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Biomedical subjects

J R Gladman

Publications and source records attributed to J R Gladman.

At least 19 recordsLinked to original sources
PubMed2003

Differences in the diagnostic accuracy of acute stroke clinical subtypes defined by multimodal magnetic resonance imaging.

BACKGROUND: Despite its importance for acute stroke management, little is known about the underlying pathophysiology when patients with acute stroke are classified using clinical methods. OBJECTIVE: To examine the relation between the magnetic resonance defined stroke subtype and clinical stroke classifications using diffusion weighted imaging (DWI), perfusion weighted imaging (PWI), and angiographic magnetic resonance techniques. METHODS: Consecutive patients with clinical syndromes consistent with acute anterior circulation stroke were assessed clinically within six hours of onset and scanned as soon as possible using multimodal magnetic resonance imaging (MRI). Patients were classified clinically into total or partial anterior circulation syndromes using the Oxford classification, or according the severity of the National Institutes of Health stroke scale (NIHSS) (severe > 15; mild/moderate 15). There were 42 with partial anterior circulation syndromes (PACS) and 42 with total anterior circulation syndromes (TACS). Patients with TACS or severe stroke were more likely to have actually suffered a stroke (Fischer's exact test, p = 0.01), to have a correctly classified stroke (chi(2) 28.2, p < 0.01), to have persisting occlusion (chi(2) 30.6, p < 0.01), and to have a large DWI-PWI mismatch (chi(2) 17.1, p < 0.01). CONCLUSIONS: There is more inaccuracy in patients presenting with acute PACS or clinically mild to moderate anterior circulation stroke than in those with TACS or severe acute stroke syndromes. The latter appear more likely to be the targets for acute stroke interventions, as they include a significantly higher proportion of patients with persisting occlusion and diffusion/perfusion mismatch.

Acute Disease↗
PubMed2001

A multicentre randomized controlled trial of leisure therapy and conventional occupational therapy after stroke. TOTAL Study Group. Trial of Occupational Therapy and Leisure.

OBJECTIVE: To evaluate the effects of leisure therapy and conventional occupational therapy (OT) on the mood, leisure participation and independence in activities of daily living (ADL) of stroke patients 6 and 12 months after hospital discharge. DESIGN: Multicentre randomized controlled trial. SETTING AND PARTICIPANTS: Four hundred and sixty-six stroke patients from five UK centres. MAIN OUTCOME MEASURES: The General Health Questionnaire (12 item), the Nottingham Extended ADL Scale and the Nottingham Leisure Questionnaire, assessed by post, with telephone clarification. RESULTS: Four hundred and forty (94%) and 426 (91%) subjects were alive at 6 and 12 months, respectively. Three hundred and seventy-four (85% of survivors) and 311 (78% of survivors) responded at 6 and 12 month follow-up respectively. At six months and compared to the control group, those allocated to leisure therapy had nonsignificantly better GHQ scores (-1.2: 95% CI -2.9, +0.5), leisure scores (+0.7, 95% CI -1.1, +2.5) and Extended ADL scores (+0.4: 95% CI -3.8, +4.5): the ADL group had nonsignificantly better GHQ scores (-0.1: 95% CI -1.8, +1.7) and Extended ADL scores (+1.4: 95% CI -2.9, +5.6) and nonsignificantly worse leisure scores (-0.3: 95% CI -2.1, +1.6). The results at 12 months were similar. CONCLUSION: In contrast to the findings of previous smaller trials, neither of the additional OT treatments showed a clear beneficial effect on mood, leisure activity or independence in ADL measured at 6 or 12 months.

Activities of Daily Living↗
PubMed2001

Development and validation of the Nottingham Leisure Questionnaire (NLQ).

OBJECTIVES: To reduce the length of the Nottingham Leisure Questionnaire (NLQ) in order to make it more suitable for postal use, and to evaluate its test-retest reliability, sensitivity, stability and validity in relation to other measures of activities of daily living (ADL), mood and handicap. METHOD: The NLQ was shortened and the response categories collapsed. Results from a previous trial which had used the NLQ were reanalysed to establish if significant group differences were maintained. The new version of the NLQ was subsequently tested for test-retest reliability on a new group of patients from the Nottingham stroke register who were asked to complete it twice. The new NLQ and other measures were sent to patients in a multicentre rehabilitation trial (TOTAL) six and twelve months after recruitment for postal completion. SUBJECTS: One hundred and thirty-seven consecutive patients from the Nottingham stroke register and 466 patients with a stroke in a multicentre rehabilitation trial. RESULTS: The original NLQ was reduced from 37 to 30 items and from five to three response categories. Data from an earlier study were reanalysed and differences between treatment groups remained. The results of a test-retest analysis using kappa showed that six items had excellent agreement, 15 good and nine fair, suggesting acceptable test-retest reliability. Results from the rehabilitation trial showed that the subjects performed all items and few additional activities were suggested. Higher NLQ scores were associated with higher subscores on the Nottingham Extended Activities of Daily Living Scale (NEADL) and lower NLQ scores with living alone and worse emotional health. CONCLUSION: The NLQ has been successfully modified for postal self-administration but there is potential for further development.

