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Biomedical subjects

Lynne Turner-Stokes

Publications and source records attributed to Lynne Turner-Stokes.

At least 19 recordsLinked to original sources
PubMed2006

Assessment of shoulder pain in hemiplegia: sensitivity of the ShoulderQ.

BACKGROUND: The ShoulderQ is a structured questionnaire designed to assess timing and severity of hemiplegic shoulder pain (HSP), in order to target pain relief effectively. It includes both verbal and visual graphic rating scale questions, simply presented for patients with language/visuo-spatial deficits following stroke. OBJECTIVE: To assess the sensitivity of the ShoulderQ to clinical improvement in shoulder pain following multi-disciplinary intervention. Design and setting. Retrospective analysis of serial questionnaires collected in the course of clinical treatment in an in-patient neurological rehabilitation unit. Subjects and interventions. Thirty consecutive adults with cognitive and communicative deficits, presenting with hemiplegic shoulder pain following acquired brain injury. Multi-disciplinary treatment was delivered through an integrated care pathway, and ShoulderQs recorded fortnightly, including at baseline and end of treatment. RESULTS: Changes on visual graphic rating scale (VGRS) were associated with verbal reports of improvement (rho 0.665, p < 0.001). Patients were divided retrospectively on the basis of their overall clinical response into responders (n = 18) and non-responders (n = 12). Responders showed significant change in both VGRS and verbal scores, whereas the non-responder group did not. A change in summed VGRS score of =3 showed 77% sensitivity and 91.3% specificity for identifying the responders, with a positive predictive value of 93.3%. Summed VGRS scores of =2 had a negative predictive value of 73.3%. CONCLUSION: In this preliminary evaluation of clinical data, the ShoulderQ appears to provide a sensitive measure of shoulder pain which is responsive to change in pain experience for those able to complete the questionnaire, despite the difficulties that many of this group of patients may have in reporting their symptoms. Set alongside previously reported test-retest reliability, the results support the utility of the ShoulderQ as a simple and practical tool for evaluation of shoulder pain in patients with severe complex disabilities.

Adult↗
PubMed2006

Goal attainment for spasticity management using botulinum toxin.

BACKGROUND AND PURPOSE: To determine whether goal attainment scaling (GAS) can demonstrate functional gains following injection of botulinum toxin (BTX) for spasticity in severely disabled patients. METHOD: Subjects were categorized as 'responder' (positive clinical outcome) and 'non-responder' (non-significant clinical outcome) on the basis of their overall clinical response. GAS scores for functional goals were calculated retrospectively and compared with standard outcome assessments undertaken at the time of intervention. Integrated care pathway (ICP) proformas were interrogated for 18 patients with acquired brain injuries. Mean age was 44.4 (SD 13.4) years. RESULTS: Baseline GAS and Barthel scores were similar for the responder and non-responder groups. The outcome GAS score was significantly greater in the responder than in the non-responder group (Mann-Whitney U = 11.0; p = 0.011) as was the change in GAS score (Mann-Whitney U = 8.0; p = 0.004). GAS scores reflected change recorded in focal outcome measures. However, the Barthel Index measured change in only one case. CONCLUSIONS: This exploratory retrospective study provides preliminary support for the hypothesis that GAS provides a useful measure of functional gains in response to treatment with BTX, and is more sensitive than global measures such as the Barthel Index.

Adult↗
PubMed2006

Multiple sclerosis: disability profile and quality of life in an Australian community cohort.

