Nadina B. Lincoln

Effects of Augmented Exercise Therapy Time After Stroke A Meta-Analysis

Background and Purpose— To present a systematic review of studies that addresses the effects of intensity of augmented exercise therapy time (AETT) on activities of daily living (ADL), walking, and dexterity in patients with stroke. Summary of Review— A database of articles published from 1966 to November 2003 was compiled from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE, and PiCarta using combinations of the following key words: stroke, cerebrovascular disorders, physical therapy, physiotherapy, occupational therapy, exercise therapy, rehabilitation, intensity, dose–response relationship, effectiveness, and randomized controlled trial. References presented in relevant publications were examined as well as abstracts in proceedings. Studies that satisfied the following selection criteria were included: (1) patients had a diagnosis of stroke; (2) effects of intensity of exercise training were investigated; and (3) design of the study was a randomized controlled trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for ADL, walking speed, and dexterity using fixed and random effect models. Correlation coefficients were calculated between observed individual effect sizes on ADL of each study, additional time spent on exercise training, and methodological quality. Cumulative meta-analyses (random effects model) adjusted for the difference in treatment intensity in each study was used for the trials evaluating the effects of AETT provided. Twenty of the 31 candidate studies, involving 2686 stroke patients, were included in the synthesis. The methodological quality ranged from 2 to 10 out of the maximum score of 14 points. The meta-analysis resulted in a small but statistically significant SES with regard to ADL measured at the end of the intervention phase. Further analysis showed a significant homogeneous SES for 17 studies that investigated effects of increased exercise intensity within the first 6 months after stroke. No significant SES was observed for the 3 studies conducted in the chronic phase. Cumulative meta-analysis strongly suggests that at least a 16-hour difference in treatment time between experimental and control groups provided in the first 6 months after stroke is needed to obtain significant differences in ADL. A significant SES supporting a higher intensity was also observed for instrumental ADL and walking speed, whereas no significant SES was found for dexterity. Conclusion— The results of the present research synthesis support the hypothesis that augmented exercise therapy has a small but favorable effect on ADL, particularly if therapy input is augmented at least 16 hours within the first 6 months after stroke. This meta-analysis also suggests that clinically relevant treatment effects may be achieved on instrumental ADL and gait speed.

An extended activities of daily living scale for stroke patients

A ranked assessment of daily living (ADL) scale has been developed to assess activities which may be important to stroke patients who have been discharged home. A questionnaire incorporating 22 ADL activities in four sections was sent by post to 80 consecutively registered stroke patients. Gutmann scaling was carried out on the returned questionnaires, producing acceptable coefficients of reproducibility and scalability. The revised questionnaire was then sent to 20 stroke patients. The same patients were sent an identical questionnaire two weeks later. The overall level of agreement between the two assessments was satisfactory. The extended ADL scale could therefore be used as a postal questionnaire to assist in the follow-up of patients discharged home after a stroke. Due to the scaling properties of the assessment, patients progress can be monitored and patients can also be compared on the basis of their scale score.

Cognitive Behavioral Psychotherapy for Depression Following Stroke A Randomized Controlled Trial

Background and Purpose— There is inconclusive evidence of the effectiveness of psychological interventions for depression after stroke. We report the results from a randomized controlled trial of cognitive behavioral therapy (CBT). Methods— Stroke patients admitted to hospital were invited to complete mood questionnaires 1, 3 and 6 months after stroke. Patients who were depressed were invited to take part in a trial and randomly allocated to receive CBT (n=39), an attention placebo intervention (n= 43), or standard care (n=41). Outcome assessments were undertaken at 3 and 6 months after recruitment, on the Beck Depression Inventory, Wakefield Depression Inventory, Extended Activities of Daily Living scale, London Handicap Scale, and a rating of satisfaction with care. Results— There were no significant differences between the groups in patients’ mood, independence in instrumental activities of daily living, handicap, or satisfaction with care. Conclusions— CBT in the treatment of depression following stroke was found to be ineffective in this study. However, because of the small sample size, method of recruitment, and selection criteria, further randomized trials are required.

