Search

Background: The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients., Objectives: This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country's development or income status, to drive global improvement in stroke services., Methods: Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries., Results: The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries., Conclusions: We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To evaluate different stroke early supported discharge (ESD) services in different geographical settings using cost-consequence analysis (CCA), which presents information about costs and outcomes in the form of a balance sheet. ESD is a multidisciplinary service intervention that facilitates discharge from hospital and includes delivery of stroke specialist rehabilitation at home., Materials and Methods: Data were collected from six purposively sampled services across the Midlands, East and North of England. All services, rural and urban, provided stroke rehabilitation to patients in their own homes. Cost data included direct and overhead costs of service provision and staff travel. Consequence data included service level adherence to an expert consensus regarding the specification of ESD service provision., Results: We observed that the most rural services had the highest service cost per patient. The main costs associated with running each ESD service were staff costs. In terms of the consequences, there was a positive association between service costs per patient and greater adherence to meeting the evidence-based ESD service specification agreed by an expert panel., Conclusions: This study found that rural services were associated with higher costs per patient, which in turn were associated with greater adherence to the expert consensus regarding ESD service specification. We suggest additional resources and costs are required in order for rural services to meet evidence-based criteria.Implications for rehabilitationThe main costs of an early supported discharge (ESD) service for stroke survivors were staff costs and these were positively associated with greater levels of rurality.Greater costs were associated with greater adherence to ESD core components, which has been previously found to enhance the effectiveness of ESD service provision.The cost-consequence analysis provides a descriptive summary for decision-makers about the costs of delivering ESD, suggesting additional resources and costs are required in order for rural services to meet evidence-based criteria.

Purpose: The context of implementation plays an important role in the delivery of optimal treatments in stroke recovery and rehabilitation. Considering that stroke systems of care vary widely across the globe, the goal of the present paper is to compare healthcare providers' priority of key areas in translating stroke research to clinical practice among High Income Countries, Upper Middle- and Lower Middle-Income Countries (HICs, UMICs, LMICs). We also aimed to compare perceptions regarding the key areas' feasibility of implementation, and formulate recommendations specific to each socioeconomic region., Methods: Data related to recommendations for knowledge translation in stroke, from a primary survey from the second Stroke Recovery and Rehabilitation Roundtable were segregated based on socioeconomic region. Frequency distribution was used to compare the key areas for practice change and examine the perceived feasibility of implementation of the same across HIC, UMIC and LMICs., Results: A total of 632 responses from healthcare providers across 28 countries were received. Interdisciplinary care and access to services were high priorities across the three groups. Transitions in Care and Intensity of Practice were high priority areas in HICs, whereas Clinical Practice Guidelines were a high priority in LMICs. Interventions specific to clinical discipline, screening and assessment were among the most feasible areas in HICs, whereas Intensity of practice and Clinical Practice Guidelines were perceived as most feasible to implement in LMICs., Conclusion: We have identified healthcare providers' priorities for addressing international practice change across socioeconomic regions. By focusing on the most feasible key areas, we can aid the channeling of appropriate resources to bridge the disparities in stroke outcomes across HICs, UMICs and LMICs.IMPLICATIONS FOR REHABILITATIONIt is pertinent to examine the differences in priorities of stroke rehabilitation professionals and the feasibility of implementing evidence-based practice across socioeconomic regions.There is an urgent necessity for the development of clinical practice guidelines for stroke rehabilitation in Low-Middle Income Countries, taking into consideration the cultural, economic and geographical constraints.In upper-middle income countries, encouraging family support and timely screening and assessment for aphasia, cognition and depression appear to be the low hanging fruits to enhance quality of life after stroke.Innovative ways to increase intensity of practice and channelling of resources to improve transitions in care may prove to be the most beneficial in advancing stroke rehabilitation in high income countries.

This study investigated the life transformation of children when a parent returned home from hospital after a stroke. The study explored children's experiences of taking on caring roles in partnership with their well parent and stroke survivors' perceptions of the young carer roles. The study aimed to identify unmet support needs in order to inform future service provision. Semi-structured interviews were conducted separately with stroke survivors ( n = 7) (age range 41-60 years, mean 50.6) and their young carers ( n = 11) (age range 11-20 years, mean 16). Interviews were audio recorded, transcribed and analysed using reflexive thematic analysis. Three overarching themes were identified: the lives of young carers, impact of stroke, and insulating the family. All the children were providing some level of care. None were in receipt of any formal support. Children moved in and out of the caring role in the absence of an adult, to act as primary carer. Young carers valued the life skills they were gaining but reported gaps in their knowledge and understanding of stroke. The well parent and young carers worked together in a bi-directional partnership to ameliorate the impact of stroke on the family. The study concluded that age appropriate and stroke specific information for children of stroke survivors could enhance agency and optimise positive outcomes of caring.

Background: Implementation of stroke early supported discharge (ESD) services has been recommended in many countries' clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale., Methods and Results: Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016-December 31, 2016), measures of ESD effectiveness were "days to ESD" (number of days from hospital discharge to first ESD contact; n=6222), "rehabilitation intensity" (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%-49%] and increased treatment intensity by 2% [95% CI, 0.3%-4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale., Conclusions: This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/; Unique identifier: ISRCTN15568163.

