Ron MacWalter

Perceived control, coping and recovery from disability following stroke

Previous research has demonstrated that perceived control beliefs predict recovery from disability, allowing for initial levels of disability, in stroke patients. Theories of mental representations and coping would suggest that this relationship might be mediated by coping, by engaging in exercise, and that emotional factors might be involved. These hypotheses were examined in a longitudinal study of 71 patients interviewed in hospital within 3 weeks of the stroke, 1 month after discharge and 6 months after discharge. The results confirmed that perceived control predicted recovery from disability but no support was found for the mediating effects of exercise or mood. While the results offer some tentative suggestions for intervention, they point to deficiencies in current theories of disability.

Recovery from disability after stroke as a target for a behavioural intervention: results of a randomized controlled trial.

Purpose. Disability following stroke is highly prevalent and is predicted by psychological variables such as control cognitions and emotions, in addition to clinical variables. This study evaluated the effectiveness of a workbook-based intervention, designed to change cognitions about control, in improving outcomes for patients and their carers. Method. At discharge, stroke patients were randomly allocated (with their carers) to a 5-week intervention (n = 103) or control (normal care: n = 100). The main outcome (at 6 months) was recovery from disability using a performance measure, with distress and satisfaction as additional outcomes. Results. The intervention group showed significantly better disability recovery, allowing for initial levels of disability, than those in the control group, F(1,201) = 5.61, p = 0.019. Groups did not differ in distress or satisfaction with care for patients or carers. The only psychological process variable improved by the intervention was Confidence in Recovery but this did not mediate the effects on recovery. Conclusions. A large proportion of intervention participants did not complete the workbook tasks. This was perhaps associated with the fairly low level of personal contact with workbook providers. The modest success of this intervention suggests that it may be possible to develop effective behavioural interventions to enhance recovery from disability in stroke patients.

The prevalence of treatable left ventricular systolic dysfunction in patients who present with noncardiac vascular episodes: A case-control study☆

OBJECTIVESnWe sought to determine the prevalence of treatable left ventricular (LV) systolic dysfunction (LVSD) in patients who present with their first noncardiac vascular episode.nnnBACKGROUNDnScreening for LV dysfunction in patients who present with their first stroke (cerebrovascular accident), their first transient ischemic attack (TIA) or their first manifestation of peripheral vascular disease (PVD) may represent a golden opportunity to identify treatable LV dysfunction, and so their known high incidence of sudden cardiac death may be reduced.nnnMETHODSnParticipating in this study were 522 (75%) of 700 consecutive patients (302 patients with stroke, TIA or PVD and 220 age- and gender-matched control subjects). Each underwent a full clinical assessment, 12-lead electrocardiography and two-dimensional echocardiography. Left ventricular dysfunction was defined as LV ejection fraction < or = 40%.nnnRESULTSnSeventy-two (28%) patients with vascular disease and 11 (5.5%) control subjects were found to have LVSD. Twenty-six (28%) stroke patients, 22 (26%) patients with TIA and 24 (31%) patients with PVD had LVSD. Left ventricular systolic dysfunction was symptomatic in 44% of patients and in 35% of control subjects.nnnCONCLUSIONSnLeft ventricular systolic dysfunction is five times more common among patients with stroke, TIA and PVD than among age- and gender-matched control subjects. Asymptomatic LVSD is more common than symptomatic LVSD in these patients. These findings suggest that routine screening of all patients with noncardiac vascular episodes for LVSD should now be considered. Future studies should investigate whether identifying and treating LVSD in these patients would reduce their known high rate of cardiac death.

Perceived control and recovery from functional limitations : Preliminary evaluation of a workbook-based intervention for discharged stroke patients

Background. Previous research has demonstrated that control cognitions predict functional limitations following stroke. This paper reports a preliminary evaluation of the effects of a workbook intervention, designed to enhance perceptions of control, in reducing disability in patients discharged from hospital following stroke. Methods. Thirty-nine patients living at home who had had a stroke within the 2 previous years completed baseline assessments of functional limitations, mood and perceived control. They were then randomly allocated to either a Workbook Intervention or a Wait control group and functional limitation and mood outcomes were assessed 1 month later. Results. Results showed no benefit of the intervention, but both groups showed reduced functional limitations. Reductions in functional limitations were correlated with increases in perceptions of control. Conclusions. Clearly, the workbook intervention needs to be strengthened before a full evaluation would be worthwhile for this clinical group. It is possible that both groups demonstrated spontaneous recovery or may have benefited from the additional attention given by the researcher. These benefits were associated with enhanced perceptions of control, contributing to previous findings suggesting that control cognitions may be both a consequence and a determinant of functional limitations.

