Review of stroke rehabilitation.
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Caregivers↗
Biomedical subjects
Anne Forster
Publications and source records attributed to Anne Forster.
A cost effectiveness analysis within a randomised controlled trial of post-acute care of older people in a community hospital.
OBJECTIVE: To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district general hospital, which admits patients aged over 76 years with acute medical conditions. DESIGN: Cost effectiveness analysis within a randomised controlled trial. SETTING: Community hospital and district general hospital in Yorkshire, England. PARTICIPANTS: 220 patients needing rehabilitation after an acute illness for which they required admission to hospital. INTERVENTIONS: Multidisciplinary care in the district general hospital or prompt transfer to the community hospital. MAIN OUTCOME MEASURES: EuroQol EQ-5D scores transformed into quality adjusted life years (QALYs), and health and social service costs over six months from randomisation. RESULTS: The mean QALY score for the community hospital group was marginally non-significantly higher than that for the district general hospital group (0.38 v 0.35) at six months after recruitment. The mean (standard deviation) costs per patient of the health and social services resources used were similar for both groups: community hospital group 7233 pounds sterling (euros 10,567; 13,341 dollars) (5031 pounds sterling), district general hospital group 7351 pounds sterling(6229 pounds sterling), and these findings were robust to several sensitivity analyses. The incremental cost effectiveness ratio for community hospital care dominated. A cost effectiveness acceptability curve, based on bootstrapped simulations, suggests that at a willingness to pay threshold of 10,000 pounds sterling per QALY, 51% of community hospital cases will be cost effective, which rises to 53% of cases when the threshold is 30,000 pounds sterling per QALY. CONCLUSION: Post-acute care for older people in a locality based community hospital is of similar cost effectiveness to that of an elderly care department in a district general hospital.
Acute Disease↗
Feasibility study of a primary care-based model for stroke aftercare.
BACKGROUND: A new primary care model for stroke aftercare has been developed to address the longer-term needs of patients who have had a stroke and their families. AIM: To test the feasibility and acceptability of the new model on patients who have had a stroke and their carers. DESIGN OF STUDY: An observational feasibility study. SETTING: Patient and carer assessments and interviews conducted in patients' homes. METHOD: Patients who have had a stroke, and their carers, were assessed using a purposely developed primary care stroke model. Qualified health- and social-care professionals acted as stroke care coordinators and carried out the assessments. Four evaluations were undertaken as part of the study: analysis of care plans, a survey of unmet needs, focus group sessions for staff, and patient/carer interviews. RESULTS: Forty-seven patients and 21 carers were recruited to the study. Analysis of care plans indicated that the assessment process was successful in identifying patient and carer problems (n = 219). Actions were instigated against 190 of these problems and, at 3 months after the assessment, 75% of the problems had been resolved. Patients/carers thought that the review process would be more valuable if conducted sooner after hospital discharge. CONCLUSION: The model was acceptable to professionals, encouraging them to work in a manner more consistent with the expressed needs of patients and carers who were adjusting to the longer-term impact of stroke. Essential aspects informing the care process were also identified. Further work is now required to investigate the effects of the intervention on patient and carer outcomes.
Aftercare↗
Use of the 'STRATIFY' falls risk assessment in patients recovering from acute stroke.
OBJECTIVES: To investigate the predictive validity and reliability of the STRATIFY falls risk assessment tool as applied to patients recovering from acute stroke. DESIGN: Prospective cohort study. SETTING: Six stroke rehabilitation units in the North of England. SUBJECTS: All patients with a diagnosis of acute stroke admitted to the participating stroke units during a 6-month study period. ASSESSMENT: on admission, falls risk (STRATIFY), disability (Barthel index), mobility (Rivermead mobility index), cognitive impairment (abbreviated mental test score) and visual neglect (Albert's test) were assessed. Then, STRATIFY was completed weekly and within 48 h of anticipated discharge. Consenting patients were contacted at 3 months after discharge to determine falls. OUTCOME MEASURES: Occurrence of a fall within 28 days of the baseline STRATIFY (in-patient study), falls in the first 3 months after discharge (post-discharge study) and falls during stroke unit stay (reliability study). RESULTS: From 387 patients admitted to the participating units during the study period, 225 contributed to the 28 day in-patient study, and 234 were followed up at 3 months after discharge. STRATIFY performed poorly in predicting falls in the first 28 days (sensitivity 11.3% and specificity 89.5%) and after discharge (sensitivity 16.3% and specificity 86.4%). Agreement was 'fair' between baseline and discharge scores (kappa = 0.263) and 'good' between the pre-hospital discharge score and that obtained in the week preceding discharge (kappa = 0.639). CONCLUSION: STRATIFY performed poorly as a predictor of falls in a heterogeneous population of stroke patients. There is a need for a disease-specific rather than a generic falls risk assessment tool.