Moving research evidence to practice can take years, if not decades, which denies stroke patients and families from receiving the best care. We present the results of an international consensus process prioritizing what research evidence to implement into stroke rehabilitation practice to have maximal impact. An international 10-member Knowledge Translation Working Group collaborated over a six-month period via videoconferences and a two-day face-to-face meeting. The process was informed from surveys received from 112 consumers/family members and 502 health care providers in over 28 countries, as well as from an international advisory of 20 representatives from 13 countries. From this consensus process, five of the nine identified priorities relate to service delivery (interdisciplinary care, screening and assessment, clinical practice guidelines, intensity, family support) and are generally feasible to implement or improve upon today. Readily available website resources are identified to help health care providers harness the necessary means to implement existing knowledge and solutions to improve service delivery. The remaining four priorities relate to system issues (access to services, transitions in care) and resources (equipment/technology, staffing) and are acknowledged to be more difficult to implement. We recommend that health care providers, managers, and organizations determine whether the priorities we identified are gaps in their local practice, and if so, consider implementation solutions to address them to improve the quality of lives of people living with stroke.

The Stroke Recovery and Rehabilitation Roundtable (SRRR) meetings bring together an international group of preclinical and clinical researchers along with statisticians, methodologists, funders and consumers, working to accelerate the development of effective treatments for stroke recovery and to support best-evidence uptake in rehabilitation practice. The first meeting (2016) focused on four recommendation areas: translation of preclinical evidence into human discovery trials; recovery biomarkers to provide knowledge of therapeutic targets and prognosis in human stroke; intervention development, monitoring, and reporting standards; and standardized measurement in motor recovery trials. The impact of SRRR is growing, with uptake of recommendations emerging, and funders exploring ways to incorporate research targets and recommendations. At our second meeting (SRRR2, 2018), we worked on new priority areas: (1) cognitive impairment, (2) standardizing metrics for measuring quality of movement, (3) improving development of recovery trials, and (4) moving evidence-based treatments into practice. To accelerate progress towards breakthrough treatments, formation of an International Stroke Recovery and Rehabilitation Alliance is our next step, where working groups will take recommendations and build partnerships needed to achieve our goals.

Background: Dopamine is a key modulator of striatal function and learning and might improve motor recovery after stroke. Previous small trials of dopamine agonists after stroke provide equivocal evidence of effectiveness on improving motor recovery. We aimed to assess the safety and efficacy of co-careldopa plus routine occupational and physical therapy during early rehabilitation after stroke., Methods: This double-blind, multicentre, randomised controlled trial of co-careldopa versus placebo in addition to routine NHS occupational and physical therapy was done at 51 UK NHS acute inpatient stroke rehabilitation services. We recruited patients with new or recurrent clinically diagnosed ischaemic or haemorrhagic (excluding subarachnoid haemorrhage) stroke 5-42 days before randomisation, who were unable to walk 10 m or more, had a score of less than 7 points on the Rivermead Mobility Index, were expected to need rehabilitation, and were able to access rehabilitation after discharge from hospital. Participants were assigned (1:1) using stratified random blocks to receive 6 weeks of oral co-careldopa or matched placebo in addition to routine NHS physiotherapy and occupational therapy. The initial two doses of co-careldopa were 62·5 mg (50 mg of levodopa and 12·5 mg of carbidopa) and the remaining doses were 125 mg (100 mg of levodopa and 25 mg of carbidopa). Participants were required to take a single oral tablet 45-60 min before physiotherapy or occupational therapy session. The primary outcome was ability to walk independently, defined as a Rivermead Mobility Index score of 7 or more, at 8 weeks. Primary and safety analyses were done in the intention-to-treat population. The trial is registered on the ISRCTN registry, number ISRCTN99643613., Findings: Between May 30, 2011, and March 28, 2014, of 1574 patients found eligible, 593 (mean age 68·5 years) were randomly assigned to either the co-careldopa group (n=308) or to the placebo group (n=285), on an average 18 days after stroke onset. Primary outcome data were available for all 593 patients. We found no evidence that the ability to walk independently improved with co-careldopa (125 [41%] of 308 patients) compared with placebo (127 [45%] of 285 patients; odds ratio 0·78 [95% CI 0·53-1·15]) at 8 weeks. Mortality at 12 months did not differ between the two groups (22 [7%] vs 17 [6%]). Serious adverse events were largely similar between groups. Vomiting during therapy sessions, after taking the study drug, was the most frequent adverse event and was more frequent in the co-careldopa group than the placebo group (19 [6·2%] vs 9 [3·2%])., Interpretation: Co-careldopa in addition to routine occupational and physical therapy does not seem to improve walking after stroke. Further research might identify subgroups of patients with stroke who could benefit from dopaminergic therapy at different doses or times after stroke with more intensive motor therapy., Funding: Medical Research Council., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Recent reviews have demonstrated that the quality of stroke rehabilitation research has continued to improve over the last four decades but despite this progress, there are still many barriers in moving the field forward. Rigorous development, monitoring and complete reporting of interventions in stroke trials are essential in providing rehabilitation evidence that is robust, meaningful and implementable. An international partnership of stroke rehabilitation experts committed to develop consensus-based core recommendations with a remit of addressing the issues identified as limiting stroke rehabilitation research in the areas of developing, monitoring and reporting stroke rehabilitation interventions. Work exploring each of the three areas took place via multiple teleconferences and a two-day meeting in Philadelphia in May 2016. A total of 15 recommendations were made. To validate the need for the recommendations, the group reviewed all stroke rehabilitation trials published in 2015 (n=182 papers). Our review highlighted that the majority of publications did not clearly describe how interventions were developed or monitored during the trial. In particular, under-reporting of the theoretical rationale for the intervention and the components of the intervention call into question many interventions that have been evaluated for efficacy. More trials were found to have addressed the reporting of interventions recommendations than those related to development or monitoring. Nonetheless, the majority of reporting recommendations were still not adequately described. To progress the field of stroke rehabilitation research and to ensure stroke patients receive optimal evidence-based clinical care, we urge the research community to endorse and adopt our recommendations.

