Stroke: rehabilitation and long-term care.
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Cerebrovascular Disorders↗
Biomedical subjects
D T Wade
Publications and source records attributed to D T Wade.
Physiotherapy intervention late after stroke and mobility.
OBJECTIVE: To determine whether the intervention of a physiotherapist improved mobility in patients seen more than one year after stroke. DESIGN: Randomised crossover trial comparing two groups offered intervention by a physiotherapist, one immediately after entry into the trial and the other after a delay of three months. The intervention consisted of identifying problems and offering advice and help to solve the problems. SETTING: Patients' homes in Oxfordshire. SUBJECTS: Patients who had reduced mobility due to a stroke more than one year before entry; 60 were recruited from a community stroke register and 34 in other ways. MAIN OUTCOME MEASURES: Standard measures of mobility including gait speed, functional ambulation categories, the Nottingham extended activities of daily living index, and individual items from the Barthel activities of daily living index and the Frenchay activities index. Measures of manual dexterity, depression, and anxiety were used as controls. RESULTS: 94 patients entered the trial and 49 were randomised to immediate and 45 to delayed physiotherapy; 89 were compared at the crossover point. At randomisation the two groups were comparable. At three months the group given early therapy showed an improvement in gait speed whereas the untreated group had declined (differences of -3.9 v 6.4 s to walk 10 m; p less than 0.01); between three and six months the group given delayed therapy showed improvement and the previously treated group declined (differences of 6.5 v -3.9 s to walk 10 m; p less than 0.01). A 9% (95% confidence interval 0% to 18%) decrease in time taken to walk 10 m was associated with treatment and a 12% (2% to 19%) increase when patients were untreated. Other measures did not change significantly. CONCLUSION: Intervention of an experienced physiotherapist late after stroke specifically improves mobility, albeit by a small amount, but the effects do not seem to be maintained, perhaps because there is an underlying decline in mobility in these patients. Gait speed offers a simple and sensitive measure of outcome.
Activities of Daily Living↗
Visuo-spatial neglect: qualitative differences and laterality of cerebral lesion.
From a large sample of patients who sustained a first stroke, 98 patients were selected with unilateral left brain damage and 92 with unilateral right brain damage. Examined on a visual search task (Star Cancellation) approximately four years after onset, we found a comparable incidence of visual inattention in the two groups. Despite this quantitative similarity, the qualitative pattern of performance was different in the two impaired samples. Patients with right brain damage showed a distinctive linear relationship whereby omission errors increased from right to left across the stimulus page. Within the left brain damaged sample, two subgroups could be discerned. As expected, one subgroup showed more contralesional than ipsilesional errors, but the other subgroup was comparable to the sample with right hemisphere damage. The reasons are discussed for these qualitative differences, drawing particular attention to the importance of motor/manual factors in the determination of performance on visual search tasks.
Aged↗
Enhanced physical therapy improves recovery of arm function after stroke. A randomised controlled trial.
Previous research on stroke rehabilitation has not established whether increase in physical therapy lead to better intrinsic recovery from hemiplegia. A detailed study was carried out of recovery of arm function after acute stroke, and compares orthodox physiotherapy with an enhanced therapy regime which increased the amount of treatment as well as using behavioural methods to encourage motor learning. In a single-blind randomised trial, 132 consecutive stroke patients were assigned to orthodox or enhanced therapy groups. At six months after stroke the enhanced therapy group showed a small but statistically significant advantage in recovery of strength, range and speed of movement. This effect seemed concentrated amongst those who had a milder initial impairment. More work is needed to discover the reasons for this improved recovery, and whether further development of this therapeutic approach might offer clinically significant gains for some patients.
Activities of Daily Living↗
Left on the right: allochiria in a case of left visuo-spatial neglect.
A patient with left visuo-spatial neglect after right fronto-parietal haemorrhage failed to cross out stimuli in left space on cancellation tests. Her bisections of horizontal lines were displaced significantly to the right of true centre. On drawing and copying tasks, she sometimes omitted features on the left (neglect) and sometimes transposed them to right space (allochiria). This co-occurrence of neglect and allochiria has been observed previously but has provoked little theoretical comment. We draw attention to aspects of the combination that seem critical to the interpretation of visuo-spatial neglect.
