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OBJECTIVE: To ensure at outset the content validity of a measure (to be developed) of social integration following stroke. DESIGN: Qualitative study, using in-depth interviews with patients at least six months following stroke. SETTING: Community setting, Bristol, UK. SUBJECTS: Thirty survivors of stroke, discharged at least six months previously from a neurological rehabilitation unit in a district general hospital. RESULTS: Patients reported a change, usually for the worse, in their levels of integration following stroke. More specifically they alluded to a decrease in both the quantity and quality of activities, especially with regard to leisure and those activities occurring outside the home. Social interaction was reduced in most patients, in terms of frequency and quality of contact. From the data, six dimensions of change in quality of interaction emerged. Finally, changes in patients' physical and financial environments were reported. Based on the findings, four diagrams were developed, providing a structure for questionnaire development. CONCLUSIONS: The results of this study confirm the findings of previously reported research. An individual's level of social integration can be affected by stroke in a wide variety of areas and along many different dimensions. Data from this study have highlighted the importance of the patient's subjective impression of the quality of both functional and social performance. This has provided the opportunity to develop a questionnaire based on the patient's perspective, rather than that of health professionals. [ABSTRACT FROM AUTHOR]

This paper describes the unsatisfactory situation that currently affects the provision of neurological services in parts of England, as identified in three recent reports, and contains a number of suggested ways in which the situation might be improved, while highlighting the good work being done by specialist nurses and therapists and by the Neurological Alliance on behalf of patients and their families.

Background: Engagement in therapeutic activity among stroke inpatients is advocated by many rehabilitation professionals. However, there is a lack of published evidence to indicate whether this is currently being achieved., Objective: To investigate the extent and types of 'rehabilitation' activities on a new neurological rehabilitation ward, and examine change in patients' behaviour related to the new environment and new initiatives., Design: Five one-week observation periods were conducted over two years, with a total of 67 patients being observed. A comparison was made with results of an earlier study of stroke patients' activities conducted at the same hospital., Results: Patients spent an average 43 min per day with therapists (9% of the working day) and this was only marginally supplemented by self-exercise (2% of the working day--approximately 10 min). However, the provision of a new rehabilitation environment was associated with a marked decrease in the time patients spent at their bedsides, and a decrease in time spent passively gazing or watching others., Conclusions: Overall there was some positive change in patients' behaviour. We suggest that structured guidance is required from the whole multidisciplinary team to stimulate more self-directed therapy practice and recreation.

The Government's Health of the nation strategy demands a reduction in the level of ill-health and death caused by stroke. This review describes the present state of knowledge on the prevention and management of stroke. Effective intervention in stroke has a number of major implications, including: health education for the public; education of health professionals (general practitioners, consultants and others); availability of guidelines and protocols; access to specialist advice, investigations and their interpretation, and rapid treatment, including surgery; availability of specially trained nurses for screening and monitoring; and availability of specialist multidisciplinary teams in hospitals and the community.

The evidence is compelling that stroke units are effective when compared to management of patients on general medical wards. However, the evidence remains equivocal that better outcome is sustained in the longer term. This paper reports an investigation of cognitive and emotional outcome, environmental consequences, social activities, and physical outcome in 57 consecutive one-year survivors of a stroke discharged from a stroke and neurological rehabilitation unit. Satisfaction with inpatient and outpatient services was also investigated. Results were compared with previously reported studies of long-term outcome after stroke. Mean Barthel activities of daily living score at one year or more post-stroke was 16.8. Arm function was impaired in 43% of the participants in the study. Nearly half had cognitive and emotional problems, 19% communication problems, and 25% problems with access both inside and outside their house. All but four of the one-year survivors were less active after their stroke than before. More than 40% were dissatisfied with at least one aspect of inpatient and/or outpatient services. The long-term consequences of stroke in all areas investigated were considerable and in line with previous reports. Some suggestions for reducing these effects are made, including better information for patients about stroke and rehabilitation, improved access to psychology services, detailed assessment prior to hospital discharge of the patient's living environment and effective coordination with social services to improve access to their living environment.