Accidental Falls↗
Effects of locality based community hospital care on independence in older people needing rehabilitation: randomised controlled trial.
OBJECTIVE: To determine the effects on independence in older people needing rehabilitation in a locality based community hospital compared with care on a ward for elderly people in a district general hospital. DESIGN: Randomised controlled trial. SETTING: Care in a community hospital and district general hospital in Bradford, England. PARTICIPANTS: 220 patients needing rehabilitation after an acute illness that required hospital admission. INTERVENTIONS: Patients were randomly allocated to a locality based community hospital or to remain within a department for the care of elderly people in a district general hospital. MAIN OUTCOME MEASURES: Primary outcomes were Nottingham extended activities of daily living scale and general health questionnaire 28 (carer). Secondary outcomes were activities of daily living (Barthel index), Nottingham health profile, hospital anxiety and depression scale, mortality, destination after discharge, satisfaction with services, carer strain index, and carer's satisfaction with services. RESULTS: The median length of stay was 15 days for both the community hospital and the district general hospital groups (interquartile range: community hospital 9-25 days; district general hospital 9-24 days). Independence at six months was greater in the community hospital group (adjusted mean difference 5.30, 95% confidence interval 0.64 to 9.96). Results for the secondary outcome measures, including care satisfaction and measures of carer burden, were similar for both groups. CONCLUSIONS: Care in a locality based community hospital is associated with greater independence for older people than care in wards for elderly people in a district general hospital.
Activities of Daily Living↗
A randomized trial evaluation of the Oswestry Standing Frame for patients after stroke.
BACKGROUND: Standing is believed to have benefits in addressing motor and sensory impairments after stroke. One device to facilitate standing for severely disabled patients is the Oswestry Standing Frame. OBJECTIVE: To evaluate the effectiveness of the Oswestry Standing Frame for severely disabled stroke patients. DESIGN: A single centre, randomized controlled trial. SETTING: An inpatient stroke rehabilitation unit. SUBJECTS: Patients were recruited if they had a clinical diagnosis of stroke, were medically stable and unable to achieve any score on the Trunk Control Test or unable to stand in mid-line without the assistance of two therapists. INTERVENTION: The intervention (n = 71) and control (n = 69) groups both received usual stroke unit care but the intervention group also received a minimum of 14 consecutive days' treatment using the standing frame. MAIN OUTCOME MEASURES: The primary outcome measure was the Rivermead Mobility Index (RMI). Secondary measures included the Barthel Index; the Rivermead Motor Assessment; the balanced sitting and sitting to standing components of the Motor Assessment Scale; the Trunk Control Test and the Hospital Anxiety and Depression Scale. Blind assessment was undertaken at baseline, six weeks, 12 weeks and six months post stroke. Information on resource use was also collected. RESULTS: There was no statistically significant difference between groups in any of the outcome measures or for resource use. Mann-Whitney U-tests for the RMI change from baseline scores to six weeks, 12 weeks and six months post stroke were p = 0.310; p = 0.970 and p = 0.282, respectively. CONCLUSION: Use of the Oswestry Standing Frame did not improve clinical outcome or provide resource savings for this severely disabled patient group.
Aged↗
Combined analysis of two randomized trials of community physiotherapy for patients more than one year post stroke.
BACKGROUND: Some patients continue to have mobility problems as a long-term consequence of stroke and it is unclear whether routine, further contact with a physiotherapy service is beneficial. Two single-centre, randomized controlled trials of physiotherapy for patients more than one year post stroke have been undertaken in Oxford and Bradford in the UK and the results from these two trials have been combined to give a more precise estimate of effectiveness. METHOD: The computerized databases from both trials were combined for a joint analysis. Outcome measures common to both trials were: Rivermead Mobility Index; gait speed measured over 10 metres; Barthel Index; Frenchay Activities Index; Hospital Anxiety and Depression Scale. RESULTS: There were 264 patients available for the combined analysis (Oxford = 94; Bradford = 170). There was a significant but clinically small improvement in mobility at three months in the combined treatment group measured by the Rivermead Mobility Index (median of the differences = 0 (95% confidence interval (CI) 0, 1); interpolated values = 0.43 (95% CI 0.08, 0.80)) and gait speed (treatment effect 2.7 m/min (95% CI 0.94, 4.46)). There were no other significant differences. Intervention given in both studies was at the discretion of the physiotherapists and was of similar and low intensity (mean visits Oxford = 4 (SD 2.5); Bradford = 5 (SD 4.5)). CONCLUSION: A more effective physiotherapy intervention is required for stroke patients with persisting mobility problems after stroke.
Aged↗
A randomized trial to evaluate an education programme for patients and carers after stroke.