Aged↗
Measurement in neurological rehabilitation.
The measurement of impairment and disability can improve patient care and is now essential in clinical audit. Practical, useful measures are slowly being developed, both for use in specific diseases and for more general use. This review discusses both new measures and new work on more well-established measures.
Activities of Daily Living↗
Evaluating outcome in stroke rehabilitation (quality control and clinical audit).
Audit may require information on case-mix, the resources available, the processes undertaken and the outcome. The most important are the first and last. Measures of case-mix relate to severity and prognosis. Measures of outcome relate to disability. Good measures exist. The difficulties are to agree on measures, to collect data routinely and reliably, and to act on the results.
Activities of Daily Living↗
Do visual field deficits exacerbate visuo-spatial neglect?
A significant association between visual field deficits (VFD) and visuo-spatial neglect is well established, although cases of double-dissociation between the two conditions are not uncommon. It has been argued that VFD typically exacerbates the behavioural manifestations of neglect. We examined a series of 51 patients with unilateral right-hemisphere stroke for the presence of visual field deficit and visuo-spatial neglect. Patients were assigned to the neglect group (N+) or the non-neglect group (N-) on the basis of their aggregate scores on the recently standardised Behavioural Inattention Test (BIT). The association between neglect and VFD was confirmed. Four groups of eight patients (N+, VFD+; N+, VFD-; N-, VFD+; N-, VFD-) were then selected from the initial sample so that they were matched for age, IQ, and days post onset of stroke. Within the neglect groups, the severity of neglect did not differ significantly between those patients with and without VFD; within the non-neglect groups, scores on subtests of the BIT likewise did not differ (with the sole exception of Letter Cancellation) between the VFD+ and the VFD- subgroups. It was concluded that visual field deficits do not exacerbate neglect, and that poor functional recovery in many patients with VFDs is due to the association of sensory loss with the underlying causal factor of neglect.
Aged↗
Visuospatial neglect: underlying factors and test sensitivity.
Visuospatial neglect, a frequent consequence of unilateral (usually right-hemisphere) stroke, is associated with poor functional recovery and in many patients is resistant to remedial treatment. Studies of the nature and prevalence of the disorder have been hindered by problems of definition and assessment. In this study 80 unselected stroke patients were assessed for the presence and severity of neglect on the behavioural inattention test. The six subtests of this battery all intercorrelated highly, and a subsequent factor analysis showed that all tests loaded significantly on one underlying factor. The construct of neglect as defined by performance on the battery is therefore robust. Nonetheless, the individual tests differed substantially in their sensitivity. Star cancellation was the most sensitive measure of neglect and correctly diagnosed all patients whose aggregate score on the full battery fell below that of the control population.
Analysis of Variance↗
The development of a disease classification system, based on the International Classification of Diseases, for use by neurologists.
Effective planning and evaluation of medical services is only possible if appropriate and reliable information is available. Diagnoses of patients seen are essential data. The epidemiological value of standard, reliable diagnostic data could also be considerable. The International Classification of Diseases (ICD) is the only system currently available which provides a common basis of classification for general statistical use. A booklet, using ICD codes, for classifying in-patients and out-patients seen by neurologists has been developed. It is simple and easy to use, affords the necessary economy of time, and should result in uniformity of coding. Reliability studies confirm that inaccuracies occur when patients' diagnoses are coded retrospectively from their medical files, even when observers are medically trained. It is recommended that doctors should accept personal responsibility for coding patients' diagnoses at the time of consultation or discharge from hospital.
Diagnosis, Differential↗
Recovery of cognitive function soon after stroke: a study of visual neglect, attention span and verbal recall.
Sixty two consecutive patients admitted to hospital and surviving 6 months were tested regularly over the first 3 months after their stroke to plot recovery in three aspects of cognition: visual neglect, assessed using a cancellation task, attention span assessed using digit span, and verbal recall, tested by counting number of words remembered from a list of 10 words. Normative data were collected for the cancellation test. Fifteen patients showed recovery from visual neglect, 10 improvement in attention span and nine improvement in verbal recall. The difficulties of measuring recovery of cognitive function after stroke are discussed.