Objective: To evaluate the clinical efficacy of an established programme of occupational therapy in maintaining functional activity and reducing further health risks from inactivity in care home residents living with stroke sequelae., Design: Pragmatic, parallel group, cluster randomised controlled trial., Setting: 228 care homes (>10 beds each), both with and without the provision of nursing care, local to 11 trial administrative centres across the United Kingdom., Participants: 1042 care home residents with a history of stroke or transient ischaemic attack, including those with language and cognitive impairments, not receiving end of life care. 114 homes (n=568 residents, 64% from homes providing nursing care) were allocated to the intervention arm and 114 homes (n=474 residents, 65% from homes providing nursing care) to standard care (control arm). Participating care homes were randomised between May 2010 and March 2012., Intervention: Targeted three month programme of occupational therapy, delivered by qualified occupational therapists and assistants, involving patient centred goal setting, education of care home staff, and adaptations to the environment., Main Outcome Measures: Primary outcome at the participant level: scores on the Barthel index of activities of daily living at three months post-randomisation. Secondary outcome measures at the participant level: Barthel index scores at six and 12 months post-randomisation, and scores on the Rivermead mobility index, geriatric depression scale-15, and EuroQol EQ-5D-3L questionnaire, at all time points., Results: 64% of the participants were women and 93% were white, with a mean age of 82.9 years. Baseline characteristics were similar between groups for all measures, personal characteristics, and diagnostic tests. Overall, 2538 occupational therapy visits were made to 498 participants in the intervention arm (mean 5.1 visits per participant). No adverse events attributable to the intervention were recorded. 162 (11%) died before the primary outcome time point, and 313 (30%) died over the 12 months of the trial. The primary outcome measure did not differ significantly between the treatment arms. The adjusted mean difference in Barthel index score at three months was 0.19 points higher in the intervention arm (95% confidence interval -0.33 to 0.70, P=0.48). Secondary outcome measures also showed no significant differences at all time points., Conclusions: This large phase III study provided no evidence of benefit for the provision of a routine occupational therapy service, including staff training, for care home residents living with stroke related disabilities. The established three month individualised course of occupational therapy targeting stroke related disabilities did not have an impact on measures of functional activity, mobility, mood, or health related quality of life, at all observational time points. Providing and targeting ameliorative care in this clinically complex population requires alternative strategies.Trial registration Current Controlled Trials ISRCTN00757750., (© Sackley et al 2015.)

Background: Stroke has a huge impact, leaving more than a third of affected people with lasting disability and rehabilitation remains a cornerstone treatment in the National Health Service (NHS). Recovery of mobility and arm function post-stroke occurs through re-learning to use the affected body parts and/or learning to compensate with the lesser affected side. Promising evidence suggests that the addition of Co-careldopa to physical therapy and occupational therapy may improve the recovery of arm and leg movement and lead to improved function., Methods/design: Dopamine Augmented Rehabilitation in Stroke (DARS) is a multi-centre double-blind, randomised, placebo, controlled clinical trial of Co-careldopa in addition to routine NHS occupational therapy and physical therapy as part of early stroke rehabilitation. Participants will be randomised on a 1:1 basis to either Co-careldopa or placebo. The primary objective of the trial is to determine whether the addition of six weeks of Co-careldopa treatment to rehabilitation therapy can improve the proportion of patients who can walk independently eight weeks post-randomisation., Discussion: The DARS trial will provide evidence as to whether Co-careldopa, in addition to routine NHS occupational and physical therapy, leads to a greater recovery of motor function, a reduction in carer dependency and advance rehabilitation treatments for people with stroke., Trial Registration: ISRCTN99643613 assigned on 4 December 2009.

Rationale, Aims and Objectives: This paper addresses the challenge of investigating fidelity in the implementation of a complex rehabilitation intervention designed to increase the level of independence in personal activities of daily living of stroke patients living in UK care homes. A programme theory of intervention fidelity was constructed to underpin a process evaluation running alongside a cluster randomized trial of the rehabilitation intervention., Methods: The programme theory has been constructed drawing on principles of realist evaluation. Using data from in-depth semi-structured interviews (n = 17) with all occupational therapists (OTs) and critical incident reports from the trial (n = 20), and drawing from frameworks for implementation, the programme theory was developed., Results: The programme theory incorporates four potential mechanisms through which fidelity within the trial can be investigated. These four programme theory areas are (1) the balancing of research and professional requirements that therapists performed in a number of areas while delivering the study interventions; (2) the OTs rapport building with care home staff; (3) the work focused on re-engineering the personal environments of care home patients; and (4) the learning about the intervention within the context of the trial and its impacts over time., Conclusions: These findings characterize the real-world nature of fidelity within intervention research, and specifically the negotiated nature of implementation within clinical settings, including individual patients' needs. This research adds to the evidence base because current frameworks for fidelity neglect the importance of learning over time of individuals and across the time span of a trial., (© 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.)

