Improving post-stroke recovery: the role of the multidisciplinary health care team

Constraint-Induced Movement Therapy Combined With Botulinum Toxin for Post-stroke Spasticity: A Systematic Review and Meta-Analysis

Stroke is considered one of the main causes of adult disability and the second most serious cause of death worldwide. The combination of botulinum toxin type A (BTX) with rehabilitation techniques such as modified constraint-induced movement therapy (mCIMT) has emerged as a highly efficient intervention for stroke patients to start synchronized motor function along with spasticity reduction. The current systematic review and meta-analysis were conducted in order to evaluate the available literature about the safety and efficacy of constraint-induced movement therapy (CIMT) combined with BTX in stroke patients with upper limb spasticity. Searches were conducted on WoS (Web of Science), Ovid, EBSCO-ASC&BSC, and PubMed for identifying relevant literature published from 2000-2020. Randomized Controlled Trials (RCTs) and Quasi-experimental studies were considered for inclusion. Rayyan (systematic review tool) QCRI (Qatar Computing Research Institute) was used for independent screening of the studies by two reviewers. For risk of bias and study quality assessment, Cochrane risk of bias tool (RoB 2) and Physiotherapy Evidence Database (PEDro) scales were used. Cochrane review manager was used to carry out the meta-analyses of the included studies. The search resulted in a total of 13065 references, of which 4967 were duplicates. After the title, abstract and full-text screening, two RCTs were deemed eligible for inclusion. Both the RCTs scored 8 on PEDro and were level evidence. The studies were heterogeneous. The findings of this meta-analysis in all the three joints post-stroke spasticity assessed on modified Ashworth scale (MAS) at four weeks post-injection aren't statistically significant (elbow P-value 0.74, wrist P-value 0.57, fingers P-value 0.42), however, according to one of the included studies the therapeutic efficacy of the combination of BTX-mCIMT injection assessed at four weeks post-injection in wrist and finger flexors was promising.  The effectiveness of BTX-CIMT combination over conventional therapy (CT) for improving post-stroke spasticity still needs to be explored with long-term, multicenter rigorously designed RCTs having a good sample size. However, the BTX-CIMT combination is promising for enhancing motor function recovery and improving activities of daily living (ADLs).

World Café- a community conversation: a Canadian perspective on stroke survivors needs for community integration

Background: Stroke is an acute condition that requires immediate care and long-term community-based chronic care supports. Communities vary in their ability to support the complex needs of this population.Objectives: To bring stroke recovery stakeholders together to discuss the needs of community-based stroke recovery and develop possible solutions across one province in Canada.Methods: The participatory research approach of the World Café was used to explore topics related to community-based stroke recovery. Three World Cafés were held in three communities, including rural, urban-multicultural, and indigenous communities. Sixty-one stakeholders participated in this study. The data was analyzed following an inductive approach for all three Word Cafés.Results: Four main themes were revealed from the data. First, Individual Needs, but Holistic Care encompassed the idea that stroke survivors' needs are complex and changing. Second, Whole of the Community indicated that all the people in stroke survivors' communities should be considered when designing solutions. Third, Transition in Care focused on the needs and solutions during the transition from hospital to community. Lastly, participants emphasized that better Connection, Collaboration, and Communication are needed among all stakeholders.Conclusions: While some similarities in needs and solutions were identified for stroke survivors across three diverse communities, differences between them were also reported. Approaches to enhance better communication among all stakeholders and facilitate a continuous transition from hospital to community are needed. Co-creating solutions with each local community should be considered as individual needs, and challenges are specific to each community.

The Effects of 4 Weeks of Chiropractic Spinal Adjustments on Motor Function in People with Stroke: A Randomized Controlled Trial

Chiropractic spinal adjustments have been shown to result in short-term increases in muscle strength in chronic stroke patients, however, the effect of longer-term chiropractic spinal adjustments on people with chronic stroke is unknown. This exploratory study assessed whether 4 weeks of chiropractic spinal adjustments, combined with physical therapy (chiro + PT), had a greater impact than sham chiropractic with physical therapy (sham + PT) did on motor function (Fugl Meyer Assessment, FMA) in 63 subacute or chronic stroke patients. Secondary outcomes included health-related quality of life and other measures of functional mobility and disability. Outcomes were assessed at baseline, 4 weeks (post-intervention), and 8 weeks (follow-up). Data were analyzed using linear mixed-effects models or generalized linear mixed models. A post-hoc responder analysis was performed to investigate the clinical significance of findings. At 4 weeks, there was a larger effect of chiro + PT, compared with sham + PT, on the FMA (difference = 6.1, p = 0.04). The responder analysis suggested the improvements in motor function seen following chiropractic spinal adjustments may have been clinically significant. There was also a robust improvement in both groups in most measures from baseline to the 4- and 8-week assessments, but between-group differences were no longer significant at the 8-week assessment. Four weeks of chiro + PT resulted in statistically significant improvements in motor function, compared with sham + PT, in people with subacute or chronic stroke. These improvements appear to be clinically important. Further trials, involving larger group sizes and longer follow-up and intervention periods, are required to corroborate these findings and further investigate the impacts of chiropractic spinal adjustments on motor function in post-stroke survivors. ClinicalTrials.gov Identifier NCT03849794.

Role of Telemedicine in Prehospital Stroke Care

PURPOSE OF REVIEW

To summarize evidence for the feasibility and the efficacy of mobile stroke units (MSUs) and telemedicine in the field to reduce time delays in offering acute stroke interventions.

RECENT FINDINGS

A mobile stroke unit is a modified ambulance and includes sophisticated equipment, either trained personnel on board, or connection with skilled physicians via telemedicine. Stroke assessment and treatment agreeability between the on board and remote neurologist is high in MSUs. MSUs are the promising option to reduce stroke symptom onset to treatment time; telemedicine platform has a satisfactory audiovisual quality, high inter-rater reliability for remote stroke symptom assessment, diagnosis, and decision to treat. Use of MSU also avoids the need for inter-hospital transfers. MSUs improve prehospital stroke care and reduce delays in access to intravenous thrombolytic and mechanical thrombectomy in selective markets. Advancement in telecommunication and modern technology has the potential to make MSU telemedicine-aided management more cost-effective. Further research is needed before its widespread implementation.

Development of a Scoring System to Predict Prolonged Post-Stroke Dysphagia Remaining at Discharge from a Subacute Care Hospital to the Home

BACKGROUND

Prolonged dysphagia is an important stroke-related complication that imposes a substantial burden on patients and families. However, simple scoring tool to predict prolonged dysphagia is not existing.