The objective of this study was to determine the experience of disability and reported symptoms in multiple sclerosis in an Australian community sample, comparing the perceptions of patients, carers and treating doctors, and to examine effects on quality of life, carer stress and utilization of health services. The study design used a prospective cross sectional community survey. The participants were persons with a confirmed diagnosis of multiple sclerosis, with quantified neurological, mobility and cognitive deficits, from a tertiary hospital database (n=101), who lived at home, and their carers and doctors. The study method used demographic, diagnostic and disease severity data extracted from the database. Structured interviews conducted at home included: (1) open questionnaires for participant, carer and general practitioner, prioritizing symptoms/problems affecting daily living; and (2) standardized assessments for patient quality of life, caregiver strain and perceived burden of care. The mean age was 49 years (range 28-64). Those more severely affected had a significantly reduced quality of life and increased carer burden than those with milder disability, but discordance between patients, carers and doctors was noted in their perception of problems and symptom experience. Rates of depression (67%) and work-related problems were high, but vocational support was rarely provided. Forty persons used interferon, of whom 20 had secondary progressive multiple sclerosis; 39% reported difficulty in accessing rehabilitation services and only 10% were referred to medical rehabilitation units. In conclusion, the rates of disability and symptom experience were similar to other series; however, access and utilization of appropriate rehabilitation and support services appears to be lacking. There were higher reported rates of depression and poor quality of life. Opportunities may possibly exist to re-deploy resources to develop vocational support, counselling and rehabilitation.

Adult↗
PubMed2006

The use of standardized outcome measures in rehabilitation centres in the UK.

AIM: To identify the standardized outcome measures currently used in routine clinical practice in rehabilitation centres in the UK. DESIGN: Cross-sectional survey by postal questionnaire. PARTICIPANTS: All UK consultant members of the British Society of Rehabilitation Medicine (BSRM) (n = 180). RESULTS: A total of 108 (60%) responses were received, representing 83 different rehabilitation services. Of these, 71 (86%) collected at least one standardized measure. The Barthel Index and the UK Functional Independence Measure and/or Functional Assessment Measure (FIM +/- FAM) were the most popular global outcome measures: 83% of units measured one or other of these. The Northwick Park Dependency Scale (NPDS) and Care Needs Assessment (NPCNA) (n = 21, 28%) were used for the more dependent patients. Depression and pain scores were more commonly used than general health measures. Sixty (72%) units routinely assessed outcome through the achievement of set goals, but only four transformed data to a goal attainment scale. Outcome measure scores were routinely reported in discharge summaries by 72% of units. CONCLUSIONS: The survey demonstrated quite widespread use of outcome assessments in routine clinical rehabilitation within the UK, with an encouraging level of common measurement in some areas of practice. The results have been used to update the BSRM 'basket of recommended measures'.

Cross-Sectional Studies↗
PubMed2003

An evaluation of aftercare following discharge from a specialist in-patient rehabilitation service.

PURPOSE: To evaluate the aftercare of patients discharged from specialist rehabilitation unit with respect to use of equipment and follow-up by therapy and care services and to assess change in dependency and care needs. DESIGN: Cross-sectional survey of a consecutive cohort of patients discharged from a regional rehabilitation unit with reference to the British Society of Rehabilitation Medicine (BSRM) standards for rehabilitation services. SUBJECTS AND METHODOLOGY: Fifty-three subjects with neurological disability were discharged during a 15-month period. Structured interviews conducted by telephone with the patient (n = 22) or carer (n = 31) between 8 and 21 (mean 15) months after discharge. Dependency and care needs were assessed using the Northwick Park Dependency Score (NPDS) and Care Needs Assessment (NPCNA) RESULTS: Approximately half the patients improved in dependency and care needs between discharge and follow-up, but a quarter deteriorated. Fifty-one (96%) were referred for continuing therapy of which 39% expressed dissatisfaction. There was a significant relationship between inadequate therapy follow-up and increased dependency (Chi Squared p = 0.002). However, where care packages were revised downwards this generally reflected improvement in independence and therefore reduced need. Fourteen (26%) discontinued use of equipment early after discharge since they found it unacceptable or unhelpful. Seventeen (38%) of this population experienced late seizures. CONCLUSIONS: Specialist rehabilitation in this group of severely disabled brain injured patients with complex needs can result in sustained improvement of function with resultant reduced care needs. However, appropriately skilled community-based services are required to maintain and build on the benefits, and are currently lacking in many districts. In particular, psychological support was notably absent. A possible relationship between late onset seizures and the use of anti-depressant medication requires further exploration, which is currently underway.