Background: One-third of stroke patients are dependent on others to get outside their homes. This can cause people to become housebound, leading to increased immobility, poor health, isolation and misery. There is some evidence that outdoor mobility rehabilitation can reduce these limitations., Objective: To test the clinical effectiveness and cost-effectiveness of an outdoor mobility rehabilitation intervention for stroke patients., Design: Multicentre, parallel-group randomised controlled trial, with two groups allocated at a 1 : 1 ratio plus qualitative participant interviews., Setting: Fifteen UK NHS stroke services throughout England, Scotland and Wales., Participants: A total of 568 stroke patients who wished to get out of the house more often, mean age of 71 years: 508 reached the 6-month follow-up and 10 were interviewed., Intervention: Control was delivered prior to randomisation to all participants, and consisted of verbal advice and transport and outdoor mobility leaflets. Intervention was a targeted outdoor mobility rehabilitation programme delivered by 29 NHS therapists to 287 randomly chosen participants for up to 12 sessions over 4 months., Main Outcome Measures: Primary outcome was participant health-related quality of life, measured by the Short Form questionnaire-36 items, version 2 (Social Function domain), 6 months after baseline. Secondary outcomes were functional ability, mobility, number of journeys (from monthly travel diaries), satisfaction with outdoor mobility (SWOM), psychological well-being and resource use [health care and Personal Social Services (PSS)] 6 months after baseline. Carer well-being was recorded. All outcome measures were collected by post and repeated 12 months after baseline. Outcomes for the groups were compared using statistical significance testing and adjusted for multiple membership to account for the effect of multiple therapists at different sites. Interviews were analysed using interpretive phenomenology to explore confidence., Results: A median of seven intervention sessions [interquartile range (IQR) 3-7 sessions], median duration of 369 minutes (IQR 170-691.5 minutes) per participant was delivered. There was no significant difference between the groups on health-related quality of life (social function). There were no significant differences between groups in functional ability, psychological well-being or SWOM at 6- or 12-month follow-ups. There was a significant difference observed for travel journeys with the intervention group being 42% more likely to make a journey compared with the control group [rate ratio 1.42, 95% confidence interval (95% CI) 1.14 to 1.67] at 6 months and 76% more likely (rate ratio 1.76, 95% CI 1.36 to 1.95) at 12 months. The number of journeys was affected by the therapist effect. The mean incremental cost (total NHS and PSS cost) of the intervention was £3413.75 (95% CI -£448.43 to £7121.00), with an incremental quality-adjusted life-year gain of -0.027 (95% CI -0.060 to 0.007) according to the European Quality of Life-5 Dimensions and -0.003 (95% CI -0.016 to 0.006) according to the Short Form questionnaire-6 Dimensions. At baseline, 259 out of 281 (92.2%) participants in the control group were dissatisfied with outdoor mobility but at the 6-month assessment this had reduced to 77.7% (181/233), a 15% reduction. The corresponding reduction in the intervention group was slightly greater (21%) than 268 out of 287 (93.4%) participants dissatisfied with outdoor mobility at baseline to 189 out of 261 (72.4%) at 6 months. Participants described losing confidence after stroke as being detrimental to outdoor mobility. Recruitment and retention rates were high. The intervention was deliverable by the NHS but had a neutral effect in all areas apart from potentially increasing the number of journeys. This was dependent on the therapist effect, meaning that some therapists were more successful than others. The control appeared to affect change., Conclusions: The outdoor mobility intervention provided in this study to these stroke patients was not clinically effective or cost-effective. However, the provision of personalised information and monthly diaries should be considered for all people who wish to get out more., Trial Registration: Current Controlled Trials ISRCTN58683841., Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 29. See the NIHR Journals Library website for further project information.

Objectives: To explore the perspectives of healthcare professionals and commissioners working with a stroke Early Supported Discharge service in relation to: (1) the factors that facilitate or impede the implementation of the service, and (2) the impact of the service., Design: Cross-sectional qualitative study using semi-structured interviews. Data were analysed by two researchers using a thematic analysis approach., Setting: Two Early Supported Discharge services in Nottinghamshire., Participants: Purposive sampling identified 35 key informants including practitioners, managers and commissioners., Results: The identified facilitators to the implementation of evidence-based services were: (1) the adaptability of the intervention to the healthcare context, (2) the role of rehabilitation assistants and (3) cross-service working arrangements. Perceived challenges included: (1) lack of clarity regarding the referral decision making process, (2) delays in securing social care input and (3) lack of appropriate follow-on services in the region. Most respondents perceived the impact of the services to be: (1) reducing in-hospital stay, (2) aiding the seamless transfer of care from hospital to the community and (3) providing intensive stroke specific therapy. Commissioners called for greater evidence of service impact and clarity regarding where it fits into the stroke pathway., Conclusions: Early Supported Discharge services were perceived as successful in providing home-based, stroke specific rehabilitation. Teams would benefit from capitalising on identified facilitators and developing strategies to address the challenges. The remit and impact of the services should be clear and demonstrable, with teams strengthening links with other health and social care providers.

Objective: To assess the treatment integrity of behavioural therapy for low mood in stroke patients with aphasia., Design: Participants were recruited to a multicentre randomized controlled trial (Communication and Low Mood; CALM trial) comparing behavioural therapy with a usual care control group., Subjects: Of the 51 participants randomly allocated to receive behavioural therapy, 44 participants completed treatment., Methods: Participants were assessed on measures of disability, language and mood. The number and length of therapy sessions, and therapist was recorded. Allocation of time to therapy components was compared across three phases of therapy. Associations between levels of disability, aphasia, mood and the therapy patients received were determined. Therapy content was compared between centres and at the beginning and end of the trial., Results: The mean number of therapy sessions was 9.1 (range 3-18, SD 2.6) and the mean duration of sessions was 58 minutes (range 30-89 minutes, SD 10.7). Allocation of time to each therapy component significantly differed across the three phases of therapy (P < 0.05). There were no significant associations (P > 0.05) between the length and number of sessions and patients' aphasia, mood or disability, suggesting similar levels of therapy were provided regardless of patients' characteristics. The content of therapy showed some differences between centres (P < 0.01) and there was programme drift in some components of therapy., Conclusions: The results support the ability of the therapists to deliver behavioural therapy according to the treatment manual. However there were differences between centres and over time in some components of therapy.

