaging and maintaining the commitment of a wide range of stakeholders across multiple organisations; addressing clinicians perceptions of evidence, workload, and payback; managing clinical and technical workability across diverse settings; and monitoring how the system is used and reconfigured by users.ConclusionsInformation to guide telestroke implementation is sparse, but available. By using multiple sources of data, sufficient information was collated to construct a web-based toolkit detailing implementation tasks, resources and challenges in the development of a telestroke system for assessment and thrombolysis delivery in acute care. The toolkit is freely available online.

Changing stroke mortality trends in middle-aged people: an age–period–cohort analysis of routine mortality data in persons aged 40 to 69 in England

Background In the UK, overall stroke mortality has declined. A similar trend has been seen in coronary heart disease, although recent reports suggest this decline might be levelling off in middle-aged adults. Aim To investigate recent trends in stroke mortality among those aged 40–69 years in England. Methods The authors used routine annual aggregated stroke death and population data for England for the years 1979–2005 to investigate time trends in gender-specific mortalities for adults aged 40 to 69 years. The authors applied log-linear modelling to isolate effects attributable to age, linear ‘drift’ over time, time period and birth cohort. Results Between 1979 and 2005, age-standardised stroke mortality aged 40 to 69 years dropped from 93 to 30 per 100 000 in men and from 62 to 18 per 100 000 in women. Mortality was higher in older age groups, but the difference between the older and younger age groups appears to have decreased over time for both sexes. Modelling of the data suggests an average annual reduction in stroke deaths of 4.0% in men and 4.3% in women, although this decrease has been particularly marked in the last few years. However, we also observed a relative rate increase in mortality among those born since the mid-1940s compared with earlier cohorts; this appears to have been sustained in men, which explains the levelling off in the rate of mortality decline observed in recent years in the younger middle-aged. Conclusions If observed trends in middle-aged adults continue, overall stroke mortalities may start to increase again.

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.

Training emergency services' dispatchers to recognise stroke: an interrupted time-series analysis

BackgroundStroke is a time-dependent medical emergency in which early presentation to specialist care reduces death and dependency. Up to 70% of all stroke patients obtain first medical contact from the Emergency Medical Services (EMS). Identifying ‘true stroke’ from an EMS call is challenging, with over 50% of strokes being misclassified. The aim of this study was to evaluate the impact of the training package on the recognition of stroke by Emergency Medical Dispatchers (EMDs).MethodsThis study took place in an ambulance service and a hospital in England using an interrupted time-series design. Suspected stroke patients were identified in one week blocks, every three weeks over an 18 month period, during which time the training was implemented. Patients were included if they had a diagnosis of stroke (EMS or hospital). The effect of the intervention on the accuracy of dispatch diagnosis was investigated using binomial (grouped) logistic regression.ResultsIn the Pre-implementation period EMDs correctly identified 63% of stroke patients; this increased to 80% Post-implementation. This change was significant (p=0.003), reflecting an improvement in identifying stroke patients relative to the Pre-implementation period both the During-implementation (OR=4.10 [95% CI 1.58 to 10.66]) and Post-implementation (OR=2.30 [95% CI 1.07 to 4.92]) periods. For patients with a final diagnosis of stroke who had been dispatched as stroke there was a marginally non-significant 2.8 minutes (95% CI −0.2 to 5.9 minutes, p=0.068) reduction between Pre- and Post-implementation periods from call to arrival of the ambulance at scene.ConclusionsThis is the first study to develop, implement and evaluate the impact of a training package for EMDs with the aim of improving the recognition of stroke. Training led to a significant increase in the proportion of stroke patients dispatched as such by EMDs; a small reduction in time from call to arrival at scene by the ambulance also appeared likely. The training package has been endorsed by the UK Stroke Forum Education and Training, and is free to access on-line.

Callers' experiences of making emergency calls at the onset of acute stroke: a qualitative study

Background Rapid access to emergency medical services (EMS) is essential at the onset of acute stroke, but significant delays in contacting EMS often occur. Objective To explore factors that influence the callers decision to contact EMS at the onset of stroke, and the callers experiences of the call. Methods Participants were identified through a purposive sample of admissions to two hospitals via ambulance with suspected stroke. Participants were interviewed using open-ended questions and content analysis was undertaken. Results 50 participants were recruited (median age 62 years, 68% female). Only one of the callers (2%) was the patient. Two themes were identified that influenced the initial decision to contact EMS at the onset of stroke: perceived seriousness, and receipt of lay or professional advice. Two themes were identified in relation to the communication between the caller and the call handler: symptom description by the caller, and emotional response to onset of stroke symptoms. Conclusions Many callers seek lay or professional advice prior to contacting EMS and some believe that the onset of acute stroke symptoms does not warrant an immediate 999 call. More public education is needed to improve awareness of stroke and the need for an urgent response.