Brain Injuries↗
PubMed2003

Outpatient cognitive behavioral pain management programs: a randomized comparison of a group-based multidisciplinary versus an individual therapy model.

OBJECTIVE: To compare the efficacy of 2 models of chronic pain management. DESIGN: Randomized comparative trial with 2 active treatment arms. SETTING: Outpatient pain management clinics. PARTICIPANTS: A total of 113 adults with chronic pain of 0.5 to 38 years duration in (mean, 8.8y). INTERVENTIONS: Cognitive behavioral therapy (including education, relaxation, use of cognitive coping strategies, pacing, exercise) delivered in group-based multidisciplinary program or in an individual therapy program. MAIN OUTCOME MEASURES: Self-report of interference with daily activities and sense of control over pain (West Haven-Yale Multidimensional Pain Inventory [WHYMPI]) and depression (Beck Depression Inventory). Secondary outcome measures were state anxiety (Spielberger State-Trait Anxiety conventory), analgesic medication consumption, general activity, and pain severity (WHYMPI). Measurement points were 0 (before treatment), 2 months (end of treatment), and 3, 6 and 12 months (follow-up). RESULTS: No significant differences were found between the 2 modes of treatment at any of the major time points (0, 2, 12mo). Both treatment conditions made significant and sustained improvements on all primary outcome measures, although sense of control over pain tended to decline by 1 year. Individually treated participants made slower gains in some areas, but showed a lesser tendency to rebound at the end of treatment. CONCLUSION: The 2 programs appear to be equally efficacious for pain management in adults with chronic pain. In practical terms, the choice of model for service provision may rest more on local issues such as the availability of space and staff time.

Activities of Daily Living↗
PubMed2003

Use of an integrated care pathway: a third round audit of the management of shoulder pain in neurological conditions.

OBJECTIVES: To complete a third round audit of management of shoulder pain using an integrated care pathway, to evaluate pro forma documentation and to determine outcome. SUBJECTS AND SETTING: Thirty-four patients with upper limb paresis admitted to a rehabilitation unit during a 22-month period had shoulder pain and were included in the integrated care pathway. METHODS: Retrospective review of pro forma documentation against pre-determined standards. RESULTS: Compared with the second round audit, performance against 5 out of 9 standards for initial assessment and documentation had improved, and ranged from 56% to 94%. Achievement of 9 further standards relating to continued management ranged from 44% to 97%. Variance was not always well recorded. Shoulder pain resolved or improved in 18/34 (53%) of patients. CONCLUSION: Introducing the pro forma improved standards of documentation and demonstrated a positive outcome in over half the patients. Some problems with developing and maintaining integrated care pathways in the context of rehabilitation are discussed.

Adult↗
PubMed2003

Screening for ability to complete a questionnaire: a preliminary evaluation of the AbilityQ and ShoulderQ for assessing shoulder pain in stroke patients.