Objective: To investigate patients' and carers' experiences of Early Supported Discharge services and inform future Early Supported Discharge service development and provision., Design and Subjects: Semi-structured interviews were completed with 27 stroke patients and 15 carers in the Nottinghamshire region who met evidence-based Early Supported Discharge service eligibility criteria. Participants were either receiving Early Supported Discharge or conventional services., Setting: Community stroke services in Nottinghamshire, UK., Results: A thematic analysis process was applied to identify similarities and differences across datasets. Themes specific to participants receiving Early Supported Discharge services were: the home-based form of rehabilitation; speed of response; intensity and duration of therapy; respite time for the carer; rehabilitation exercises and provision of technical equipment; disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Participants receiving Early Supported Discharge or conventional community services experienced difficulties related to: limited support in dealing with carer strain; lack of education and training of carers; inadequate provision and delivery of stroke-related information; disjointed transition between Early Supported Discharge and ongoing rehabilitation services., Conclusions: Accelerated hospital discharge and home-based rehabilitation was perceived positively by service users. The study findings highlight the need for Early Supported Discharge teams to address information and support needs of patients and carers and to monitor their impact on carers in addition to patients, using robust outcome measures.

Background: Recovery from stroke requires the provision of specialist rehabilitative care, yet there is a lack of research evidence on optimal methods of delivery and inequitable service provision across countries. Following consensus on Early Supported Discharge, our aim was to define core components of evidence-based community stroke services., Design: We used a modified Delphi approach with a purposive sample of 26 UK-based expert panellists (10 academics, 15 stroke service leads or commissioners, one stroke survivor). Statements based on research literature and policy documents were generated by an independent, mixed academic and service improvement team of nine. In three rounds of consultation panellists indicated their level of agreement with statements. Free text comments were analysed thematically., Results: Consensus of opinion (>70% agreement) was obtained on 76 of 80 statements. Panellists agreed that stroke specialist care tailored to clinical need should be provided following discharge from hospital. Flexible care pathways should be commissioned and provided through strategic and collaborative leadership across health and social care. Teams need to deliver stroke specialist rehabilitation, handing over responsibility to non-specialist services when patient rehabilitation goals have been met. Lack of consensus on whether to provide services exclusively for stroke patients and the need of support for carers highlights areas for further research., Conclusions: Consensus on the provision of evidence-based community stroke rehabilitation has been reached. Commissioning services with a clearly defined remit, which can deliver tailored care to individual stroke patients, is a challenge that needs further exploration.

Background: Stroke is a worldwide problem and is a leading cause of adult disability, resulting in dependency in activities of daily living (ADL) for around half of stroke survivors. It is estimated that up to 25% of all care home residents in the USA and in the UK have had a stroke. Stroke survivors who reside in care homes are likely to be more physically and cognitively impaired and therefore more dependent than those able to remain in their own home. Overall, 75% of care home residents are classified as severely disabled, and those with stroke are likely to have high levels of immobility, incontinence and confusion, as well as additional co-morbidities. It is not known whether this clinically complex population could benefit from occupational therapy in the same way as community-dwelling stroke survivors. The care home population with stroke differs from the general stroke population living at home, and a review was needed to examine the benefits of occupational therapy provided to this specific group. This review therefore focused on occupational therapy interventions for ADL for stroke survivors residing in care homes., Objectives: To measure the effects of occupational therapy interventions (provided directly by an occupational therapist or under the supervision of an occupational therapist) targeted at improving, restoring and maintaining independence in ADL among stroke survivors residing in long-term institutional care, termed collectively as 'care homes'. As a secondary objective, we aimed to evaluate occupational therapy interventions for reducing complications such as depression and low mood., Search Methods: We searched the Cochrane Stroke Group Trials Register (August 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, September 2012), MEDLINE (1948 to September 2012), EMBASE (1980 to September 2012), CINAHL (1982 to September 2012) and 10 additional bibliographic databases and six trials registers. We also handsearched seven journals, checked reference lists and obtained further information from individual trialists., Selection Criteria: Randomised controlled trials investigating the impact of an occupational therapy intervention for care home residents with stroke versus standard care., Data Collection and Analysis: The lead review author performed all searches. Two review authors then independently assessed all titles and abstracts of studies and selected trials for inclusion, with a third review author resolving any discrepancies. The same two review authors independently extracted data from all included published sources to ensure reliability. Primary outcomes were performance in ADL at the end of scheduled follow-up and death or a poor outcome. Secondary outcomes aimed to reflect the domains targeted by an occupational therapy intervention., Main Results: We included in the review one study involving 118 participants. We found one ongoing study that also met the inclusion criteria for the review, but the data were not yet available., Authors' Conclusions: We found insufficient evidence to support or refute the efficacy of occupational therapy interventions for improving, restoring or maintaining independence in ADL for stroke survivors residing in care homes. The effectiveness of occupational therapy for the population of stroke survivors residing in care homes remains unclear, and further research in this area is warranted.

Objective: The aim was to evaluate behavioural therapy as a treatment for low mood in people with aphasia., Design: A randomized controlled trial comparing behavioural therapy plus usual care with a usual care control. Potential participants with aphasia after stroke were screened for the presence of low mood. Those who met the criteria and gave consent were randomly allocated., Setting: Participants were recruited from hospital wards, community rehabilitation, speech and language therapy services and stroke groups., Subjects: Of 511 people with aphasia identified, 105 had low mood and were recruited., Interventions: Behavioural therapy was offered for up to three months. Outcomes were assessed three and six months after random allocation., Main Measures: Stroke Aphasic Depression Questionnaire, Visual Analog Mood Scales 'sad' item, and Visual Analogue Self-Esteem Scale., Results: Participants were aged 29 to 94 years (mean 67.0, SD 13.5) and 66 (63%) were men. Regression analysis showed that at three months, when baseline values and communication impairment were controlled for, group allocation was a significant predictor of the Stroke Aphasic Depression Questionnaire (P < 0.05), visual analogue 'sad' (P = 0.03), and Visual Analogue Self-Esteem Scale (P < 0.01). At six months, group alone was a significant predictor of the Stroke Aphasic Depression Questionnaire (P < 0.05), and remained significant when baseline values were controlled for (P = 0.02). Mean Stroke Aphasic Depression Questionnaire 10-item hospital version scores decreased from baseline to six months by six points in the intervention group as compared with an increase of 1.9 points in the control group., Conclusions: Behavioural therapy seemed to improve the mood of people with aphasia.