We describe the experience of setting up a 16-bed unit for the rehabilitation of non-progressive and progressive neurological disorders. Its aim was the active involvement of patients and their families in the rehabilitation process. Various innovations were instigated by the multidisciplinary teams, including early visits home and a leisure service. Over the first two years, 318 patients were admitted to the unit, 51% attributable to stroke.

Ninety seven patients with stroke who had participated in a randomised trial of conventional physical therapy nu an enhanced therapy for arm function were followed up at one year. Despite the emphasis of the enhanced therapy approach on continued use of the arm in everyday life, the advantage seen for some patients with enhanced therapy at six months after stroke had diminished to a non-significant trend by one year. This was due to some late improvement in the conventional therapy group whereas the enhanced therapy group remained static or fell back slightly. It is recommended that trials should be conducted comparing very intensive therapy for the arm with controls without treatment. This would provide a model of the effects of therapy on intrinsic neural recovery that would be relevant to all areas of neurological rehabilitation.

Background and Purpose: Little attention has been focused on quality of life in stroke outcome research. The purpose of this review is to outline the meaning of the concept, describe important methodological issues and methods of assessment, review existing quality of life measures, and discuss criteria for selecting an appropriate instrument., Summary of Review: The following 10 quality of life instruments were reviewed: COOP Charts; Euroqol; Frenchay Activities Index; Karnofsky Performance Status Scale; McMaster Health Index Questionnaire; Medical Outcomes Study 20-Item Short-Form Health Survey; Nottingham Health Profile; Quality of Life Index; Quality of Well-being Scale; and the Sickness Impact Profile. They were evaluated in terms of length, time needed to complete, content, scoring, and psychometric characteristics., Conclusions: Emphasis should be placed on further psychometric evaluation of existing quality of life measures rather than on generating new instruments. There is particular need for supplementary data on the responsiveness of the instruments to changes in patients' clinical status over time. The choice of a suitable quality of life instrument should be based not only on psychometric properties but also on careful consideration of the research question, the relevance to the objectives of the study, the feasibility of the instrument, and the specific characteristics of the stroke patients under investigation.

After reviewing the size of the problem of multiple sclerosis, and the likely case-load for doctors in different settings, this paper than proceeds to consider the major challenges in management and rehabilitation for this disease. The latter resolve themselves into what to discuss with the patient; relapses and their prevention, including general advice on such matters as stress, pregnancy, and infection; major problems including bladder and bowel dysfunction, sexual difficulties, spasticity, ataxia and incoordination, vision, and intellectual and psychological manifestations, and other problems, such as menstruation, obesity, and pressure sores. The paper concludes with a discussion of the role of specialist physicians.

In a preliminary study a group of hemiplegic patients have been assessed for return of arm function for periods up to 64 weeks after stroke. The assessment procedure employs a few simple and easily performed tests which take into account principles of the central nervous control of movement. The tests are highly repeatable and can be carried out by staff untrained in medicine or any form of physical therapy. Patients have been divided into two groups on the basis of the scores obtained in the tests at 16 weeks after stroke. The group scoring 80% or more are very likely subsequently to recover useful function of the arm and hand. The group of patients scoring less than 80% at 16 weeks after stroke are likely subsequently to recover limited arm movements and little hand movement. The preliminary results would suggest that the tasks provide a guide to prognosis and an indiction of the most suitable type of general physical therapy.

One hundred and sixty-two patients were referred to a rehabilitation unit after an acute stroke. The patterns of recovery of overall functional ability, arm function, walking and speech in 92 of 101 survivors have been analysed. In all modalities the majority of recovery occurs within 3 months; although improvement is seen thereafter it does not reach statistical significance. Possible reasons for the apparent lack of late recovery are discussed.