MATERIALS AND METHODS

This retrospective cohort study used data from April 2010 to March 2016. Adult patients with first-ever stroke were included. The outcome was swallowing function at discharge from the subacute care hospital to the patient's home. We collected the following factors obtained at discharge from the University of Fukui Hospital: age, sex, type of stroke, comorbidities, smoking status, alcohol use, denture use, functional dependency in daily living before admission, National Institutes of Health Stroke Scale score (NIHSS) at admission, and Functional Independence Measure(FIM). Data were divided into a training set (70%) and test set (30%). Lasso and logistic regression were used for feature selection, a scoring system was then developed, and its prediction performance evaluated.

RESULTS

This study enrolled 462 patients with acute stroke. Using lasso and logistic regression, three variables (functional dependency before admission, Functional Independence Measure [FIM]-cognitive and FIM-motor scores at transfer) remained statistically significant predictors of prolonged dysphagia. Risk scores were categorized as low risk (0-2), moderate risk (3-4), and high risk (5-7), with dysphagia rates of 0%-1%, 13%-29%, and 50%-100%, respectively. A newly developed score ≥3 was the optimal cutoff for identifying patients with the potential risk of prolonged dysphagia (C-statistics, 0.92 in the test set).

CONCLUSION

The developed scoring system is simple and has a high performance in predicting prolonged dysphagia after acute stroke.

Evidence-based stroke rehabilitation: do priorities for practice change and feasibility of implementation vary across high income, upper and lower-middle income countries?

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.

Prevalence of Balance Impairment and Factors Associated with Balance among Patients with Stroke. A Cross Sectional Retrospective Case Control Study

Stroke is a major cause of disability worldwide, and balance impairments are common disabling factors in patients with stroke, leading to falls. Thus, the study objectives were as follows: (i) To find the prevalence of balance impairment among patients with stroke. (ii) To find out the factors associated with balance impairment in patients with stroke. This cross-sectional retrospective case control study involved eighty-one post stroke patients with a mean age of 58.36 ± 14.06, recruited from six hospitals, who underwent an assessment of balance, walking speed, depression and isometric strength of the ankle and knee. These patients were later categorized into subjects with good balance (<45) in the Berg balance scale (BBS) and those with poor balance (≥45), as cases and controls, to assess the factors associated with balance impairment using binary logistic regression. The prevalence of balance impairment among patients with stroke was 48.1%. The reduction in power of knee flexors (OR = 0.858), knee extensors (OR = 0.880) and ankle dorsiflexors (OR = 0.820) was found to be significantly associated with balance impairment, along with speed (OR = 1.187 (95% CI = 1.100, 1.280)), depression (OR = 1.331 (95% CI = 1.055-1.679)) and activities of daily living (OR = 0.313 (95% CI = 0.150-0.650)). In summary, around half of the patients with stroke exhibited balance impairments, with females being more prone.

Identifying and Responding to Delirium in Acute Stroke: Clinical Team Members' Understandings

Delirium is associated with increased mortality, morbidity, and length of hospital stay. In the acute stroke setting, delirium identification is challenging due to the complexity of cognitive screening in this patient group. The aim of this study was to explore how members of interprofessional stroke-unit teams identified and responded to a potential delirium in a patient. Online focus groups and interviews utilizing case vignettes were conducted with 15 participants: nurses, occupational therapists, speech and language therapists, and physiotherapists working in acute stroke services. Participants' understandings of delirium varied, most participants did not identify the symptoms of a possible hypoactive delirium, and nearly all participants discussed delirium symptoms in tentative terms. Aspects of interprofessional working were discussed through the expression of distinct roles around delirium identification. Although participants demonstrated an ethos of person-focused care, there are ongoing challenges involved in early identification and management of delirium in stroke survivors.

mHealth applications to support caregiver needs and engagement during stroke recovery: A content review

Caregiving in stroke results in severe physical, psychological, and social impacts on the caregiver. Over the past few years, researchers have explored the use of mHealth technologies to support healthcare-related activities due to their ability to provide real-time care at any given place or time. The purpose of this content review is to investigate mHealth apps in supporting stroke caregiving engagement based on three aspects: motivation, value, and satisfaction. We searched app stores and repositories for apps related to stroke caregiving published up to September 2020. Extracted apps were reviewed and filtered using inclusion criteria, and then downloaded onto compatible devices to determine eligibility. Results were compared with evidence-based frameworks to identify the ability of these apps in engaging and supporting the caregiver. Forty-seven apps were included in this review that enabled caregivers to support their needs, such as adjustment to new roles and relationships, involvement in care and caring for oneself using several different functionalities. These functionalities include information resources, risk assessment, remote monitoring, data sharing, reminders and so on. However, no single app was identified that focuses on all aspects of stroke caregiving. We also identified several challenges faced by users through their reviews and the factors associated with value and satisfaction. Our findings can add to the knowledge of existing mHealth technologies and their functionalities to support stroke caregiving needs, and the importance of considering user engagement in the design. They can be used by developers and researchers looking to design better mHealth apps for stroke caregiving.

"It's Difficult, There's No Formula": Qualitative Study of Stroke Related Communication Between Primary and Secondary Healthcare Professionals

Introduction:

Stroke survivors have complex health needs requiring long-term, integrated care. This study aimed to elicit generalists’ and specialists’ experience of stroke-related interprofessional communication, including perceived barriers and enablers.

Design and Setting:

Qualitative study involving generalist (primary care) and specialist services (acute and community) in England. Six focus groups (n = 48) were conducted.

Method:

Healthcare professionals were purposively selected and invited to participate. Audio-recordings were transcribed verbatim and analysed using Framework Analysis.

Results:

Four themes were identified: 1) Generalists and specialists have overlapping roles but are working in silos; 2) Referral decision-making process as influential to generalist-specialist communication; 3) Variable quality of communication; and 4) Improved dialogue between generalist and specialist services.

Conclusions:

Generalists and specialists recognise the need for better communication with each other. Current care is characterised by silo-based working that ignores the contribution of other sectors. Failure to bridge this communication gap will result in people with stroke continuing to experience unmet stroke needs and fragmented care.

Influence of systemic infection and comorbidities on rehabilitation outcomes in severe acquired brain injury

BACKGROUND

Severe infectious complications are a frequent problem in patients with disability due to a severe acquired brain injury. Previous studies reported that the rehabilitation outcome is significantly lower in patients colonized or infected. However, these results could be influenced by comorbidities of those patients admitted in rehabilitation hospital with a lower functional status.

AIM

To explore the influence of systemic infection, in particular concerning multidrug resistant bacteria and analyze the role of comorbidities, as a risk factor for the development of systemic infection, on rehabilitation outcomes in patients with severe brain injury.