Despite the recent advances in stroke rehabilitation research, the translation of research evidence into practice remains a challenge. The purpose of this article is to communicate practical experience and describe research methodologies used to promote change and implementation of stroke rehabilitation research in three international settings. In England, the development of an evidence-based consensus document, combined with qualitative and quantitative methods, was used to promote practice change in community-based stroke services. The Canadian research program involved synthesis of evidence, creation of user friendly information, and development of multimodal knowledge transfer strategies to promote change at an individual clinician level. Australian researchers followed a multistep process, involving audit and feedback, identification of barriers, and tailored education to improve implementation of one clinical guideline recommendation. Reducing the evidence-practice gap requires the development of active management strategies. This article highlights the importance of close collaboration between stakeholders - both in terms of the transfer of evidence into clinical practice and for optimizing future Phase IV implementation research endeavours., (© 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.)

Objective: To investigate two approaches to treating patients with persistent dressing problems and cognitive difficulties following stroke., Design: Pilot randomized controlled trial., Setting: Inpatient stroke rehabilitation service., Subjects: Seventy consecutive stroke patients with persistent dressing problems and accompanying cognitive difficulties at two weeks after their stroke., Interventions: Patients were randomly allocated to six weeks of either a systematic neuropsychological approach, based on analysis of dressing problems and further cognitive testing, or to the control group who received conventional (functional) dressing practice. Both groups received treatment three times a week in accordance with two separately prepared manuals., Main Measures: Nottingham Stroke Dressing Assessment (NSDA), Line Cancellation, 10-hole peg transfer test, Object Decision, Gesture Imitation. Patients were assessed at six weeks after randomization by an independent assessor masked to group allocation., Results: Both neuropsychological and functional groups improved performance on the NSDA over the treatment period (31% and 22%, respectively) but there was no significant difference between groups at six weeks. However, the neuropsychological group showed a significantly greater improvement on a line cancellation test of visual neglect (t(62) = 2.1, P < 0.05) and a planned subanalysis for those with right hemisphere damage showed a trend towards better dressing outcome (P = 0.07, one-tailed)., Conclusions: Results demonstrate the potential benefits of a systematic neuropsychological approach to dressing therapy, particularly for patients with right hemisphere damage. This study suggests the need for a phase III study evaluating the efficacy of a systematic neuropsychological approach in treating dressing difficulties, targeting patients with right hemisphere stroke and visuospatial impairments.

Background: The occupational therapy (OT) in care homes study (OTCH) aims to investigate the effect of a targeted course of individual OT (with task training, provision of adaptive equipment, minor environmental adaptations and staff education) for stroke survivors living in care homes, compared to usual care., Methods/design: A cluster randomised controlled trial of United Kingdom (UK) care homes (n = 90) with residents (n = 900) who have suffered a stroke or transient ischaemic attack (TIA), and who are not receiving end-of-life care. Homes will be stratified by centre and by type of care provided and randomised (50:50) using computer generated blocked randomisation within strata to receive either the OT intervention (3 months intervention from an occupational therapist) or control (usual care). Staff training on facilitating independence and mobility and the use of adaptive equipment, will be delivered to every home, with control homes receiving this after the 12 month follow-up.Allocation will be concealed from the independent assessors, but the treating therapists, and residents will not be masked to the intervention. Measurements are taken at baseline prior to randomisation and at 3, 6 and 12 months post randomisation. The primary outcome measure is independence in self-care activities of daily living (Barthel Activities of Daily Living Index). Secondary outcome measures are mobility (Rivermead Mobility Index), mood (Geriatric Depression Scale), preference based quality of life measured from EQ-5D and costs associated with each intervention group. Quality adjusted life years (QALYs) will be derived based on the EQ-5D scores. Cost effectiveness analysis will be estimated and measured by incremental cost effectiveness ratio. Adverse events will be recorded., Discussion: This study will be the largest cluster randomised controlled trial of OT in care homes to date and will clarify the currently inconclusive literature on the efficacy of OT for stroke and TIA survivors residing in care homes., Trial Registration: ISRCTN00757750.

Background: Up to 42% of all stroke patients do not get out of the house as much as they would like. This can impede a person's quality of life. This study is testing the clinical effectiveness and cost effectiveness of a new outdoor mobility rehabilitation intervention by comparing it to usual care., Methods/design: This is a multi-centre parallel group individually randomised, controlled trial. At least 506 participants will be recruited through 15 primary and secondary care settings and will be eligible if they are over 18 years of age, have had a stroke and wish to get out of the house more often. Participants are being randomly allocated to either the intervention group or the control group. Intervention group participants receive up to 12 rehabilitation outdoor mobility sessions over up to four months. The main component of the intervention is repeated practice of outdoor mobility with a therapist. Control group participants are receiving the usual intervention for outdoor mobility limitations: verbal advice and provision of leaflets provided over one session.Outcome measures are being collected using postal questionnaires, travel calendars and by independent assessors. The primary outcome measure is the Social Function domain of the SF36v2 quality of life assessment six months after recruitment. The secondary outcome measures include: functional ability, mobility, the number of journeys (monthly travel diaries), satisfaction with outdoor mobility, mood, health-related quality of life, resource use of health and social care. Carer mood information is also being collected.The mean Social Function score of the SF-36v2 will be compared between treatment arms using a multiple membership form of mixed effects multiple regression analysis adjusting for centre (as a fixed effect), age and baseline Social Function score as covariates and therapist as a multiple membership random effect. Regression coefficients and 95% confidence intervals will be presented., Discussion: This study protocol describes a pragmatic randomised controlled trial that will hopefully provide robust evidence of the benefit of outdoor mobility interventions after stroke for clinicians working in the community. The results will be available towards the end of 2012., Trial Registration: ISRCTN58683841.