This report investigates the amounts of physiotherapy and occupational therapy given to acute stroke patients over the first 6 months, the factors that determine how much therapy a patient receives, and the effects of therapy upon outcome. The study is based on 162 acute stroke patients referred to a stroke rehabilitation unit. In this group the average daily rate of treatment during active rehabilitation, for both therapies combined, was 46 minutes, with a maximum of 42 minutes a day for physiotherapy and 48 minutes a day for occupational therapy. The major factors associated with the amount of therapy given related to the severity of the stroke: more therapy was given to those with lower initial functional ability, worse sitting balance, or greater loss of use of arm or leg. This association with severity probably accounts for the association between therapy and shoulder disease. A minor factor governing the amount of therapy given was the patient's degree of recovery: those who recovered less well received more therapy. It was not possible to demonstrate a specific beneficial effect of therapy.

Data relating to 976 patients registered as suffering an acute stroke has been analysed to determine the natural history of speech disturbance: these patients came from a community survey of 215,000 people over a 28 month period. Of the 545 patients assessed within 7 days of stroke, 24% were aphasic and 28% unassessable. At 3 weeks, when over 90% of survivors were tested, 20% of those tested had aphasia. At 6 months only 12% of survivors had significant aphasia, but 44% of patients and 57% of carers thought speech was abnormal. Of those aphasic within 7 days, 40% remained so at 6 months; 60% of those aphasic at 3 weeks remained so. There was a high correlation between early and late aphasia scores. Aphasia was associated with more severe disability (degree of limb weakness, loss of function, loss of IQ), and with a less good recovery of social activities, but did not cause any measurable increase in stress upon carers. In a Health District of 250,000 people, about 60 patients each year may be referred for speech therapy after an acute stroke.

Ninety-nine patients had their function recorded regularly over the first 13 weeks after their stroke. Five functional areas were studied: urinary continence, mobility, the ability to dress, feeding, and the ability to transfer from bed to chair. Thirty-two patients died before 13 weeks. Forty-five of the 67 survivors had assessments twice weekly from within 4 days of their stroke. Recovery in these 45 patients occurred fastest in the first 2 weeks, by which time at least 50% of recovery had occurred, but it was still continuing at 13 weeks. Urinary incontinence present between 7 and 10 days after stroke was the most important adverse prognostic factor both for survival and for recovery of function. Age was the second most important factor. Hospital discharge seemed to occur once recovery had stopped, although four of the 49 patients discharged had been fully independent for at least 12 days prior to discharge. It is suggested that rehabilitative therapy should concentrate less on physical function and more on cognitive ability.

This study investigated the importance of the side of weakness and sex of the patient in patient outcome after stroke. It was based upon 162 consecutive acute stroke patients attending a rehabilitation unit. Results suggest that functional recovery was not influenced by the factors investigated, provided that measurements were made at set times poststroke. However, patients with right hemiplegia attended rehabilitation longer so they appeared to have made a better functional recovery when activity of daily living (ADL) ability was measured at discharge. Although right hemiplegia was associated with aphasia and left hemiplegia with spatial disorder and loss of sitting balance, these associations were not strong enough to affect functional recovery. Sex of the patient had no significant effect upon either the frequency of initial deficits or upon outcome, and there was no obvious interaction between the two variables (side and sex) and outcome.

The value of strength of voluntary grip as an indicator of recovery of arm function was assessed by testing 38 recent stroke patients using a sensitive electronic dynamometer, and comparing the results with those from five other arm movement and function tests (Motricity Index, Motor Club Assessment, Nine Hole Peg Test, and Frenchay Arm Test). This procedure allowed measurement of grip in a large proportion of patients, and strength correlated highly with performance on the other tests. Measuring grip over a six month follow up period was a sensitive method of charting intrinsic neurological recovery. The presence of voluntary grip at one month indicates that there will be some functional recovery at six months.

Data from a sample of 532 patients seen within seven days of an acute stroke has been analysed to compare the prognostic importance of urinary incontinence with that of a history of any depression of consciousness. Urinary incontinence was more specific and had a higher predictive value. Considering conscious patients with moderate or severe initial disability, after six months 53 per cent of incontinent patients had died and 57 per cent of the survivors were still moderately or severely disabled whereas only 19 per cent of continent patients had died and 80 per cent of survivors made a good recovery. We conclude that early urinary incontinence is an important indicator of poor prognosis, identifying patients who may need extra attention.