Occupational therapy for stroke patients not admitted to hospital : a randomised controlled trial

BACKGROUND Patients who have a stroke are not always admitted to hospital, and 22-60% remain in the community, frequently without coordinated rehabilitation. We aimed to assess the efficacy of an occupational therapy intervention for patients with stroke who were not admitted to hospital. METHODS In this single-blind randomised controlled trial, consecutive stroke patients on a UK community register in Nottingham and Derbyshire were allocated randomly to up to 5 months of occupational therapy at home or to no intervention (control group) 1 month after their stroke. The aim of the occupational therapy was to encourage independence in personal and instrumental activities of daily living. Patients were assessed on outcome measures at baseline (before randomisation) and at 6 months. The primary outcome measure was the score on the extended activities of daily living (EADL) scale at 6 months. Other outcome measures included the Barthel index, the general health questionnaire 28, the carer strain index, and the London handicap scale. All assessments were done by an independent assessor who was unaware of treatment allocation. The analysis included only data from completed questionnaires. FINDINGS 185 patients were included: 94 in the occupational therapy group and 91 in the control group. 22 patients were not assessed at 6 months. At follow-up, patients who had occupational therapy had significantly higher median scores than the controls on: the EADL scale (16 vs 12, p<0.01, estimated difference 3 [95% CI 1 to 4]); the Barthel index (20 vs 18, p<0.01, difference 1, [0-1]); the carer strain index (1 vs 3, p<0.05, difference 1 [0 to 2]); and the London handicap scale (76 vs 65, p<0.05, difference 7, [0.3 to 13.5]). There were no significant differences on the general health questionnaire between the patient or carer. INTERPRETATION Occupational therapy significantly reduced disability and handicap in patients with stroke who were not admitted to hospital.

Use of Time by Stroke Patients. A Comparison of Four European Rehabilitation Centers

Background and Purpose— Differences exist between European countries in the proportion of patients who die or become dependent after stroke. The aim of the present study was to identify differences in the use of time by stroke patients in 4 rehabilitation centers in 4 European countries. Methods— In each of the 4 centers, 60 randomly selected stroke patients were observed at 10-minute intervals using behavioral mapping. Observations took place on 30 weekdays selected at random, on equal numbers of morning, afternoon, and evening sessions. A logistic generalized estimating equation model with correction for differences in case mix and multiple testing was used for the analysis. Results— Overall time available from different professions was the highest in the United Kingdom, but patients in the United Kingdom spent on average only 1 hour per day in therapy. This was significantly less than patients in Belgium and Germany, who spent ≈2 hours, and patients in Switzerland who spent ≈3 hours per day in therapy. In all centers, patients spent less than half their time in interactions and >72% of the time in nontherapeutic activities. Conclusions— Important differences in the use of time were established, which appeared dependent on management decisions rather than the number of staff available. Patients in the Swiss and German centers spent more time in therapy, possibly because of the structured organization of rehabilitation. Further studies will verify whether this has an effect on outcome.

Reliability and Revision of the Nottingham Sensory Assessment for Stroke Patients

Summary The Nottingham Sensory Assessment is a standardised scale for assessing sensory impairment in stroke patients. In the first study, a revised version of the scale was developed by reviewing the assessments of 61 patients admitted to a stroke unit. The scale was shortened by reducing testing of the unaffected limb to light touch, temperature and kinaesthetic sensation. An heirarchy of items was identified so that testing could be discontinued if no impairment was detected in the distal portion of the limb. In a second study, the reliability of the revised Nottingham Sensory Assessment was checked by two physiotherapists, who both assessed 27 stroke patients. Kappa co-efficients showed acceptable agreement on 12 out of 86 items. The light touch and pressure scales were the most reliable and pin-prick and temperature scales were the least reliable.

Somatosensory impairment after stroke: frequency of different deficits and their recovery

Objective: To investigate the frequency of somatosensory impairment in stroke patients within different somatosensory modalities and different body areas, and their recovery. Design: Prospective observational study. Setting: Two stroke rehabilitation units. Subjects: Seventy patients with a first stroke (36 men, 34 women; average age, 71, SD 10.00 years; average time since stroke onset, 15 days) were assessed on admission and two, four and six months after stroke. Interventions: Not applicable. Main measure: Nottingham Sensory Assessment. Results: Somatosensory impairment was common after stroke; 7—53% had impaired tactile sensations, 31—89% impaired stereognosis, and 34—64% impaired proprioception. When comparing somatosensory modalities within body areas the kappa values were low (kappa values <0.54). Recovery occurred over time, though not significantly in lower limb tactile sensations. Stroke severity was the main factor influencing initial somatosensory impairment, but accounted for a small amount of the variance (21—41%). Initial somatosensory impairment was significantly related to somatosensory ability at six months, accounting for 46—71% of the variance. Conclusions: Proprioception and stereognosis were more frequently impaired than tactile sensations. The different somatosensory modalities showed only slight agreement between impairment within the same body areas, suggesting that the modalities are independent of each other and all should be assessed. High agreements were found between different body areas for each somatosensory modality. Somatosensory impairment was associated with stroke severity, however low variance indicated other factors were involved.