Objective: Despite recent high-profile advances in our understanding of rehabilitation post-stroke, the evidence base remains weaker than in other areas of stroke management. Under the aegis of the European Stroke Organisation a select committee was assembled to collate and appraise the evidence base for rehabilitation interventions., Methods: Following systematic literature searching, relevant abstracts were screened for data quality and relevance. These data were summarized and presented to the members of the expert panel, who, both individually and across group discussions, modified the content. The process was repeated until a final document was produced that all members of the panel and the European Stroke Organisation editorial group were happy with., Results: The final guidelines offer a comprehensive review of post-stroke rehabilitation, incorporating discussion of optimal timing, setting and duration of therapy as well as individual sections on the role of professions allied to medicine; use of assistive technologies and dealing with the common complications encountered during the rehabilitation period., Conclusion: There is a lack of robust evidence for many of the prevalent post-stroke rehabilitation interventions. Available data are discussed and presented as key points; more importantly, specific areas that require further study are also highlighted., Methods: Following systematic literature searching, relevant abstracts were screened for data quality and relevance. These data were summarized and presented to the members of the expert panel, who, both individually and across group discussions, modified the content. The process was repeated until a final document was produced that all members of the panel and the European Stroke Organisation editorial group were happy with., Results: The final guidelines offer a comprehensive review of post-stroke rehabilitation, incorporating discussion of optimal timing, setting and duration of therapy as well as individual sections on the role of professions allied to medicine; use of assistive technologies and dealing with the common complications encountered during the rehabilitation period., Conclusion: There is a lack of robust evidence for many of the prevalent post-stroke rehabilitation interventions. Available data are discussed and presented as key points; more importantly, specific areas that require further study are also highlighted.

A Consensus Conference on Stroke in 1988 concluded that rehabilitation for stroke in the United Kingdom was poorly organised, was not based on evidence, and was associated with poor outcomes compared with similar health care systems. In addition, there were significant variations in the quality of services and outcome across different areas of the country. Efforts to improve care included increased investment into services and research, development of multidisciplinary national guidelines for all aspects of stroke care, and a regular national audit of stroke rehabilitation. The last 20 years have seen dramatic improvements in the development of a coherent policy for the management of stroke patients in the United Kingdom, underpinned by well-organised services within a framework of guidelines and performance review. However, further work is needed to increase the evidence base for the nature, duration, and effectiveness of complex rehabilitation interventions and to improve multidisciplinary interactions and communications with patients and their caregivers. Of the further work required, the leading priority is to increase therapy input to make the best use of time that patients spend in rehabilitation settings.

The evidence to support stroke rehabilitation has expanded dramatically in the last decade. In order to ensure that the resultant research findings can be generalized to all patients after stroke, research in the next decade must shift to multicentre trial activity. Published evidence from the stroke unit, early supported discharge and out-patient trials is strong and supports the beneficial effects of these stroke rehabilitation services. Evidence for individual therapeutic practices is continuing to develop, but in many areas further research is required. The benefits of task-specific interventions and the need to practise these with intensity are core findings from the current research literature. Technological and capacity-building advances, along with newly developing stroke research networks, will ensure that the future of stroke rehabilitation is strong and progressing towards becoming truly evidence-based.

Background and Purpose: Virtual environments for use in stroke rehabilitation are in development, but there has been little evaluation of their suitability for this purpose. We evaluated a virtual environment developed for the rehabilitation of the task of making a hot drink., Methods: Fifty stroke patients undergoing rehabilitation in a UK hospital stroke unit were involved. The performance of stroke rehabilitation patients when making a hot drink had the neurological impairments associated with performance of this task, and the errors observed were compared for standardized task performance in the real world and in a virtual environment. Neurological impairments were measured using standardized assessments. Errors in task performance were assessed rating video recordings and classified into error types., Results: Real-world and virtual environment performance scores were not strongly associated (rho=0.30; P<0.05). Performance scores in both settings were associated with age, Barthel ADL score, Mini Mental State Examination score, and tests of visuospatial function. Real-world performance only was associated with arm function and sequencing ability. Virtual environment performance only was associated with language function and praxis. Participants made different errors during task performance in the real world and in the virtual environment., Conclusions: Although this virtual environment was usable by stroke rehabilitation patients, it posed a different rehabilitation challenge from the task it was intended to simulate, and so it might not be as effective as intended as a rehabilitation tool. Other virtual environments for stroke rehabilitation in development require similar evaluation.

Family members of stroke survivors are often not supported for their caring role, with many reporting adjustment difficulties. This paper describes the development and content of a group-based intervention for informal carers of stroke survivors. The intervention is based on the theoretical foundation of the biopsychosocial model with the aim to understand and address the physical, psychological and social factors of caring for stroke survivors. Findings from a comprehensive literature review and a qualitative study with carers and stroke professionals were synthesized to guide the intervention development. The Template for Intervention Description and Replication (TIDieR) checklist was used as a framework to describe the intervention. The intervention integrates cognitive-behavioural approaches via the identification of the biopsychosocial (physical, emotional, social) factors that can have an impact on the well-being of carers. It includes education on stroke-specific topics and advice on coping strategies. It consists of six structured two-hour group sessions facilitated in a community setting. It provides information and support on adjusting to the caring role in the first year post-stroke. Intervention materials were designed for addressing carers' specific needs using psychological techniques, such as problem-solving, goal setting and relaxation exercises. We have underlined the importance for describing and reporting the process of intervention development for complex interventions in the context of stroke rehabilitation. An intervention addressing the needs of informal stroke carers (Biopsychosocial Intervention for Stroke Carers; BISC) has been developed and described. BISC was further evaluated in a single-centre feasibility randomized controlled trial. [ABSTRACT FROM AUTHOR]