DESIGN

This research is a cohort, prospective-observational study, comparing patients with and without systemic infections, in terms of rehabilitation outcomes.

SETTING

An Italian Intensive Care Rehabilitation Department.

POPULATION

A group of 221 patients (mean age: 59 years, range: 16-93 years, 127 males, 94 females) with severe acquired brain injury admitted to rehabilitation hospital.

METHODS

We compared the rehabilitation outcomes between patients with and without a systemic infection (at least a positive blood culture) during the rehabilitation period. A secondary analysis was performed on 70 patients with infection versus 70 patients without infection, matched for functional status at admission. The used clinical scores were: Cumulative Illness Rating Scale for Geriatrics (CIRS-G), Coma Recovery Scale Revised (CRS-R), Glasgow Coma Scale (GCS), Functional Independence Measure (FIM), Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS), Levels of Cognitive Functioning (LCF) administered at admission and discharge. Length of hospitalization and the role of comorbidities were also considered.

RESULTS

The group of patients with systemic infection (in particular due to Gram-negative bacteria) had a significantly lower outcome for 5 out 6 clinical scales and with a more than doubled length of hospitalization (P<0.001). However, these patients with, at least, a positive blood culture resulted having lower functional status at admission. In the secondary analysis, worst outcome was found in patients with positive blood culture in terms of FIM (P=0.033), GOS (P=0.048), and CRS-R (P=0.001).

CONCLUSIONS

Systemic infections during rehabilitation increased the length of hospitalization and reduce the rehabilitative outcomes, even when the analysis was performed on groups matched for the functional status at admission. Moreover, the cardiological and endocrine metabolic comorbidities seem to influence the outcome, without representing a further risk factor for systemic infection.

CLINICAL REHABILITATION IMPACT

The impact of infections during rehabilitation inpatient should be more taken into account, with specific procedures and suitable environments to avoid the diffusions of infections.

Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study

BACKGROUND

The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake.

METHODS

Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups.

RESULTS

Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols.

CONCLUSIONS

Despite initial high 'buy-in' from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).

Stroke systems of care in low-income and middle-income countries: challenges and opportunities

The burden of stroke is higher in low-income and middle-income countries (LMICs) than in high-income countries and is rising. Even though there are global policies and guidelines for implementing stroke care, there are many challenges in setting up stroke services in LMICs. Despite these challenges, there are many models of stroke care available in LMICs-eg, multidisciplinary team care led by a stroke neurologist, specialist-led care by neurologists, physician-led care, hub and spoke models incorporating stroke telemedicine (ie, telestroke), and task sharing involving community health workers. Alternative strategies have been developed, such as reorganising the existing hospital infrastructure by training health professionals to implement protocol-driven care. The future challenge is to identify what elements of organised stroke care can be implemented to make the largest gain. Simple interventions such as swallowing assessments, bowel and bladder care, mobility assessments, and consistent secondary prevention can prove to be key elements to improving post-discharge morbidity and mortality in LMICs.

A protocol for a qualitative synthesis exploring people with stroke, family members, caregivers and healthcare professionals experiences of early supported discharge (ESD) after stroke

Early supported discharge (ESD) facilitates a person with a stroke to be discharged from the acute hospital environment earlier than conventional care to continue their rehabilitation within the home with members of the multi-disciplinary team. A number of quantitative studies have highlighted benefits of ESD including a reduction in the length of inpatient stay, cost savings, as well as reducing long term dependency. This systematic review and qualitative synthesis explores the perspectives and experiences of those involved in ESD including people with stroke, family members, caregivers as well as the healthcare professionals involved in the delivery of the service. A comprehensive literature search will be completed in the following databases CINAHL, PubMed Central, Embase, Medline, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journals, The Cochrane Library, PsycARTICLES and Scopus. Qualitative or mixed methods studies that include qualitative data on the perspectives and experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service will be included. Methodological quality will be appraised using the ten-item Critical Appraisal Skills Programme checklist for qualitative research by two independent reviewers with a third reviewer involved should differences of opinion arise. Findings will be synthesised using thematic synthesis.    It is anticipated that the qualitative synthesis will provide a deeper understanding of the experiences of ESD which may serve to inform practice as well as assist in the development of new ESD services. PROSPERO registration: CRD42020135197 - 28/04/2020.

Cardiorespiratory strain during stroke rehabilitation: Are patients trained enough? A systematic review

BACKGROUND

Rehabilitation is a mandatory component of stroke management, aiming to recover functional capacity and independence. To that end, physical therapy sessions must involve adequate intensity in terms of cardiopulmonary stress to meet the physiological demands of independent living.

OBJECTIVE

The aim of this systematic review was to determine the current level of cardiopulmonary strain during rehabilitation sessions in stroke patients.

METHODS

Three electronic databases (PubMed, CINAHL and Embase. com) were searched to identify observational studies that documented cardiopulmonary strain during rehabilitation sessions in post-stroke patients (last search performed in February 2019). A manual cross-referencing search was also performed. To be included, articles needed to report data related to both cardiopulmonary strain (heart rate, oxygen consumption or energy expenditure) and active therapy time. The methodological quality of each study was assessed with the Evidence-Based Librarianship Critical Appraisal Tool. Data related to both cardiorespiratory strain and active therapy time were extracted from selected articles.

RESULTS

Four of 43 full-text articles assessed for eligibility met the inclusion criteria. Results extracted from these articles suggested that the intensity of rehabilitation sessions was insufficient to induce a cardiopulmonary training effect in a post-stroke context as measured by metabolic stress. Patients were inactive from 21% to 80% of the therapy time. The Evidence-Based Librarianship tool scores ranged from 65% (15/23) to 91% (21/23), which indicates questionable to good quality.

CONCLUSION

The current literature on cardiopulmonary solicitation during stroke rehabilitation sessions is poor in terms of both the number of studies available and their methodological quality. Summarized results tend to support previous claims that rehabilitation sessions offered to stroke patients are of suboptimal cardiopulmonary strain, which can interfere with their capacity to regain functional independence.

