Search

Background It is reported that the longer-term outcomes for stroke survivors are poor, with a range of unmet needs identified. Objectives The aims were to develop and test a longer-term stroke care strategy focused on improving the quality of life of stroke survivors and their carers by addressing unmet needs, and maintenance and enhancement of participation (i.e. involvement in life situations). Design Five overlapping workstreams were undertaken – (1) refinement of content by semistructured interviews with stroke survivors and their carers and by a review of the literature to inform content and delivery of the care strategy; (2) exploration of service models by national survey and focus groups with purposely selected services; (3) intervention development by interaction with a reference group of stroke survivors, carers, and health and social care professionals; (4) refinement and pilot implementation of the developed intervention in three stroke services (case studies); and (5) a cluster randomised controlled feasibility trial in 10 stroke services across England and Wales. Setting The intervention development work and feasibility trial were in stroke services (inclusive of primary, secondary, community and social care provision) across England and Wales. Participants Participants were stroke survivors resident in the community and their carers, and health and social care professionals in the included stroke services. Data sources Interviews with 28 stroke survivors and their carers at least 9 months post stroke ascertained their needs and the barriers to and facilitators of addressing those needs. Additional literature reviews identified 23 needs. No evidence-based interventions to address these needs were reported; self-management was highlighted as a possible delivery mechanism. In workstream 2, a national survey revealed that the most common model of stroke service provision was care up to 12 months post stroke, reported by 46 (40%) services. Thirty-five (30%) services provided care up to 6 months post stroke and 35 (30%) provided care beyond 12 months, thus identifying 6 months post stroke as an appropriate delivery point for a new intervention. Through focus groups in a range of services, stroke survivors’ perceived unmet needs and the barriers to and enablers of service provision were identified. Intervention Using information obtained in workstreams 1 and 2 and working closely with a stakeholder reference group, we developed an intervention based on the unmet needs prioritised by stroke survivors and their carers (workstream 3). In workstream 4, action groups (clinicians, stroke survivors and researchers) were established in three stroke services that led implementation in their service and contributed to the iterative refinement of the intervention, associated training programme and implementation materials. The intervention (called New Start) was delivered at 6 months post stroke. Key components were problem-solving self-management with survivors and carers, help with obtaining usable information, and helping survivors and their carers build sustainable, flexible support networks. Results A cluster randomised feasibility trial (workstream 5) was successfully implemented in 10 stroke services across England and Wales, with associated process and health economic evaluations. Five services were randomised to provide New Start, while five continued with usual care; 269 participants were recruited. Progression criteria – in terms of our pre-determined (red, amber, green) criteria for progress to a full trial: target stroke survivor recruitment rates were achieved, on average, across sites (24.1 per site over 6 months, green); 216 (80.3%) registered stroke survivors returned follow-up questionnaires at 9 months (84.1% in the intervention arm and 75.8% in the usual care arm, green); according to data reported by sites, overall, 95.2% of registered stroke survivors were offered at least one session of the intervention (green); all five intervention sites had at least two facilitators deemed competent, delivered the New Start intervention and provided it to stroke survivors (green). However, at some sites, there were concerns regarding the number of stroke survivors being offered, accepting and receiving the intervention. Only small differences in outcomes and costs were observed between the New Start and usual care groups, and considerable uncertainty around the cost-effectiveness remains. Conclusions We report a complex programme of work that has described the longer-term needs of stroke survivors and highlighted evidence and service gaps. Working closely with stroke survivors, an intervention was developed that has been refined in three services and feasibility tested in a cluster randomised controlled trial. Further refinement of the target population and optimisation of the intervention materials is required prior to a full randomised controlled trial evaluation. Future work Optimisation of the intervention, and clearer specification of recipients, are required prior to a full trial evaluation. Trial registration Current Controlled Trials ISRCTN38920246. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

BackgroundSedentary behaviour has been the focus of considerable clinical, policy and research interest due to its detrimental effects on health and wellbeing. This systematic review aims to (1) develop a more precise description of different categories of interventions that aim to reduce sedentary time in adults by identifying specific components that form an intervention; (2) explore the effect of different categories of interventions in reducing time spent sedentary in adults.MethodsTen electronic databases, websites of relevant organisations (e.g. the Sedentary Behaviour Research Network), and relevant reviews were searched. Inclusion criteria: Randomised controlled trials (RCTs), including cluster and randomised cross-over trials, in the adult population (clinical and non-clinical). Any study including a measure of sedentary behaviour was included even if reducing sedentary behaviour was not the primary aim. Exclusion criteria: Interventions delivered in schools, colleges, or workplaces; studies investigating the immediate effects of breaking up sitting time as part of a supervised (usually laboratory-based) intervention. Two review authors conducted data extraction and quality assessment (GRADE approach).ResultsSearches identified 39,223 records, of which 85 studies met the inclusion criteria and were included in the review. Interventions shown to significantly reduce time spent sedentary were those which incorporated the provision of information, education, or support (advice/recommendations), in conjunction with either counselling (mean difference: -52.24 minutes/day; 95% CI: -85.37 to -19.10) or a form of structured/prescribed physical activity (standardised mean difference: -0.15; 95% CI: -0.23 to -0.07). However, this positive effect was not maintained at follow-up. No interventions were shown to break up prolonged sitting.ConclusionsThis review presents a novel way of categorising interventions according to the types of components they comprised. There is evidence that interventions might be effective in reducing time spent sedentary immediately post-intervention. There were limited studies measuring sustained behaviour change.