OBJECTIVES: To assess the repeatability of the AbilityQ--a screening tool to assess technical ability to complete a questionnaire--in patients with complex disabilities following stroke. To evaluate the validity of the AbilityQ in predicting repeatability and consistency of response to verbal and visual analogue scale questions in the ShoulderQ in those with shoulder pain. DESIGN: In a cross-sectional study, the AbilityQ and 'ShoulderQ' were administered on two consecutive days by a single investigator. SETTING: Six regional rehabilitation centres in the UK managing patients with severe complex neurological disability. SUBJECTS: Forty-nine patients with anterior or posterior circulation strokes: 13 (63%) had cognitive deficits and 28 (57%) had communicative deficits. RESULTS: Thirty-one (63.3%) patients required some degree of help in completing the AbilityQ. Percentage agreement for individual questions between day 1 and day 2 ranged from 55 to 88% with kappa values from 0.07 to 0.79. Repeatability of ShoulderQ responses was 36-72% for the verbal questions (kappa values 0.16-0.56). For visual analogue scale (VAS) questions, agreement +/- 1 on a 10-point scale was 36-59% with intraclass correlation coefficients 0.50-0.60 (p < 0.01). High verbal (> or = 3/4) and VAS scores (3/3) on the AbilityQ had positive predictive values for good repeatability in the ShoulderQ of 80% and 58% respectively. Mismatched AbilityQ responses to verbal and VAS questions showed a positive predictive value of 92% for similar inconsistency in the ShoulderQ and a negative predictive value of 90%. CONCLUSIONS: In this preliminary evaluation the AbilityQ and the ShoulderQ each demonstrated a moderate level of repeatability in a group of patients expected to have difficulty in completing questionnaires. The AbilityQ appears to have some clinical usefulness in identifying those able to respond to the ShoulderQ and, where responses to verbal and VAS questions conflict, may offer some guidance as to which are most likely to be accurate in that individual. Further development is underway.

Adult↗
PubMed2002

Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway. Part 1: Diagnosis, frequency and impact.

BACKGROUND: Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to explore the available evidence on which to base an integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting. It is divided into two parts. AIMS AND OBJECTIVES: In part 1 we review the frequency of depression in stroke and its impact on functional recovery. Also the different methods for diagnosis and measurement. METHODS: Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews. MAIN FINDINGS: PSD is common and is associated with cognitive, functional and social deficits which potentially limit the outcome from rehabilitation. However, diversity of assessment tools and diagnostic criteria confound assimilation of the available literature. The Beck Depression Inventory (BDI), Hamilton Depression Rating Scale and Zung Self-rating Depression Scale were most commonly used and have demonstrable validity in stroke patients but tend to exclude those with aphasia. Instruments developed specifically to include aphasic patients, such as the Stroke Aphasic Depression Scale, are promising but have yet to be fully evaluated. CONCLUSIONS: Further work is required to adapt and evaluate instruments to measure depression in the context of stroke. Development of an integrated care pathway may help to establish a more consistent approach to assessment and diagnosis of PSD.

Critical Pathways↗
PubMed2002

Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway. Part 2: Treatment alternatives.

BACKGROUND: Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to the development of an evidence-based integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting, and is divided into two parts. In part 1 we reviewed the frequency of depression in stroke, its impact on functional recovery and the different methods for assessment. AIMS AND OBJECTIVES: In part 2, we discuss the rationale for treatment of PSD, appraise the evidence for effectiveness of the different antidepressant drugs, and consider whether we can identify a recommended first-line treatment for use in our ICP. METHODS: Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews. MAIN FINDINGS: From the few controlled trials of anti-depressant therapy in PSD, both tricyclics and selective serotonin re-uptake inhibitors (SSRIs) appear to be effective, but the latter may be preferable in stroke because of their prompt action and better side-effect profiles. Within the group of SSRIs there is currently no direct evidence to guide the choice of agent. In the absence of firm guidance, sertraline was chosen on theoretical grounds as one of the most potent with minimal sedative effects and no reported interaction with warfarin. Citalopram may offer an appropriate second choice. CONCLUSIONS: A suggested regimen for the use of sertraline in PSD was put forward. Development of an ICP may help to establish a more consistent approach to assessment and treatment of PSD, and form a basis for future comparison of different treatments as they become available.

Antidepressive Agents↗
PubMed2002

Managing depression in brain injury rehabilitation: the use of an integrated care pathway and preliminary report of response to sertraline.