Incidence of stroke in the diabetic compared with the non-diabetic population: A systematic review protocol

People with diabetes have a largely increased risk of stroke compared with people without diabetes. Exact data on incidence of stroke in people with and without diabetes are important for improvements in preventive diabetes care, avoidance of fatal outcomes and as a solid basis for health policy and the economy. However, published data are conflicting, underlining the necessity for this systematic review of population-based studies on incidence, relative risks (RRs) and changes in stroke rates over time. The purpose of our review is to evaluate the incidence of stroke in the diabetic population and its differences with regard to sex, ethnicity, age and regions; to compare the incidence rate (IR) in the diabetic and non-diabetic populations and to investigate time trends. We will perform a systematic literature search in MEDLINE, Embase and LILACS designed by an experienced information scientist. Two review authors will independently screen the abstracts and full texts of all references on the basis of inclusion criteria regarding types of study, types of population and the main outcome. Data extraction and assessment of risk of bias will be undertaken by two review authors working independently. We will assess IR or cumulative incidence (CumI) and RR of stroke comparing the diabetic and non-diabetic populations. The attributable risk (AR = proportion of stroke among persons with diabetes that is attributable to diabetes) and the population attributable risk (PAR = proportion of stroke in the whole population that is attributable to diabetes) will be considered where available. In conclusion, this review will help to summarize the available evidence for incidence of stroke in the diabetic and nondiabetic population. The publication of this protocol will contribute to making the search strategy, methods, and assessment of reviews transparent and accessible for all involved professional groups.

A co-production approach guided by the behaviour change wheel to develop an intervention for reducing sedentary behaviour after stroke

Background

Stroke survivors are highly sedentary; thus, breaking up long uninterrupted bouts of sedentary behaviour could have substantial health benefit. However, there are no intervention strategies specifically aimed at reducing sedentary behaviour tailored for stroke survivors. The purpose of this study was to use co-production approaches to develop an intervention to reduce sedentary behaviour after stroke.

Methods

A series of five co-production workshops with stroke survivors, their caregivers, stroke service staff, exercise professionals, and researchers were conducted in parallel in two-stroke services (England and Scotland). Workshop format was informed by the behaviour change wheel (BCW) framework for developing interventions and incorporated systematic review and empirical evidence. Taking an iterative approach, data from activities and audio recordings were analysed following each workshop and findings used to inform subsequent workshops, to inform both the activities of the next workshop and ongoing intervention development.

Findings

Co-production workshop participants (n = 43) included 17 staff, 14 stroke survivors, six caregivers and six researchers. The target behaviour for stroke survivors is to increase standing and moving, and the target behaviour for caregivers and staff is to support and encourage stroke survivors to increase standing and moving. The developed intervention is primarily based on co-produced solutions to barriers to achieving the target behaviour. The developed intervention includes 34 behaviour change techniques. The intervention is to be delivered through stroke services, commencing in the inpatient setting and following through discharge into the community. Participants reported that taking part in intervention development was a positive experience.

Conclusions

To our knowledge, this is the first study that has combined the use of co-production and the BCW to develop an intervention for use in stroke care. In-depth reporting of how a co-production approach was combined with the BCW framework, including the design of bespoke materials for workshop activities, should prove useful to other researchers and practitioners involved in intervention development in stroke.

Methodological Quality of Physical Therapy Guidelines and Their Suitability for Adaptation: A Scoping Review

OBJECTIVE

Clinical practice guidelines (CPGs) can be characterized to the extent that they specifically address physical therapists and mainly contain recommendations for physical therapist interventions. The primary aim of this study was to identify existing physical therapy CPGs regardless of medical condition, with a secondary aim of assessing their methodological quality to determine whether they are potentially suitable for adaptation.

METHODS

Systematic searches of the Medline and Physiotherapy Evidence Database were performed (August 2019), and the websites of World Confederation for Physical Therapy members were screened (September 2019). Only CPGs published in German or English were included. Two independent reviewers screened records according to previously defined inclusion criteria. Information was extracted regarding country of origin, year of publication, and clinical subject area addressed. Four independent reviewers assessed the quality of physical therapy CPGs using the Appraisal of Guidelines Research and Evaluation instrument. A descriptive data analysis was performed.

RESULTS

Thirty-five CPGs met the inclusion criteria; 46% (16/35) of the included CPGs were from the United States, and 31% (11/35) were from the Netherlands. Assessment using the Appraisal of Guidelines Research and Evaluation tool resulted in the following domain scores, presented as median percentage (interquartile range): domain 1 (scope and purpose), 76 (63-92); domain 2 (stakeholder involvement), 63 (55-76); domain 3 (rigor of development), 67 (53-75); domain 4 (clarity of presentation), 74 (67-77); domain 5 (applicability), 44 (30-57); and domain 6 (editorial independence), 52 (35-66).

CONCLUSIONS

In general, the methodological quality of the included CPGs was moderate to good. Possibilities of adapting recommendations from existing CPGs should be considered with the development of new physical therapy CPGs.

IMPACT STATEMENT

This study can raise awareness of existing physical therapy CPGs and can support their application by physical therapists. Further, the study can support decisions on adapting existing CPGs with the planning of new physical therapy CPGs.

The physical environment and multi-professional teamwork in three newly built stroke units

PURPOSE

To explore multi-professional teamwork in relation to the physical environment in three newly built or renovated stroke units.

MATERIALS AND METHODS

An observational study was undertaken. The participants were all staff members of a multi-professional team working in the reviewed stroke units. The data were collected using behavioural mapping and semi-structured observations, and they were analysed by content analysis and descriptive statistics.

RESULTS

Out of all the observations in the behavioural mapping, very few were of two or more members from the team together with a patient. None of the included stroke units had a co-location for all the members of the multi-professional team. Three main categories emerged from the analysis of the interviews: (i) the hub of the unit; (ii) the division of places; and (iii) power imbalance. All the categories reflected the teamwork in relation to parts of the physical environment.

CONCLUSION

The design of the physical environment is important for multi-professional teamwork. Emphasis must be placed on better understanding the impact of the physical environment and on incorporating the evidence related to multi-professional teamwork during the design of stroke units.IMPLICATIONS FOR REHABILITATIONUnderstanding the link between the physical environment and effective teamwork can lead to more tailored and supportive design solutions.The design of the physical environment should be considered as a vital part of effective teamwork in stroke units.The physical environment should include shared workstations, allowing team members to meet and communicate face to face.

Friendships after severe traumatic brain injury: a survey of current speech pathology practice

OBJECTIVE

To investigate current speech pathology practice regarding working with friends.

METHOD

An online survey was conducted with 68 speech pathologists who worked with TBI across metropolitan and rural settings in Australia. The survey investigated the reasons speech pathologists work with friends, barriers to working with friends and perceptions of successful friendships post TBI. Descriptive statistics and content analysis of open ended responses were used to analyze the data.

RESULTS

There were more speech pathologists (40%) who did not include friends compared to those who did. Friends were most commonly included in the rehabilitation process, through the provision of education programs. The primary rationale for working with friends was to prevent negative psychosocial outcomes for the person with TBI. There were numerous barriers to working with friends, most commonly the inability to access friends.