Activities of Daily Living↗
PubMed2000

Functional recovery of community stroke patients.

PURPOSE: The aims were to describe the functional abilities of and services provided to stroke patients not admitted to hospital a year after stroke and to investigate factors associated with receiving rehabilitation services. METHOD: A cohort of stroke patients who had not been admitted to hospital were notified by general practitioners. Patients were assessed at a month and a year after stroke on measures of impairment and disability. The rehabilitation received was recorded. There were 124 stroke patients notified by GP's who had not been admitted to hospital. Of these 70 were assessed at both one month and one year after stroke. RESULTS: Patients showed persistent impaired levels of disability one year after stroke, as measured by the Extended Activities of Daily Living (EADL) scale. There was no significant improvement in Barthel scores and only a slight improvement on the EADL from one month to one year after stroke. There were no patients with severe mobility or severe arm impairment. Most patients had some cognitive impairment but there was no significant change between a month and a year. The provision of rehabilitation services increased between a month and a year after stroke. Rehabilitation was provided to those patients with impaired motor function. CONCLUSIONS: Stroke patients not admitted to hospital have significant levels of disability which does not change substantially in the year after stroke. Rehabilitation was provided on the basis of physical function, rather than cognitive function.

Chi-Square Distribution↗
PubMed2000

Predicting outcome in acute stroke.

The natural history of acute stroke is well defined. Predicting outcome in individuals, however, remains difficult, because prognostic studies examining associations between clinical signs or syndromes and outcome differ in patient selection, timing and choice of neurological assessments and outcome measures. Accuracy has been disappointing. Osler in 1892 stated that the 'course of the disease ... is dependent on the situation and extent of the lesion'. Until recently, it has not been possible to examine the stroke prognosis, using Osler's approach, with any great accuracy. The advent of diffusion weighted magnetic resonance imaging (DWI), which is highly sensitive to the pathophysiological changes underlying stroke, offers this possibility as it measures the site and extent of irreversible infarction. This review summarises the results of syndrome or sign-based predictive studies and shows how DWI may explain different outcomes in patients with identical neurological presentations, according to the 'situation and extent of the lesion'.

Acute Disease↗
PubMed2000

Improving long-term rehabilitation.

The long-term problems of stroke are both physical and mental. Rehabilitation (active promotion of recovery), maintenance (active prevention of deterioration), and care (support for those with disabilities) are intertwined elements of service provision aimed at reducing these problems. Over time, the prevention of deterioration becomes dominant. Currently there is interest in 'intermediate care'--services aiming to provide choices other than inadequate care at home, inappropriate care in hospital, or expensive care in long-term institutions. There is also interest in stroke coordinators to manage community services. These developments have exposed problems of inequity (e.g. minority groups) and service provision (e.g. a shortage of trained staff). This had led to experiments in novel approaches such as generic workers and co-workers. There is interest too in examining ways in which the social and built environment can be altered to increase the participation of disabled people in society.

Community Health Services↗
PubMed1999

Limitations of clinical diagnosis in acute stroke.

Trials in acute stroke have recruited on the basis of clinical diagnosis. Using MRI we have shown that clinical diagnosis is more limited than previously appreciated, thus trials may have been underpowered or confounded.

Clinical Trials as Topic↗
PubMed1999

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.

Activities of Daily Living↗
PubMed1998

The scope for rehabilitation in severely disabled stroke patients.

PURPOSE: To argue the case that patients who are severely disabled by stroke may benefit from rehabilitation. To identify critical areas where more research may be helpful. METHOD: Discussion of four negative views which could be cited as drawbacks to rehabilitation in this group. These are: (1) that patients with severe stroke do not recover; (2) that they are too ill to receive rehabilitation; (3) that rehabilitation is ineffective even when possible; and (4) that even if rehabilitation is effective, it is not cost-effective. RESULTS: There is little work in this area. There are problems with measurement of disability in this group. None of the four negative views are supported by current evidence, and what little evidence there is provides grounds for optimism that further work could be worthwhile. CONCLUSIONS: Specific recommendations for further work include: (1) the development of better measurement scales; (2) to determine the cost of care of severely disabled stroke patients; (3) to gain a better appreciation of the value of changes in disability states; and (4) to perform an overview analysis of rehabilitation interventions examining the degree to which severity of disability affects the response to treatment.