AIMS: To use data generated from an integrated care pathway (ICP) to describe the characteristics of patients presenting with depression in a brain injury rehabilitation programme and to assess their response to treatment with sertraline. SETTING: A regional rehabilitation unit providing inpatient rehabilitation for young patients (16-65) with severe complex disabilities. DESIGN: Prospective cohort study of 82 patients admitted to the unit during the 15-month period between between 1 September 1999 and 1 December 2000. Response to sertraline was assessed in an open-label, before-and-after study design. METHODS AND DESIGN: All admissions were screened and included in the ICP if there was clinical suspicion of depression, past or present. Antidepressant medication was prescribed, where appropriate, according to the ICP protocol. Depression was diagnosed on clinical grounds against DSM-IV criteria, and measured where feasible using the Beck Depression Inventory (BDI-II) administered by interview, pretreatment and at 6-8 weeks. RESULTS: Of 82 admissions 41 (50%) were managed using the ICP and 27 (64%) were either started on or changed to sertraline--21 for depression +/- lability and six for emotional lability only. All of the depressed patients improved clinically at some level and no significant side-effects were observed. The BDI-II was assessable in 17/21 who showed a mean improvement of 14.5 +/- 9.7 (confidence interval (CI) 9.3-19.7, p < 0.001). Eleven patients (52%) had previously failed to respond with a different selective serotonin re-uptake inhibitor (SSRI) agent but still made a significant response when changed to sertraline with a mean reduction in BDI-II of 16.3 +/- 10.9 (CI 8.4-24.11, p < 0.001). CONCLUSIONS: The ICP was practical to use and provided systematic data on assessment of depression and response to treatment in 'real-life' clinical practice in a brain injury rehabilitation setting. Sertraline appears to be useful and well-tolerated in this context. A full placebo-controlled study is now required.

Adolescent↗
PubMed2002

Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway.

BACKGROUND: Shoulder pain is a common complication of stroke. It can impede rehabilitation and has been associated with poorer outcomes and prolonged hospital stay. This systematic review was undertaken to inform the development of an evidence-based integrated care pathway (ICP) for the management of hemiplegic shoulder pain (HSP). AIMS AND OBJECTIVES: 1) To provide a background understanding of the functional anatomy of the shoulder and its changes following stroke. 2) To review the literature describing incidence and causation of HSP and the evidence for factors contributing to its development. 3) To appraise the evidence for effectiveness of different interventions for HSP. METHODS: Data sources comprised a computer-aided search of published studies on shoulder pain in stroke or hemiplegia and references to literature used in reviews (total references = 121). MAIN FINDINGS: Although a complex variety of physical changes are associated with HSP, these broadly divide into 'flaccid' and 'spastic' presentations. Management should vary accordingly; each presentation requiring different approaches to handling, support and intervention. (1) In the flaccid stage, the shoulder is prone to inferior subluxation and vulnerable to soft-tissue damage. The arm should be supported at all times and functional electrical stimulation may reduce subluxation and enhance return of muscle activity. (2) In the spastic stage, movement is often severely limited. Relieving spasticity and maintaining range requires expert handling; overhead exercise pulleys should never be used. Local steroid injections should be avoided unless there is clear evidence of an inflammatory lesion. CONCLUSIONS: HSP requires co-ordinated multidisciplinary management to minimize interference with rehabilitation and optimize outcome. Further research is needed to determine effective prophylaxis and document the therapeutic effect of different modalities in the various presentations. Development of an integrated care pathway provides a reasoned approach to management of this complex condition, thus providing a sound basis for prospective evaluation of different interventions in the future.

Analgesics↗
PubMed2002

A completed audit cycle and integrated care pathway for the management of depression following brain injury in a rehabilitation setting.