Adult↗
The Barthel ADL Index: a reliability study.
The Barthel Index is a valid measure of disability. In this study we investigated the reliability of four different methods of obtaining the score in 25 patients: self-report, asking a trained nurse who had worked with the patient for at least one shift, and separate testing by two skilled observers within 72 hours of admission. Analysis of total (summed) scores revealed a close correlation between all four methods: a difference of 4/20 points was likely to reflect a genuine difference. In individual items, most disagreement was minor and involved the definition of middle grades. Asking an informed nurse or relative was as reliable as testing, and is quicker.
Activities of Daily Living↗
The Barthel ADL Index: a standard measure of physical disability?
There is no agreed single measure of physical disability for use either clinically or in research. It is argued that acceptance of a single standard measure of activities of daily living (ADL) might increase awareness of disability, improve clinical management of disabled patients, and might even increase acceptance of published research. The Barthel ADL Index is proposed as the standard index for clinical and research purposes. Its validity, reliability, sensitivity, and utility are discussed. The Barthel Index is as good as any other single simple index, and should be adopted as the standard against which future indices are compared. The temptation to use variations on the standard Barthel Index should be resisted.
Activities of Daily Living↗
Dysphagia in acute stroke.
A prospective study was undertaken to define the incidence, duration, and consequences of dysphagia in an unselected group of 91 consecutive patients who had suffered acute stroke. The site of the present lesion and of any previous stroke was determined clinically and was confirmed by computed tomography of the brain or necropsy in 40 cases. Of 41 patients who had dysphagia on admission, 37 had had a stroke in one cerebral hemisphere. Only seven patients showed evidence of lesions in both hemispheres. Nineteen of 22 patients who survived a stroke in a hemisphere regained their ability to swallow within 14 days. Dysphagia in patients who had had a stroke in a cerebral hemisphere was associated in this study with a higher incidence of chest infections, dehydration, and death.
Acute Disease↗
Motor loss and swallowing difficulty after stroke: frequency, recovery, and prognosis.
Data relating to motor loss and swallowing difficulties in a community sample of 976 patients who suffered an acute stroke have been analysed. About 17% of patients seen within one week had no paralysis; at 6 months 48% of survivors had no paralysis and 9% had severe paralysis. The Motricity Index used to study motor loss related to functional loss and walking ability; it seems to be a simple valid measure of motor loss. Severe paralysis was associated with a high fatality rate, and only 6%-10% of survivors of an initially severe paralysis made a full recovery by 6 months. If severe persisted at 3 weeks, full recovery was not observed. Loss of sitting balance was associated with a poor outcome. Of conscious patients seen within one week, 14% choked on attempting to swallow and a further 28% had abnormal swallowing: this 42% of patients had a high fatality rate.
Activities of Daily Living↗
Selection of aphasic stroke patients for intensive speech therapy.
Selection criteria for intensive speech therapy and the number of patients fulfilling these were investigated in 441 acute strokes coming from a Health District population during one year. Five patients from a total of 71 referred with speech and/or language difficulties were considered suitable for intensive speech therapy at 4 weeks after stroke. Although such therapy was not actually given, by 26 weeks three of the five had recovered and 14 further patients were considered suitable to receive intensive therapy. The most important selection criteria were Functional Communication Profile score of less than 85 and a clinical judgement that the patient was well enough to take part. It is recommended that decisions as to appropriateness of patients for intensive speech therapy be delayed beyond 4 weeks after stroke.
Aged↗
Functional abilities after stroke: measurement, natural history and prognosis.
Actual functional performance of 976 acute stroke patients was assessed using the Barthel index: the data were analysed to determine the frequency of disability after stroke, the validity of the Barthel index, and the recovery seen. At 6 months, over 45% of survivors were functionally independent. Validity of the Barthel index was confirmed: it related as expected with motor loss and factor analysis showed a single major factor. The items of the Barthel index form an hierarchical scale. There was some recovery between 3 weeks and 6 months in almost all patients: the major prognostic factors were urinary incontinence, functional ability, sitting balance and age.
Activities of Daily Living↗