CONCLUSIONS

Making and keeping friends are a significant part of most people's lives. Therefore, it is important to consider their role in contributing to improved outcomes for people with TBI. With communication partner training being an integral component to recovery and maintenance of relationships post TBI, the development of targeted education and training materials is warranted, to enable the inclusion of friends in the rehabilitation process.

Emotional stimulation during motor exercise: An integration to the holistic rehabilitation framework

Over the recent years, plenty of studies have been carried out concerning disabilities and rehabilitation. However, very few of them have focused on proposing or creating a holistic framework meant to maximize the merits of rehabilitation treatments. More importantly, an even smaller number has taken into consideration the immense impact of emotions and the crucial role they display concerning patients' performance during rehabilitation. The purpose of this study is to examine and highlight the direct connection of patients' performance quality with an artificially induced positive or negative emotional state. For that reason, we conducted an experiment regarding the convergence of emotions with the motor exercise. Specifically, our study was conducted with 45 participants and the GAPED database was employed as an emotional classifier. The effect of the visual stimulus was combined with a simple bicep exercise which introduces the motor element in our study. Statistical analysis of the yielding EMG & Acellerometer signals demonstrated a considerable difference in the quality of the physical activity of each subject induced by different emotional triggers. As a result, it is pivotal to integrate a holistic approach to rehabilitation in future clinical trials, aiming to reinforce the patient involvement and engagement process and thus the efficacy of the treatment.

The development of a return to work intervention programme for stroke survivor (SReTWIP): a Delphi survey

BACKGROUND

Even though clearly defined pathways for vocational re-entry are well recognized for conditions such as mental health, musculoskeletal dysfunction (MSD) and traumatic brain injury (TBI), none has been identified for stroke. There has been a lack of consensus regarding such clear pathways to vocational re-entry and the essential contents of return to work (RTW) interventions for stroke survivors. As part of a larger study aimed to design a RTW programme for stroke survivors, this study describes the concluding process through which Stroke Return to Work Intervention Programme (SReTWIP) was developed.

METHODS

Experts in the field of neurorehabilitation and vocational rehabilitation (VR) from 6 countries participated in this 3-round Delphi survey via e-mail. Concept mapping was used to triangulate findings from the Delphi with previous phases of the larger study. Content thematic analysis was conducted on qualitative data while descriptive statistic was used to analyze quantitative data.

RESULTS

Fifteen experts with a mean age and mean duration of practice of 44.73 ± 9.48 years and 18.26 ± 8.71 years respectively participated in this study. The developed RTW programme (SReTWIP) is a 12 week programme that consisted of four interconnected phases of intervention viz.: an assessment phase, clinic-based work and non-work specific intervention phase, a work test placement phase and a client full participation in worker role phase. The experts agreed on a set of implementation strategies that included the use of interdisciplinary team, the tailoring of intervention to meet stroke survivor's need, as well as the use of case management approach.

CONCLUSION

The SReTWIP is the first step in developing a VR pathway that can ultimately enhance the RTW rates and quick resumption of the worker role of stroke survivors. The stroke survivor can move along the different phases of the SReTWIP after achieving competency in a preceding phase. Future work will include a feasibility study with other key stakeholders involved in RTW such as employers, informal caregivers and stroke survivors before its implementation.

A multifaceted continuing professional development intervention to move stroke rehabilitation guidelines into professional practice: A feasibility study

INTRODUCTION

Rehabilitation post-stroke is critical for maximizing patient outcomes. This study assessed the feasibility of implementing and evaluating a continuing professional development (CPD) intervention aimed at increasing the uptake of stroke best practice guidelines among physiotherapists (PTs), occupational therapists (OTs) and speech-language pathologists (SLPs) in six university-affiliated stroke rehabilitation centers in Quebec, Canada.

METHOD

Twelve stroke best practice recommendations with reflective tools were sent weekly by e-mail. Participants' eligibility criteria included: a) profession; b) practicing more than 1 year in a stroke rehabilitation program; c) fluency in French or English; and d) basic computer literacy. Feasibility (operationalized via participation, satisfaction and relevance), cognitive impact, perceived application in practice and expected patient outcomes were measured over 24 weeks using three questionnaires and analyzed using descriptive statistics.

RESULTS

The sample totaled 62 of 133 eligible (47%) clinicians. Satisfaction, relevance and cognitive impact of delivered information varied across disciplines and recommendations. Agreement with the recommendations was high across disciplines. On average, three-interdisciplinary recommendations (related to post-stoke depression, post-stoke fatigue and patients' and caregivers' learning needs) were rated as the most relevant for at least one patient. The majority of clinicians would use the recommendations for a specific patient and expected health benefits by applying those recommendations.

CONCLUSION

This study demonstrated the feasibility of assessing the impact of a CPD intervention in stroke rehabilitation uptake and informed the design of a research program aimed at increasing the use of stroke evidence-based rehabilitation interventions.

The impact of a patient-directed activity program on functional outcomes and activity participation after stroke during inpatient rehabilitation—a randomized controlled trial

Objective:

Individuals post stroke are inactive, even during rehabilitation, contributing to ongoing disability and risk of secondary health conditions. Our aims were to (1) conduct a randomized controlled trial to examine the efficacy of a “Patient-Directed Activity Program” on functional outcomes in people post stroke during inpatient rehabilitation and (2) examine differences three months post inpatient rehabilitation discharge.

Design:

Randomized control trial.

Setting:

Inpatient rehabilitation facility.

Subjects:

Patients admitted to inpatient rehabilitation post stroke.

Interventions:

Patient-Directed Activity Program (PDAP) or control (usual care only). Both groups underwent control (three hours of therapy/day), while PDAP participants were prescribed two additional 30-minute activity sessions/day.

Main measures:

Outcomes (Stroke Rehabilitation Assessment of Movement Measure, Functional Independence Measure, balance, physical activity, Stroke Impact Scale) were collected at admission and discharge from inpatient rehabilitation and three-month follow-up.

Results:

Seventy-three patients (PDAP ( n = 37); control ( n = 36)) were included in the primary analysis. Patients in PDAP completed a total of 23.1 ± 16.5 sessions (10.7 ± 8.5 upper extremity; 12.4 ± 8.6 lower extremity) during inpatient rehabilitation. No differences were observed between groups at discharge in functional measures. PDAP completed significantly more steps/day (PDAP = 657.70 ± 655.82, control = 396.17 ± 419.65; P = 0.022). The Stroke Impact Scale showed significantly better memory and thinking (PDAP = 86.2 ± 11.4, control = 80.8 ± 16.7; P = 0.049), communication (PDAP = 93.6 ± 8.3, control = 89.6 ± 12.4; P = 0.042), mobility (PDAP = 62.2 ± 22.5, control = 53.8 ± 21.8; P = 0.038), and overall recovery from stroke (PDAP = 62.1 ± 19.1, control = 52.2 ± 18.7; P = 0.038) for PDAP compared to control. At three months post discharge, PDAP ( n = 11) completed significantly greater physical activity ( P = 0.014; 3586.5 ± 3468.5 steps/day) compared to control ( n = 10; 1760.9 ± 2346.3 steps/day).