OBJECTIVES: To evaluate the effectiveness of an education programme for patients and carers recovering from stroke. DESIGN: Randomized controlled trial. SUBJECTS AND SETTING: One hundred and seventy patients admitted to a stroke rehabilitation unit and 97 carers of these patients. INTERVENTIONS: The intervention group received a specifically designed stroke information manual and were invited to attend education meetings every two weeks with members of their multidisciplinary team. The control group received usual practice. MEASURES: Primary outcome was knowledge of stroke and stroke services. Secondary outcomes were handicap (London Handicap Scale), physical function (Barthel Index), social function (Frenchay Activities Index), mood (Hospital Anxiety and Depression Scale) and satisfaction (Pound Scale). Carer mood was measured by the General Health Questionnaire-28. RESULTS: There was no statistical evidence for a treatment effect on knowledge but there were trends that favoured the intervention. The education programme was associated with a significantly greater reduction in patient anxiety score at both three months (p =0.034) and six months (p =0.021) and consequently fewer 'cases' (Hospital Anxiety and Depression Scale anxiety subscale score > or =11). There were no other significant statistical differences between the patient or carer groups for other outcomes, although there were trends in favour of the education programme. CONCLUSION: An education programme delivered within a stroke unit did not result in improved knowledge about stroke and stroke services but there was a significant reduction in patient anxiety at six months post stroke onset.
Adult↗
A survey to investigate the role of the district nurse in stroke care.
The long-term needs of people who have had a stroke and their carers are not being adequately addressed. A stroke care coordinator based in primary care might improve service delivery: the district nurse has been suggested as a possible candidate. A postal survey was conducted with three primary care trusts in Bradford to investigate the current role of the district nurse in stroke care and to examine their potential as stroke care coordinator. District nurses from 24 (59%) teams responded to the survey. Twenty-two (44%) were aware of the national clinical guidelines for stroke and five (10%) had received stroke-related training within the previous year. The district nurses demonstrated insight into the types of longer term problems experienced by people who have had a stroke and their carers. While findings of the survey suggests that they would be a likely candidate for the stroke care coordinator role, there are major educational, training and organizational challenges to implementing this change.
Community Health Nursing↗
An estimate of post-acute intermediate care need in an elderly care department for older people.
There is an expectation that intermediate care services for older people will be widely introduced in England. The planning of such services should be based on an understanding of required capacity. The present study provides a needs estimate for post-acute intermediate care. Older patients admitted acutely to an elderly care department in a district general hospital serving a large city in northern England were followed prospectively by a research team until medical stability had occurred in the opinion of the senior ward nurses and the responsible consultant. The clinical staff then determined if the patient had continuing post-acute care needs or if imminent discharge was possible. Out of 1211 acutely admitted patients, 997 became medically stable and 312 [25.8% of admissions; 95% confidence interval (CI) = 23.3-28.2%] were considered to require post-acute care, and of these, 251 (20.7% of admissions; 95% CI = 18.4-23.0%) needed post-acute rehabilitation care. In conclusion, the present authors suggest that intermediate care services providing post-acute care for older people should have a capacity to address the needs of up to one-quarter of acute admissions to a district general hospital elderly care department.
Aftercare↗
Developing a primary care-based stroke service: a review of the qualitative literature.
The aim of this review was to identify the most frequently encountered longer-term problems experienced by stroke patients and their informal carers. Systematically identified qualitative studies describing self-reported experiences of stroke-related long-term problems were independently reviewed and the findings analysed using a clustering technique. Twenty-three qualitative studies, which included approximately 500 patients and 180 carers, were identified by the search methods. Most of the studies were cross-sectional, United Kingdom-based, and employed semi-structured individual interviews. The review identified 203 problem areas, which were categorised into five domains: hospital experience; transfer of care; communication; services; and social and emotional consequences. The largest domain was the social and emotional consequences of stroke, representing 39% of all problem areas. These included problems relating to mood, social changes, attitudes to recovery, and changes in self-perception and relationships. Service deficiencies, encompassing both health and social care, was the second largest domain, accounting for 29% of the problem areas. The review provides a basis for a user-focused, longer-term stroke service. The need for responses that go beyond the traditional physical rehabilitation approach is evident, and research to identify broader treatment strategies is now required.
Adaptation, Psychological↗
Developing a primary care-based stroke model: the prevalence of longer-term problems experienced by patients and carers.