Objective: To develop an intervention and undertake a proof-of-concept evaluation of its feasibility, acceptability, and impact on recorded patient activity levels during inpatient stroke rehabilitation. Design: A longitudinal cohort design. Setting: Three inpatient stroke rehabilitation services. Subjects: Stroke survivors receiving inpatient rehabilitation. Intervention: A programme designed to increase patient activity, including individualised patient timetables, independent practice, therapeutic group work, and structured social activities was developed and implemented without additional resource. Main measures: Patients’ recorded activity levels were compared for two weeks before and after implementation of the programme. Data regarding the estimated time spent in different types of activity were extracted from patient treatment records, patients’ and therapists’ diaries, or timetables (if used) to measure patient activity levels Results: At baseline, recorded activity levels were low; patients undertook a mean of 61 minutes (SD = 39) of activity per day. After implementation of the programme, recorded activity levels significantly increased to a mean of 123 minutes (SD = 88) per day ( p = 0.0001). The time spent in all types of recorded activity increased ( p = 0.0001–0.002), except psychology where the increase did not reach significance ( p = 0.670). Conclusions: A structured programme can significantly increase recorded patient activity levels during inpatient stroke rehabilitation without additional resource.

Supplemental material, Supplementary_file_I for Why do stroke survivors not receive recommended amounts of active therapy? Findings from the ReAcT study, a mixed-methods case-study evaluation in eight stroke units by David J Clarke, Louisa-Jane Burton, Sarah F Tyson, Helen Rodgers, Avril Drummond, Rebecca Palmer, Alex Hoffman, Matthew Prescott, Pippa Tyrrell, Lianne Brkic, Katie Grenfell and Anne Forster in Clinical Rehabilitation

BackgroundRoutine mood screening is recommended after stroke. However, clinicians report difficulty selecting appropriate tools from the wide range available. We aimed to systematically review the psychometric properties and clinical utility of mood screening tools for stroke survivors.MethodElectronic databases (AMED, EMBASE, CINAHL, Medline and PsycINFO) were searched to identify studies assessing the sensitivity and specificity of mood screening tools. Tools that demonstrated at least 80% sensitivity and 60% specificity with stroke survivors with identifiable cut-off scores indicating major and/or any mood disorder in at least one study were selected and clinical utility was assessed. Those with high clinical utility (against predefined criteria) were selected for recommendation.ResultsThirty papers examining 27 screening tools were identified and 16 tools met the psychometric and clinical utility criteria: 10 were verbal self-report tools, four were observational and two incorporated visual prompts for those with communication problems. Only the Stroke Aphasic Depression Questionnaire –Hospital version (SADQ-H) met all the psychometric and utility criteria. The nine-item Patient Health Questionnaire (PHQ-9) can detect major depression and the 15-item Geriatric Depression Scale (GDS-15) can identify milder symptoms; both are feasible to use in clinical practice. The Hospital Anxiety and Depression Scale (HADS) was the only tool able to identify anxiety accurately, but clinical utility was mixed.ConclusionsValid and clinically feasible mood screening tools for stroke have been identified but methodological inconsistency prevented recommendations about the optimal cut-off scores.

Objective: To explore how multi-disciplinary team meetings operate in stroke rehabilitation. Design: Non-participant observation of multi-disciplinary team meetings and semi-structured interviews with attending staff. Setting and participants: Twelve meetings were observed (at least one at each site) and 18 staff (one psychologist, one social worker; four nurses; four physiotherapists four occupational therapists, two speech and language therapists, one stroke co-ordinator and one stroke ward manager) were interviewed in eight in-patient stroke rehabilitation units. Results: Multi-disciplinary team meetings in stroke rehabilitation were complex, demanding and highly varied. A model emerged which identified the main inputs to influence conduct of the meetings were personal contributions of the members and structure and format of the meetings. These were mediated by the team climate and leadership skills of the chair. The desired outputs; clinical decisions and the attributes of apparently effective meetings were identified by the staff. A notable difference between the meetings that staff considered effective and those that were not, was their structure and format. Successful meetings tended to feature a set agenda, structured documentation; formal use of measurement tools; pre-meeting preparation and skilled chairing. These features were often absent in meetings perceived to be ineffective. Conclusions: The main features of operation of multi-disciplinary team meetings have been identified which will enable assessment tools and interventions to improve effectiveness to be developed.

Objective: To evaluate the impact of a toolkit of psychometrically robust measurement tools, the Greater Manchester Assessment for Stroke Rehabilitation (G-MASTER) toolkit, on the use of measurement tools during stroke rehabilitation Design: Mixed methods cohort design using non-participant observation of multi-disciplinary team meetings and semi-structured interviews with members of the team over three months before and three months after implementation of the assessment toolkit. Development and implementation of the toolkit are also described. Setting: Ten in-patient stroke services in a large UK city. Subjects: Members of the participating multi-disciplinary stroke teams. Results: Before implementation standardised measures were seldom used in team meetings. After implementation, use of all measurement tools significantly increased (36% to 81% of occasions, PConclusions: A toolkit of standardised measurement tools can be feasibly and acceptably implemented into stroke rehabilitation. It increases the use of measurement tools by the multi-disciplinary team and improves the processes and quality of care.