A randomised controlled trial of domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital.

This study compared the functional ability and perceived health status of stroke patients treated by a domiciliary rehabilitation team or by routine hospital-based services after discharge from hospital. Patients discharged from two acute and three rehabilitation hospitals in Nottingham were randomly allocated in three strata (Health Care of the Elderly, General Medical and Stroke Unit) to receive domiciliary or hospital-based care after discharge. Functional recovery was assessed by the Extended Activities of Daily Living (ADL) scale three and six months after discharge and perceived health at six months was measured by the Nottingham Health Profile. A total of 327 eligible patients of 1119 on a register of acute stroke admissions were recruited over 16 months. Overall there were no differences between the groups in their Extended ADL scores at three or six months, or their Nottingham Health Profile scores at six months. In the Stroke Unit stratum, patients treated by the domiciliary team had higher household (p = 0.02) and leisure activity (p = 0.04) scores at six months than those receiving routine care. In the Health Care of the Elderly stratum, death or a move into long-term institutional care at six months occurred less frequently in patients allocated to the routine service, about half of whom attended a geriatric day hospital. Overall there was no difference in the effectiveness of the domiciliary and hospital-based services, although younger stroke unit patients appeared to do better with home therapy while some frail elderly patients might have benefited from day hospital attendance.

Effect of severity of arm impairment on response to additional physiotherapy early after stroke

Objective: To investigate effect of initial severity of arm impairment on response to additional physiotherapy for the arm after stroke. Design: In this controlled trial, patients were randomized into one of three groups: routine physiotherapy (RPT) patients received no additional physiotherapy; qualified physiotherapy (QPT) patients received additional treatment from a qualified physiotherapist; assistant physiotherapy (APT) patients received additional treatment from a trained supervised assistant. Comparisons between the whole groups found no significant differences and have been reported elsewhere. In a post hoc analysis, the groups were subdivided according to severity of initial arm impairment. The subgroups were then compared. Setting: A general hospital with acute and rehabilitation facilities for stroke patients. Subjects: Patients (n= 282) between one and five weeks after stroke. Interventions: Ten hours additional physiotherapy were given over a five-week period. The treatment approach reflected current usual British practice. ‘Blind’ outcome assessment was performed after intervention, and at three and six months after stroke. Main outcome measures: Rivermead Motor Assessment Arm Scale, Action Research Arm Test. Results: In more severe patients, no benefits of additional treatment were detected. In less severe patients, significant benefits were found in those who completed treatment with the trained assistant. However, a considerable number of patients did not complete the additional treatment. The content of treatment differed between the QPT and APT groups. Treatment of less severe APT patients emphasized repetitive supervised practice of movements and functional tasks. No significant effects of additional treatment were found in terms of shoulder pain or spasticity. Conclusions: Regardless of whether additional physiotherapy was given or not, patients with severe arm impairment improved very little in arm function. Enabling adaptation to loss of arm function may be an appropriate rehabilitation strategy for some patients. Trends in the data confirm findings of some previous studies that intensive treatment for patients with some motor recovery of the upper limb is effective. Following patient assessment and treatment planning by a qualified physiotherapist, it may be appropriate for guidance of repetitive practice of motor and functional tasks to be delegated to trained and closely supervised assistant staff.

The unreliability of sensory assessments

The intra- and inter-rater reliability of a standardized assessment of sensory impairment were investigated. Twenty stroke patients were assessed at home by the same physiotherapist on two occasions. There was good consistency overtime on most items. Twenty patients in hospital were assessed by two physiotherapists. The results indicate poor agreement between assessors. Twenty-five patients were assessed by a physiotherapist and a doctor. Results indicate low agreement between these assessors. Results indicate poor inter-rater reliability on a standardized assessment. It is suggested that this may also be a problem for clinical assessments of sensory impairment after stroke.