Improving Emotional Outcomes following Acute Stroke: A Preliminary Evaluation of a Work-Book Based Intervention

Sixteen acute stroke patients (6 males and 10 females) who received a self-help workbook addressing both medical and psychological issues on discharge from hospital showed Significantly lower anxiety and depression levels and a non-significant trend toward greater satisfaction with advice/information than 53 patient controls. (28 male, 25 female) recruited to an earlier study who did not receive the workbook. All patients had been admitted to hospital with a first stroke, were aged less than 80 years, and had a residual disability at discharge. There were no significant group differences in age, sex distribution or neurological impairment measured within 48 hours of admission to hospital, thus our findings suggest that a workbook-based intervention can improve short-term emotional outcomes. A large-scale randomised controlled trial is needed.

Spousal caregiver confidence and recovery from ambulatory activity limitations in stroke survivors.

OBJECTIVEnThis study examined whether spousal confidence in care-recipient recovery can predict recovery from activity limitations following stroke and how spousal confidence relates to stroke survivor self-efficacy for recovery.nnnDESIGNnA prospective design was used. Measures were gathered from stroke survivor/spouse dyads at two time points, both postdischarge from the hospital following stroke (N=109).nnnMAIN OUTCOME MEASURESnThe dependent variable was recovery from ambulatory activity limitations over 6 weeks, as measured by the Functional Limitations Profile. A single spousal confidence item was tailored to an ambulatory behavior that the stroke survivors could not perform at Time 1.nnnRESULTSnSpousal confidence was correlated with ambulation recovery (r=-0.23, p<.05) and stroke survivor self-efficacy for recovery (r=.25, p<.05). Higher spousal confidence was associated with a better recovery and greater stroke survivor self-efficacy for recovery, but not with initial health status or practical support received.nnnCONCLUSIONnThe relationship between caregiver confidence, care-recipient self-efficacy for recovery, and recovery outcomes needs further elucidation.

Stroke Survivors' Evaluations of a Stroke Workbook-Based Intervention Designed to Increase Perceived Control over Recovery.

Objective: To report stroke survivors’ experiences and perceived usefulness of an effective self-help workbook-based intervention. Design: A cross-sectional study involving the intervention group of an earlier randomized controlled trial. Setting: At the participants’ homes approximately seven weeks post-hospital discharge. Method: Following the five-week implementation period of the intervention, stroke survivors (n = 59) completed a structured exercise designed to assess and prioritize perceived usefulness of the intervention components. Demographic, clinical and psychological measures from the original study were included. Results: Ninety per cent (n = 53) of respondents rated the stroke workbook intervention as being better than slightly useful. A factor analysis of the completed responses derived three components, which were labelled information, support and behavioural activities. Repeated measures analysis of variance (ANOVA) showed information and support to be significantly more useful than the behavioural activities (F (2, 116) = 60.79, p = .001). Behavioural activities were more highly rated by women than men (p = .02) and by those without a caregiver than those with (p = .02). Participants with high desire rated all three components of the intervention more useful than those with low desire (p = .01). Conclusions: Those who used the intervention generally found it useful, with information and social support being perceived as being more useful than behavioural activities. Perceiving the behavioural activities as least useful may impede the uptake of recovery-promoting activities, which may have consequences for the effect of rehabilitation, and recovery.

Subacute gastric volvulus--a rare cause of vomiting in the elderly.

We report a case of an important and uncommon cause of vomiting in an elderly female patient who had no previous apparent gastrointestinal problems. A diaphragmatic hernia with gastric volvulus, which presented non-specifically but was an important diagnosis to make.

The importance of identifying intracranial haemorrhage as a cause of transient focal neurological symptoms.

Until recently, there have been no reports of intracerebral haemorrhage presenting with transient neurological symptoms. We present two cases of intracerebral haemorrhage presenting as transient ischaemic attacks and discuss the radiological changes on early and late CT scans. It would seem justified to scan most patients presenting with TIA early to institute appropriate secondary prevention measures.

Empyema of lung associated with streptococcus milleri infection

Empyema of the lung is a very serious illness which must be detected quickly and treated aggressively. We report an unusual case of empyema of the lung associated with a boating accident while the patient was fishing in a sea loch off the west coast of Scotland.