Psychoeducation can provide information and support to cope with the physical and emotional effects of a health condition. This scoping review aimed to identify the evidence regarding psychoeducational interventions for people after a Transient Ischemic Attack (TIA) and minor stroke. This review was conducted in accordance with the PRISMA Extension for Scoping Reviews. Three electronic databases (MEDLINE, Embase, PsycINFO) were searched for articles on interventions related to psychoeducational support post-TIA and minor/mild stroke. Search retrieved 3722 articles. Three reviewers independently screened titles, abstracts, full-texts, and extracted data for included studies. Study quality was assessed using the JADAD scale. TIDieR checklist was used to describe interventions. Fifteen RCTs were included. Twelve studies were of high quality (JADAD score ≥2), two were of low quality. A total of 1500 participants were recruited across studies. Definition of TIA and minor stroke was unclear, leading to the exclusion of several studies. Various interventions were included, including education/psychoeducation (n = 4); exercise and lifestyle advice (n = 3); telephone-based education/counseling (n = 3); secondary prevention education (n = 1); motivational interviewing (n = 2); self-management (n = 2). Interventions were inconsistently described, with information missing about who delivered it and tailoring. Definitions of stroke severity are not adequately reported. There are a variety of interventions including education about a range of stroke-specific topics. Many interventions are not adequately described, thus making it difficult to determine if the aim was to provide information or support post-TIA/minor stroke. There is a need for an in-depth systematic review to develop a clear definition of psychoeducation. [ABSTRACT FROM AUTHOR]

Objective: Randomised controlled trials have shown the benefits of Early Supported Discharge (ESD) of stroke survivors. Our aim was to evaluate whether ESD is still beneficial when operating in the complex context of frontline healthcare provision. Design: We conducted a cohort study with quasi experimental design. A total of 293 stroke survivors (transfer independently or with assistance of one, identified rehabilitation goals) within two naturally formed groups were recruited from two acute stroke units: ‘ESD’ n=135 and ‘Non ESD’ n=158 and 84 caregivers. The ‘ESD’ group accessed either of two ESD services operating in Nottinghamshire, UK. The ‘Non ESD’ group experienced standard practices for discharge and onward referral. Outcome measures (primary: Barthel Index) were administered at baseline, 6 weeks, 6 months and 12 months. Results: The ESD group had a significantly shorter length of hospital stay (P=0.029) and reported significantly higher levels of satisfaction with services received (P<0.001). Following adjustment for age differences at baseline, participants in the ESD group (n=71) had significantly higher odds (compared to the Non ESD group, n=85) of being in the ⩾90 Barthel Index category at 6 weeks (OR = 1.557, 95% CI 2.579 to 8.733), 6 months (OR = 1.541, 95% CI 2.617 to 8.340) and 12 months (OR 0.837, 95% CI 1.306 to 4.087) respectively in relation to baseline. Carers of patients accessing ESD services showed significant improvement in mental health scores (P<0.01). Conclusion: The health benefits of ESD are still evident when evidence based models of these services are implemented in practice. [ABSTRACT FROM AUTHOR]

Introduction: The daily task of dressing oneself requires multiple complex skills,which are often taken for granted by those free from ill-health or disability. Independence in dressing allows an individual to maintain a sense of dignity and choice over his or her appearance. Occupational therapy aims to restore independent functional performance in daily activities. Dressing independence requires both physical and cognitive skills. For survivors of stroke, impairment of such skills can pose great difficulty to their dressing performance. Method: The aim of this study was to examine the effect of arm paresis and cognitive impairment on upper body dressing ability using a cognitively impaired cohort of stroke participants (n = 70), and to explore the importance of bimanual activity when dressing in the presence of cognitive impairment. Dressing ability was assessed at baseline and immediately following a 6-week period of dressing practice with an occupational therapist. Results: Thirty-six participants were able to use a bimanual dressing method at baseline.The chi-square test for independence indicated a strong association between dressing method (bimanual or unimanual) and independence in upper body dressing, p<0.001. The dressing success of the bimanual group was significantly greater than that of the unimanual group at both assessment time points. Conclusion: Cognitively impaired stroke survivors do perform better at upper body dressing when they are able to use both hands as compared with one, but those with arm paresis preventing bimanual activity may still improve their dressing performance significantly with practice. [ABSTRACT FROM AUTHOR]

Background: Long-term care for stroke survivors is fragmented and lacks an evidence-based, easy-to-use tool to identify persistent long-term problems among stroke survivors and streamline referral for treatment. We sought to develop a poststroke checklist (PSC) to help health care professionals identify poststroke problems amenable to treatment and subsequent referral. Methods: An instrument development team, supported by measurement experts, international stroke experts, and poststroke care stakeholders, was created to develop a long-term PSC. A list of long-term poststroke problem areas was generated by an international, multidisciplinary group of stroke experts, the Global Stroke Community Advisory Panel. Using Delphi methods, a consensus was reached on which problem areas on the list were most important and relevant to include in a PSC. The instrument development team concurrently created the actual checklist, which provided example language about how to ask about poststroke problem areas and linked patient responses to a specific referral process. Results: Eleven long-term poststroke problem areas were rated highly and consistently among stroke experts participating in the Delphi process (n = 12): secondary prevention, activities of daily living, mobility, spasticity, pain, incontinence, communication, mood, cognition, life after stroke, and relationship with caregiver. These problem areas were included in the long-term PSC. Conclusions: The PSC was developed to be a brief and easy-to-use tool, intended to facilitate a standardized approach for health care providers to identify long-term problems in stroke survivors and to facilitate appropriate referrals for treatment. [Copyright &y& Elsevier]