Conclusion:

Functional outcome improvement was comparable between groups; however, PDAP participants completed more steps and perceived greater recovery.

Two-year safety and clinical outcomes in chronic ischemic stroke patients after implantation of modified bone marrow-derived mesenchymal stem cells (SB623): a phase 1/2a study

OBJECTIVE

The aim of this study was to evaluate the safety and clinical outcomes associated with stereotactic surgical implantation of modified bone marrow-derived mesenchymal stem cells (SB623) in patients with stable chronic ischemic stroke.

METHODS

This was a 2-year, open-label, single-arm, phase 1/2a study; the selected patients had chronic motor deficits between 6 and 60 months after nonhemorrhagic stroke. SB623 cells were administered to the target sites surrounding the subcortical stroke region using MRI stereotactic image guidance.

RESULTS

A total of 18 patients were treated with SB623 cells. All experienced at least 1 treatment-emergent adverse event (TEAE). No patients withdrew due to adverse events, and there were no dose-limiting toxicities or deaths. The most frequent TEAE was headache related to the surgical procedure (88.9%). Seven patients experienced 9 serious adverse events, which resolved without sequelae. In 16 patients who completed 24 months of treatment, statistically significant improvements from baseline (mean) at 24 months were reported for the European Stroke Scale (ESS) score, 5.7 (95% CI 1.4-10.1, p < 0.05); National Institutes of Health Stroke Scale (NIHSS) score, -2.1 (95% CI -3.3 to -1.0, p < 0.01), Fugl-Meyer (F-M) total score, 19.4 (95% CI 9.9-29.0, p < 0.01); and F-M motor scale score, 10.4 (95% CI 4.0-16.7, p < 0.01). Measures of efficacy reached plateau by 12 months with no decline thereafter. There were no statistically significant changes in the modified Rankin Scale score. The size of transient lesions detected by T2-weighted FLAIR imaging in the ipsilateral cortex at weeks 1-2 postimplantation significantly correlated with improvement in ESS (0.619, p < 0.05) and NIHSS (-0.735, p < 0.01) scores at 24 months.

CONCLUSIONS

In this completed 2-year phase 1/2a study, implantation of SB623 cells in patients with stable chronic stroke was safe and was accompanied by improvements in clinical outcomes.Clinical trial registration no.: NCT01287936 (clinicaltrials.gov).

Stroke survivors' experiences of team support along their recovery continuum

Background

A coordinated stroke rehabilitation care team is considered optimal for supporting stroke survivors from diagnosis to recovery. Despite this recognition, many stroke survivors cannot access essential rehabilitation services. Furthermore, there is a lack of understanding of stroke patients’ and their caregivers’ rehabilitation needs and wishes. We sought to gain insight into healthcare and social structures from the perspective of patients and caregivers that can better support long-term stroke recovery.

Methods

We conducted individual interviews with 24 participants comprised of stroke survivors, spousal caregivers, stroke support group coordinators, and speech pathologist. Participants were recruited through three stroke survivor support groups. An empowerment lens was integrated into data analysis and data interpretation.

Results

Two dominant themes captured participants’ experiences through stroke survivors’ trajectory of care. 1) Experiences of managing stroke. This theme identified stroke survivors and spousal caregivers’ experiences with stroke recovery, rehabilitation, and fulfilling unmet needs. 2) Resources of support. This theme described the social and financial support structures drawn upon to assist with stroke rehabilitation.

Conclusions

The study highlighted a lack of teamwork between stroke survivors, spousal caregivers, and health professionals. This fragmented care was compounded by inequities in rehabilitation programs and health services resulting in what appeared to be a disempowering rehabilitation process. Although stroke recovery groups were a significant source of support for stroke survivors and spousal caregivers, participants perceived they were overlooked, by stroke recovery healthcare providers, as a site for stroke recovery healthcare services. An empowerment approach to stroke rehabilitation involves collaboration between stroke survivors, caregivers, healthcare providers, health services, and existing community stroke support structures. Framing stroke based care through an empowerment lens may serve to address stroke rehabilitation inadequacies and inequities.

Predictors of prolonged hospital stay in a Comprehensive Stroke Unit

OBJECTIVE

to analyze the in-hospital complications of prolonged hospital stay in patients with ischemic stroke or transient ischemic attack, admitted to the stroke unit of a tertiary hospital.

METHOD

this is an evaluative correlational study. All first-ever ischemic stroke or transient ischemic attack patients admitted were retrospectively analyzed. During hospital stay, the predictors of long-term hospitalization considered were: 1) clinical complications (pneumonia, urinary tract infection, pressure damage and deep vein thrombosis), and 2) neurological complications (malignant ischemic stroke and symptomatic hemorrhagic transformation).

RESULTS

353 patients were discharged in the study period. Mean age was 64.1±13.7 years old and 186 (52.6%) were men. The mean time of hospital stay was 13.7±14.3 days. Pneumonia (25.3±28.8 days, p<0.001), urinary tract infection (32.9±45.2 days, p<0.001) and malignant stroke (29.1±21.4 days, p<0.001) increased significantly the length of hospital stay compared to patients without any complications (11.2±7.1 days).

CONCLUSION

this study showed that three complications delayed hospital discharge in patients admitted in a stroke unit, two preventable ones: pneumonia and urinary tract infection. More intense measures to avoid them should be included in the performance indicators to reduce the length of hospital stay in stroke units.

Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls

Acute brain ischemia causes changes in several neural networks and related cortico-subcortical excitability, both in the affected area and in the apparently spared contralateral hemisphere. The modulation of these processes through modern techniques of noninvasive brain stimulation, namely repetitive transcranial magnetic stimulation (rTMS), has been proposed as a viable intervention that could promote post-stroke clinical recovery and functional independence. This review provides a comprehensive summary of the current evidence from the literature on the efficacy of rTMS applied to different clinical and rehabilitative aspects of stroke patients. A total of 32 meta-analyses published until July 2019 were selected, focusing on the effects on motor function, manual dexterity, walking and balance, spasticity, dysphagia, aphasia, unilateral neglect, depression, and cognitive function after a stroke. Only conventional rTMS protocols were considered in this review, and meta-analyses focusing on theta burst stimulation only were excluded. Overall, both HF-rTMS and LF-rTMS have been shown to be safe and well-tolerated. In addition, the current literature converges on the positive effect of rTMS in the rehabilitation of all clinical manifestations of stroke, except for spasticity and cognitive impairment, where definitive evidence of efficacy cannot be drawn. However, routine use of a specific paradigm of stimulation cannot be recommended yet due to a significant level of heterogeneity of the studies in terms of protocols to be set and outcome measures that have to be used. Future studies need to preliminarily evaluate the most promising protocols before going on to multicenter studies with large cohorts of patients in order to achieve a definitive translation into daily clinical practice.

What do speech-language pathologists describe as most important when trying to achieve client participation during aphasia rehabilitation? A qualitative focus group interview study

Purpose: The aim of this study was to investigate what speech-language pathologists describe as most important when trying to achieve client-oriented participation during aphasia rehabilitation. Method: A qualitative study including semi-structured focus group interviews with 11 speech-language pathologists. Interviews were analysed with the use of systematic text condensation. Result: Four main themes emerged from the analysis. (1) It is important to take the vulnerability of the client group into account. (2) It is important to address the client's process of realisation by navigating around unrealistic wishes and goals. (3) It is challenging to involve clients when the evidence-base for clinical practice is limited. (4) It is crucial to make therapy meaningful to the client. Conclusion: This study showed that speech-language pathologists perceived prediction of a clinical course in aphasia rehabilitation as challenging due to the vulnerable client group and the perceived need to guide the clients through the rehabilitation process. They talked about how unrealistic client goals, and the lack of a solid evidence-base to guide their clinical practice, made collaborative goal setting and treatment planning challenging. Due to these barriers, the speech-language pathologists struggled to achieve client participation, and thereby aphasia rehabilitation could not be described as fully client-oriented.

Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls

Acute brain ischemia causes changes in several neural networks and related cortico-subcortical excitability, both in the affected area and in the apparently spared contralateral hemisphere. The modulation of these processes through modern techniques of noninvasive brain stimulation, namely repetitive transcranial magnetic stimulation (rTMS), has been proposed as a viable intervention that could promote post-stroke clinical recovery and functional independence. This review provides a comprehensive summary of the current evidence from the literature on the efficacy of rTMS applied to different clinical and rehabilitative aspects of stroke patients. A total of 32 meta-analyses published until July 2019 were selected, focusing on the effects on motor function, manual dexterity, walking and balance, spasticity, dysphagia, aphasia, unilateral neglect, depression, and cognitive function after a stroke. Only conventional rTMS protocols were considered in this review, and meta-analyses focusing on theta burst stimulation only were excluded. Overall, both HF-rTMS and LF-rTMS have been shown to be safe and well-tolerated. In addition, the current literature converges on the positive effect of rTMS in the rehabilitation of all clinical manifestations of stroke, except for spasticity and cognitive impairment, where definitive evidence of efficacy cannot be drawn. However, routine use of a specific paradigm of stimulation cannot be recommended yet due to a significant level of heterogeneity of the studies in terms of protocols to be set and outcome measures that have to be used. Future studies need to preliminarily evaluate the most promising protocols before going on to multicenter studies with large cohorts of patients in order to achieve a definitive translation into daily clinical practice.

Computed tomography perfusion in detecting malignant middle cerebral artery infarct

Background:

Computed tomography perfusion (CTP) is an emerging modality which produces maps of time-to- peak (TTP), cerebral blood flow (CBF), and cerebral blood volume (CBV), with a computerized automated map of the infarct and penumbra. This modality provides a better evaluation of the extent of infarction, making it a potential method for assessing patients suffering from large middle cerebral artery (MCA) infarctions.

Methods:

A prospective cohort study of all patients in Hospital Kuala Lumpur, Malaysia, who presented with the clinical diagnosis of a large MCA infarction within 48 h of onset were subjected to CT brain, and CTP scans on admission and were followed up to determine the development of malignant infarction requiring surgical decompression.

Results:

CTP parameters were generally lower in patients with malignant brain infarct (MBI) group compared to the nonMBI group. The largest mean difference between the group was noted in the TTP values (P = 0.005). CTP parameters had a comparable positive predictive value (83%–90%) and high net present value (88–93). CBF with cutoff value of >32.85 of the hemisphere could accurately predict malignant infarctions in 81.4% of cases. The National Institutes of Health Stroke Scale score of more than 13.5 was also found to be able to accurately determine malignant infarct (97.6%). Functional outcome of patients based on Glasgow outcome scale was similar on discharge, however, showed improvement at 6 months during reviewed base on modified Rankin scale (P < 0.001).

Conclusion:

CTP parameters should be included in the initial evaluation of patients to predict malignant brain infarction and facilitate surgical treatment of large MCA infarctions.

Key messages:

CT perfusion parameters have an important role in predicting malignant brain infarction and should be included in the initial evaluation of patients to facilitate the early identification and surgical treatment of large middle cerebral artery infarctions, to improve patient’s prognosis.

Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit

Objectives:

To evaluate the effectiveness of an early mobility protocol for stroke patients in the intensive care unit.

Methods:

Participants were patients with first or recurrent stroke (n=60, age=49.02±6.36 years, body mass index=32.95±5.67 kg/m²) admitted to the intensive care stroke unit in general hospitals, Riyadh during October and December 2016. Single group pretest-posttest design involving an early mobility protocol was started within first 24 hours admission. Pre and post measurements of muscle strength, pulmonary function and quality of life were carried out.

Results:

There were significant improvements in muscle strength of upper and lower extremities´ muscles after treatment (p<0.05), pulmonary functions including Forced Vital Capacity, Forced Expiratory Volume 1 (p<0.05) and quality of life, namely, Barthel Index and modified Rankin Scale (p<0.01).

Conclusion:

This study demonstrates that initiating an early mobility protocol is safe and effective for intensive care unit stroke patients and supports introducing the current protocol as a standard protocol in neurogenic Intensive Care Units.