BACKGROUND: Over the last two decades, the need for a longer-term perspective to stroke management has become increasingly recognised. This paper reports a component of a larger project aimed at developing a systematic, primary care-based service for stroke aftercare. AIM: To identify the types and prevalence of longer-term problems experienced by stroke patients and their carers in the United Kingdom (UK). METHOD: Systematically identified quantitative surveys reporting the prevalence of long-term stroke-related problems were reviewed and the findings extracted and interpreted against a patient and carer defined classification system, identified during an earlier review of the qualitative stroke literature. RESULTS: Twenty-seven UK surveys, including approximately 6000 patients and 3000 carers, and two literature reviews were identified by the search methods. Most of the problem areas identified in the qualitative stroke literature review were reported in the quantitative surveys and an additional two problems were identified (falls and sexual problems). The prevalence of problems in each of the areas was as follows: 19% to 62% for emotional problems; 18% to 46% for social problems; 13% to 77% for service issues; 18% to 88% for poor communication; 33% to 100% for transfer of care; and 10% to 73% for other areas. CONCLUSION: This review confirms the findings and recommendations from earlier work about the need for a longer-term holistic approach to the rehabilitation of stroke patients and support for carers. Having established the nature and frequency of the main problems experienced by stroke patients and their carers, the appropriate evidence-based interventions need to be identified and consolidated into a stroke service, facilitated by a robust patient-assessment process.
Caregivers↗
Physiotherapy for patients with mobility problems more than 1 year after stroke: a randomised controlled trial.
BACKGROUND: Community physiotherapy is often prescribed for stroke patients with long-term mobility problems. We aimed to assess the effectiveness of this treatment in patients who had mobility problems 1 year after stroke. METHODS: We screened 359 patients older than 50 years for a single-masked, randomised controlled trial to assess the effects of community physiotherapy. Assessments were made at baseline, 3, 6, and 9 months in 170 eligible patients assigned treatment or no intervention. The primary outcome measure was mobility measured by the Rivermead mobility index. Secondary outcome measures were gait speed, number of falls, daily activity (Barthel index scores), social activity (Frenchay activities index), hospital anxiety and depression scale, and emotional stress of carers (general health questionnaire 28). Analyses were by intention to treat. FINDINGS: Follow-up was available for 146 patients (86%). Changes in scores on the Rivermead mobility index (score range 0-15) differed significantly between treatment and control groups at 3 months (p=0.018), but only by a median of 1 point (95% CI 0-1), with an interpolated value of 0.55 (0.08-1.04). Gait speed was 2.6 m/min (0.30-4.95) higher in the treatment group at 3 months. Neither treatment effect persisted at 6-months' and 9-months' follow-up. Treatment had no effect on patients' daily activity, social activity, anxiety, depression, and number of falls, or on emotional stress of carers. INTERPRETATION: Community physiotherapy treatment for patients with mobility problems 1 year after stroke leads to significant, but clinically small, improvements in mobility and gait speed that are not sustained after treatment ends.
Accidental Falls↗
Reliability of gait speed measured by a timed walking test in patients one year after stroke.
OBJECTIVE: To assess the reliability of gait speed in late-stage stroke patients. DESIGN: Test-retest reliability of three timed walks to 10 metres repeated during two assessments one week apart. SETTING: The patient's home. SUBJECTS: Twenty-two stroke patients with mobility problems more than one year after stroke. MAIN OUTCOME MEASURE: Gait speed measured in seconds taken to walk 10 metres. STATISTICAL ANALYSIS: Intraclass correlations (ICCs) with 95% confidence interval (CI) and the Bland and Altman method for assessing agreement by calculating the mean difference between measurements (d); the 95% CI for d; the standard deviation of the difference (SDdiff); a reliability coefficient and the 95% limits of agreement. RESULTS: There was a trend for decreased times taken to walk 10 metres both within each assessment and between assessments. ICCs for within-assessment reliability were 0.95-0.99. The d (SDdiff) for the second and third walks for assessment 1 was -1.00 (2.63) seconds and for assessment 2 was -0.70 (1.58) seconds. The reliability coefficient was 5.26 for assessment 1 and 3.17 for assessment 2. ICCs for between-assessment reliability were 0.87-0.88. The d (SDdiff) for the comparison of the third walks at assessment 1 and assessment 2 was -0.90 (5.01) seconds. The reliability coefficient was 10.02 and the 95% limits of agreement were -10.92 to +9.12 seconds. CONCLUSION: Within-assessment gait speed measured at home is highly reliable. The between-assessment reliability of gait speed measurement is less reliable but comparable with other studies.
Adult↗
Research networks for stroke rehabilitation: opportunities and barriers.
The previous negative attitude to stroke care is gradually giving way to a more positive approach, stimulated by a growing evidence base and policy initiatives such as the requirement that stroke units be established in all district general hospitals. There is now a new opportunity to link groups of stroke units into research networks to support the implementation of multi-centre trials. Such trials have the potential to increase patient recruitment rates, and will enhance the generalisability of the findings. Recent experience in establishing a stroke rehabilitation research network is reported in this paper.
Accidental Falls↗