OBJECTIVE: To develop an evidence-based multidisciplinary integrated care pathway (ICP) for the management of depression following brain injury in a rehabilitation setting, and to assess its impact on standards of care and documentation. SETTING: A regional rehabilitation unit providing inpatient rehabilitation for young patients (16-65) with complex disabilities mainly resulting from brain injury. METHODS AND DESIGN: A completed cycle of audit including: standards set for documentation, assessment, management and review; an initial retrospective audit of documented patient management against those standards during a five-year period (26 patient records); ICP development by a multidisciplinary team of doctors, psychologists and nurses based on clinical opinion and systematic review of the literature; re-audit from the ICP documentation (48 patient records) over a period of 15 months. RESULTS: The initial audit demonstrated borderline acceptable documentation of baseline mood state and start of medication (54-61%), but poor documentation of review (29%) and subsequent treatment (27%). Introduction of the ICP improved all standards of documentation to 94-100%, except for assessment using a validated measure (84%) and follow-up assessment (76%). CONCLUSIONS: This ICP raised staff awareness of depression, leading to improved documentation and possibly also standards of care.

Adolescent↗
PubMed2002

The associated reaction rating scale: a clinical tool to measure associated reactions in the hemiplegic upper limb.

OBJECTIVE: To determine what items should be included in a clinical assessment tool developed to measure associated reactions in the hemiplegic upper limb and to assess the reliability of the resultant measure. DESIGN: Development through a structured consultative process using focus group methodology. Evaluation of inter- and intra-rater reliability between two independent observers. SUBJECTS: Nineteen consecutive hemiplegic patients admitted to Northwick Park Hospital for rehabilitation following stroke. METHODS: Focus groups were conducted in two centres, comprising physiotherapists experienced in the clinical management of brain injury. The groups identified four key characteristics related to severity of associated reactions, which became the items of the rating scale. Evaluation of inter- and intra-rater reliability was undertaken by comparison of agreement between ratings of associated reactions occurring during a single standardized task (sit-to-stand), by two senior physiotherapists in 19 subjects. RESULTS: There were good correlations between the two raters in total (rho 0.89 p < 0.005) and modal scores (rho 0.88 p < 0.005). Reliability testing of each item revealed moderate to very good inter-rater agreement (weighted kappa values 0.43-0.85) and good to very good intra-rater agreement (weighted kappa values 0.61-0.87). A slight tendency for one rater to score more severely than the other only reached significance for one item (excursion). Overall (modal) severity scores showed a good level of agreement (kappa 0.76-0.81) both between and within raters. CONCLUSION: Items to be included in a clinical assessment tool to measure associated reactions in the hemiplegic upper limb were determined. Reliability of the resultant measure was found to be encouraging. These results however apply only to observations made during a specific standardized task (sit-to-stand) and further study of sensitivity to change and reproducibility in different tasks is required before the findings can be extrapolated into routine practice.

Adult↗
PubMedDate not supplied

Botulinum toxin in the management of spasticity in adults.

Botulinum toxin (BTX) is a powerful neurotoxin which blocks cholinergic transmission at the neuromuscular junction. Judiciously applied, it can reduce local muscle overactivity while maintaining the strength in other muscles. To date BTX has not been licensed for use in spasticity in the UK and the literature pertaining to clinical practice is still relatively scant. However, controlled trials have provided evidence of the effectiveness of BTX both in reducing spasticity itself and in achieving functional gain. The guidance given here to clinicians involved in the management of spasticity covers the types of patient suitable for treatment using BTX, the appropriate dosage, and the necessary follow-up procedures and documentation.

Anti-Dyskinesia Agents↗
PubMedDate not supplied

The development of clinical governance in the UK: its implications for rehabilitation medicine.

Clinical governance has been introduced in the UK as a mechanism to improve the quality of health services, and the professional performance of clinicians. Specialist societies have a pivotal role to play in developing systems to support its implementation in clinical practice. Rehabilitation medicine is a specialty characterised by closely integrated interdisciplinary teamwork. The particular issues that this poses for clinical governance may also be relevant to other specialities. This paper presents an overview of the development of audit and clinical governance procedures in the UK and their specific implications for rehabilitation medicine. It also summarises the work undertaken to date by the British Society for Rehabilitation Medicine towards implementation of clinical governance, to improve the quality of care offered to patients.

Clinical Competence↗