Data collected in a population-based study on 976 patients suffering an acute stroke have been analysed to discover the frequency of disturbance of selected cognitive functions, particularly orientation, non-verbal reasoning, and copying. Further analysis investigated how these deficits related to other impairments, their prognostic importance, and their recovery. Considering patients assessed within the first week, only 45% were orientated, only 44% could be assessed for IQ and their average score was 94 (SD 16), and only 36% could copy a cross satisfactorily. Seventeen per cent of patients had a reduced level of consciousness preventing assessment, and the other unassessable patients had other impairments such as aphasia preventing assessment. In general failure to pass these tests was associated with evidence of a more severe stroke; the patients had other impairments such as a more severe paralysis. No independent effect of cognitive dysfunction upon recovery could be demonstrated. By 6 months most surviving patients passed all the tests used.

In 83 patients with stroke, multiple regression analysis was used to identify 5 variables, measured at the 1st assessment shortly after stroke, that related to the Barthel ADL score at 6 months. The variables were age, the presence of hemianopia or visual inattention, the presence of urinary incontinence, the motor deficit in the affected arm, and the patient's sitting balance. A 2nd equation, based upon the initial Barthel score with age and hemianopia added, was also developed. The success of the 1st equation in predicting the final Barthel score was about 55%, a rate better than that yielded by the 2nd equation, and also better than that produced by adding the average improvement score to the patient's initial score.

Effective planning and evaluation of medical services is only possible if appropriate and reliable information is available. Diagnoses of patients seen are essential data. The epidemiological value of standard, reliable diagnostic data could also be considerable. The International Classification of Diseases (ICD) is the only system currently available which provides a common basis of classification for general statistical use. A booklet, using ICD codes, for classifying in-patients and out-patients seen by neurologists has been developed. It is simple and easy to use, affords the necessary economy of time, and should result in uniformity of coding. Reliability studies confirm that inaccuracies occur when patients' diagnoses are coded retrospectively from their medical files, even when observers are medically trained. It is recommended that doctors should accept personal responsibility for coding patients' diagnoses at the time of consultation or discharge from hospital.

Information from a two year, longitudinal study on a community sample of patients with acute stroke was analysed to determine the effects of the stroke on the mood of the chief carer (the person living with the patient). Increased anxiety was the most commonly reported change six months after stroke. Significant depression was seen in 11-13% of carers over the first two years after stroke. The patient's functional disability was associated with depression in the carer over the first year but not at two years. A perceived poor recovery by the patient, a low level of general activities by the patient, and depression in the patient were also associated with depression in the carer within the first year. At two years after stroke none of the measured factors were related to a carer's level of depression. Carers of patients who have suffered stroke showed anxiety and emotional distress unrelated to the patient's physical disability after two years. More help from stroke support groups for carers is perhaps needed.

The Bristol Stroke Unit was set up in 1975 in order to provide a service for stroke patients and to undertake both service and biomedical research. During the first 5 years, 472 stroke patients were seen and 388 were treated. Detailed information was kept on most patients and this has been used for studies on prediction and outcome. General principles of management evolved and these are itemized. Important developments include the expansion of the Unit remit to include the management of other disabling disorders such as multiple sclerosis, a greater emphasis on service research, and the development of a voluntary service.

This paper describes preliminary studies on a screening test for aphasia which takes 3-10 minutes to complete and which is suitable for use by general practitioners, junior medical staff and other non-specialists. Data are presented to show that it is a reliable, valid assessment. Using cut-off values derived from normal people, the test is sensitive, but its specificity is limited by such associated factors as hemianopia. Using cut-off values derived from patients known to have aphasia, its specificity is improved. An abnormal result needs to be interpreted in the light of all available clinical information. The test should help identify patients with linguistic disturbance.