Cerebrovascular Disorders↗
PubMed1998

Rehabilitation needs of community stroke patients.

PURPOSE: The aim was to identify stroke patients not admitted to hospital, to assess their disabilities and the rehabilitation provided. METHOD: Stroke patients were notified by General Practitioners, assessed a month after stroke on measures of impairment and disability and the rehabilitation received was recorded. There were 124 patients notified and 93 assessed. RESULTS: Patients showed an average decline of 1.7 on the Barthel Index and 3.6 on the Extended Activities of Daily Living scale from before to after stroke. There were 27% with severe mobility problems and 47% with clinically relevant arm impairment. Many patients had cognitive impairment with only 9% having no deficit. Mood problems were less common with 26% anxious and 13% depressed. Significant stress occurred in 15% of carers. The provision of rehabilitation was low and there was poor correspondence between impairments and services provided. CONCLUSION: There is an unmet potential for rehabilitation in stroke patients not admitted to hospital.

Activities of Daily Living↗
PubMed1997

A randomized controlled trial of enhanced Social Service occupational therapy for stroke patients.

OBJECTIVE: To determine whether stroke patients referred to the Social Service occupational therapy service would benefit from an enhanced service compared to the usual service. DESIGN: Randomized controlled study allocating patients to the enhanced service or the usual service. SUBJECTS: Stroke patients discharged home from hospital and referred to Social Service occupational therapy department. OUTCOME MEASURES: The sections and total score from the Nottingham Extended Activities of Daily Living Scale (EADL), the Barthel Index, the General Health Questionnaire (GHQ) and the number of pieces of equipment provided were analysed. RESULTS: One hundred and eleven stroke patients were recruited to this study. Fifty-three were randomly allocated to the enhanced service and 58 to the usual service. Patients receiving the enhanced service were seen more quickly after referral, for longer, and received significantly more visits (p < 0.01) than those receiving the usual service. Three months after entry to the study the enhanced service group had better EADL (p < 0.01) than the usual service group. This benefit remained significant in only the mobility section of the EADL at six months. Careers of the stroke patients in the enhanced group had lower GHQ scores (p < 0.05) than those in the usual group at six months. CONCLUSIONS: This trial supports the use of domiciliary occupational therapy for stroke patients after discharge from hospital in terms of improvements in functional outcomes in the short term, but the long-term benefits remain unclear.

Activities of Daily Living↗
PubMed1997

The role of leisure in stroke rehabilitation.

Stroke patients often fail to resume full lives, even if they make a good physical recovery, and social and leisure pursuits show a particular decline. The usual goals of rehabilitation are mobility and independence in self-care, but recovery in a broader sense may be impeded if health professionals concentrate exclusively on these. Leisure has been shown to be closely associated with life satisfaction and would be a worthwhile, and now measurable, goal of rehabilitation. Elderly people show a decline in leisure activity which has been studied extensively and may provide a useful model for the more rapid decline seen in stroke patients. Further research is needed to confirm the finding that specialized occupational therapy can be effective in raising leisure activity, and to show whether this will translate into improved psychological well-being.

Cerebrovascular Disorders↗
PubMed1995

Effect of age upon the induction and maintenance of anticoagulation with warfarin.

We aimed to examine the effect of age upon the control of anticoagulation with warfarin in ordinary clinical practice, using a retrospective examination of routine anticoagulation clinic records from the University Hospital, Nottingham. Considerable over-anticoagulation (international normalisation ratio (INR) > 6.0) during induction occurred in 54 (11%) of 495 patients and was more likely in older patients (p < 0.05). Lesser degrees of over-anticoagulation during induction (INR > 4.0) were also more common in older patients, occurring in 58% of those aged 75 or above. Loading doses of warfarin were not reduced in older patients. INR in the maintenance phase rose with age (p < 0.001) despite lower maintenance doses of warfarin (p < 0.001). An INR > 6.0 in the maintenance phase was noted in 24 (3%) of 739 patients and again was more likely in older patients (p < 0.05). Patients using ambulance transport to the clinic were older than those who did not (p < 0.01) and those aged over 75 had shorter intervals between clinic visits (p < 0.01). We conclude that doctors using warfarin therapy do not take sufficient account of the increased sensitivity of older people to warfarin. Hospital anticoagulant policies need implementation and evaluation.

Age Factors↗