One hundred and fifteen patients with carefully defined Friedreich's ataxia were assessed clinically and electrocardiographically for evidence of heart disease. Cardiac symptoms, of which dyspnoea and palpitations were the most frequent, occurred in less than 30 per cent. Abnormalities on clinical examination were present in a similar proportion; harsh systolic murmurs, ventricular hypertrophy and added heart sounds were the commonest of these. Cardiac failure and persistent arrhythmias were rare and occurred late in the evolution of the neurological disease. Two patients presented with heart disease before developing neurological symptoms. Cardiac signs and symptoms were uncommon in patients without electrocardiographic abnormalities. About two-thirds of the cases had definitely abnormal ECG recordings. The characteristic finding was of widespread T-wave inversion with ventricular hypertrophy. Serial ECGs, recorded over periods of up to 32 years, were available in 30 cases and showed that abnormalities may develop in patients with Friedreich's ataxia at any time up until 20 years after the onset of neurological symptoms. In four patients initial ECG abnormalities had either improved or disappeared subsequently.

Sixty two consecutive patients admitted to hospital and surviving 6 months were tested regularly over the first 3 months after their stroke to plot recovery in three aspects of cognition: visual neglect, assessed using a cancellation task, attention span assessed using digit span, and verbal recall, tested by counting number of words remembered from a list of 10 words. Normative data were collected for the cancellation test. Fifteen patients showed recovery from visual neglect, 10 improvement in attention span and nine improvement in verbal recall. The difficulties of measuring recovery of cognitive function after stroke are discussed.

Stroke patients consume nearly one-twentieth of all National Health Service resources, and much of this is attributable to the admission of patients with acute strokes to hospital. However, patients rarely need to be admitted for diagnostic or therapeutic reasons, and rehabilitation given in hospital is sometimes inappropriate. The major reason for admission relates to nursing during the acute illness, yet this could be done at home in more cases than at present. It is suggested that rehabilitation services should be more readily available to patients at home, so that fewer need to be admitted and so that those admitted can return home sooner. This might lead to a more appropriate rehabilitation, less anxiety and depression in the patient and his family, and a more efficient use of limited resources.

A prospective study was undertaken to define the incidence, duration, and consequences of dysphagia in an unselected group of 91 consecutive patients who had suffered acute stroke. The site of the present lesion and of any previous stroke was determined clinically and was confirmed by computed tomography of the brain or necropsy in 40 cases. Of 41 patients who had dysphagia on admission, 37 had had a stroke in one cerebral hemisphere. Only seven patients showed evidence of lesions in both hemispheres. Nineteen of 22 patients who survived a stroke in a hemisphere regained their ability to swallow within 14 days. Dysphagia in patients who had had a stroke in a cerebral hemisphere was associated in this study with a higher incidence of chest infections, dehydration, and death.

This is a prospective study of recovery of aphasia in 19 stroke patients selected from 117 consecutive hospital admissions by virtue of having significant aphasia and surviving 13 weeks. Aphasia was measured using the Frenchay Aphasia Screening Test (FAST) at frequent intervals from early after stroke. A wide variation in speed and extent of recovery was seen, particularly when compared with mean scores. Patients who made the most recovery had started to improve by 40 days post-stroke. An aphasic patient's FAST score at 13 weeks post-stroke could be predicted from his first score (within 2 weeks).

Three cases of hand contractures due to Parkinson's disease and possible mechanisms that may be involved in their pathogenesis are described.

In a preliminary study, return of arm function in hemiplegic patients has been assessed for periods up to 64 weeks after stroke using two methods of testing. The first method concerns the performance of simple motor tasks involving the arm and hand. The second method is a pursuit tracking task using elbow movements. Patients were divided into two groups depending on whether they scored above 80% (Group I) or below 80% (Group II) on the first method at 16 weeks after stroke. When the two arm assessment methods were compared with clinical assessments for all the patients, general agreement was shown. Among Group I patients there was also significant agreement between the assessments; among Group II patients the agreement was poor. The two arm assessment methods, however, showed mutual agreement. In conclusion, both arm assessments provide a general prediction of the recovery of movement control of patients following stroke.