The effects of a single session of chiropractic care on strength, cortical drive, and spinal excitability in stroke patients

The objective of this study was to investigate whether a single session of chiropractic care could increase strength in weak plantar flexor muscles in chronic stroke patients. Maximum voluntary contractions (strength) of the plantar flexors, soleus evoked V-waves (cortical drive), and H-reflexes were recorded in 12 chronic stroke patients, with plantar flexor muscle weakness, using a randomized controlled crossover design. Outcomes were assessed pre and post a chiropractic care intervention and a passive movement control. Repeated measures ANOVA was used to asses within and between group differences. Significance was set at p < 0.05. Following the chiropractic care intervention there was a significant increase in strength (F (1,11) = 14.49, p = 0.002; avg 64.2 ± 77.7%) and V-wave/Mmax ratio (F(1,11) = 9.67, p = 0.009; avg 54.0 ± 65.2%) compared to the control intervention. There was a significant strength decrease of 26.4 ± 15.5% (p = 0.001) after the control intervention. There were no other significant differences. Plantar flexor muscle strength increased in chronic stroke patients after a single session of chiropractic care. An increase in V-wave amplitude combined with no significant changes in H-reflex parameters suggests this increased strength is likely modulated at a supraspinal level. Further research is required to investigate the longer term and potential functional effects of chiropractic care in stroke recovery.

[Dynamics of mortality rates in different types of stroke in the territories included in the Federal program of reorganization of care for stroke patients]

AIM

To study and analyze the dynamics of one-day, 7-day and 28-day mortality rates in different types of stroke.

MATERIAL AND METHODS

The retrospective study was based on the data of the territorial population register for 2009-2016 from seven territories of the Russian Federation in which the Federal program of reorganization of care for stroke patients came into force in 2009. The study population included men and women, aged 25 years and older, registered in the study area. A total of 29.779 stroke cases were identified. The mortality rate was calculated as the ratio of the number of stroke cases that ended fatally to the number of stroke cases per year. The dynamics of the mortality rate of the following types of stroke was analyzed: subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and ischemic stroke (IS).

RESULTS

Between 2009 and 2010, there was an increase in SAH one-day, 7-day and 28-day mortality rates and in ICH one-day, 7-day mortality rates. In the period from 2009 to 2010, the increased ICH 28-day mortality rates tended to increase, while the IS one-day, 7-day and 28-day mortality rates decreased. One-day, 7-day and 28-day mortality rates in SAH, ICH, IS had a declining trend from 2010 to 2016. A slight increase in SAH one-day mortality rate in 2014 and 2015 and SAH 7-day mortality rate in 2013 was observed. The same trend was noted for ICH mortality rates in 2013 and 2016 and in 2013, respectively. The IS one-day, 7-day and 28-day mortality rates slightly increased in 2014.

CONCLUSION

According to the territorial-population register from 2009 to 2016, a significant decrease in one-day, 7-day and 28-day mortality rates in all types of stroke in the studied territories was registered. There is no doubt that this is due to the successful implementation of the Federal program of reorganization of care for stroke patients carried out in this period in the territories included in the study.

"In Safe Hands" - A costly integrated care program with limited benefits in stroke unit care

Given reported favourable outcomes of accountable care unit models of health care delivery (Taylor et al., 2017; Stein et al., 2015; Kara et al., 2015), the Clinical Excellence Commission of NSW has embraced "In Safe Hands" (ISH) to enhance coordination of care. ISH embraces the structured interdisciplinary bedside round (SIBR) component, for which reported outcomes include reduced length of stay (Taylor et al., 2017; Stein et al., 2015; Kara et al., 2015), possible reduction in overall costs of care (Kara et al., 2015), and enhanced patient and staff satisfaction (O'Leary et al., 2011). It is not yet clear whether the benefits of such a model are translatable to the Australian Health Care System (Hunyh et al., 2016) and/or established units with an already strong multi-disciplinary approach to patient care. The purpose of this prospective cohort study of 200 participants was to assess the effect(s) of implementation of ISH in a stroke unit of a tertiary hospital in Sydney, Australia. Data on length of stay, re-admission rates, adverse events, as well as patient and nursing satisfaction, were collected pre and post implementation. There was no significant difference in length of stay in median days (5 (IQR 2-7) versus 4 (IQR 2-6), P = 0.55) or incidence of adverse events (10% versus 12%, P = 0.82). Stroke outcome disability scores were not affected by the intervention. There were no significant differences overall in reported patient and nursing satisfaction. Implementation of the ISH program cost approximately AUD$ 1805/week (USD$ 1365) in wages. The ISH program was a costly intervention of limited benefit in a well-established acute stroke unit. We here discuss potential reasons for the failure of this intervention to achieve its primary aim in this setting.

Municipal Cross-Disciplinary Rehabilitation following Stroke in Denmark and Norway: A Qualitative Study

AIM

To explore and compare the content of rehabilitation practices in, respectively, a Danish and a Norwegian region, focusing on how the citizens' rehabilitation needs are met during rehabilitation in the municipalities.

METHOD

Six Danish and five Norwegian cases were followed 12 months after the onset of stroke. Field work and focus group interviews with multidisciplinary teams in the municipalities were conducted. The conceptual frame of the International Classification of Functioning was used to outline general patterns and local variation in the rehabilitation services.

FINDINGS

Each of the settings faces different challenges and opportunities in the provision of everyday life-supportive rehabilitation services. Rehabilitation after stroke in both settings basically follows the same guidelines, but the organization of rehabilitation programmes is more specialized in Denmark than in Norway. Team organization, multidisciplinarity, and collaboration to assess and target the patients' needs characterized the Danish rehabilitation services. Decentralized coordination and monodisciplinary contributions with scarce or unsystematic collaboration were common in the Norwegian cases. Seamless holistic rehabilitation was challenged in both countries, but more notably in Norway. The municipal services emphasized physical functioning, which could conflict with the patients' needs. Cognitive disturbances to and aspects of activity or participation were systematically addressed by the interdisciplinary teams in Denmark, while practitioners in Norway found that these disturbances were scarcely addressed.

DISCUSSION

The study showed major differences in municipal stroke rehabilitation services in the Northern Norway and Central Denmark Regions-in their ability to conduct everyday life-supportive rehabilitation services. Despite the fact that biopsychosocial conceptions of disease and illness, as recommended in the ICF, have been generally accepted, they seemed scarcely implemented in the political and health managerial arenas, especially in Norway. These national diversities can partly be explained by the size of the municipalities and the available health profiles in delivering patient and family-centred rehabilitation services.

Situational Analysis: Community Care for Survivors of Stroke and Suggestions for Improving the Provision of Care

This descriptive qualitative study aimed to analyze the community care situation for survivors of stroke and provide suggestions for improving care. The study was conducted in a district of Chiang Mai Province. Purposive sampling was employed based on inclusion criteria to select 51 key informants comprised of 1) three health personnel, 2) 13 community leaders, 3) three local government officers, 4) 13 village health volunteers, and 5) 13 caregivers who took care of survivors of stroke. The data collection consisted of in-depth interviews and focus group discussions, based on the Expanded Chronic Care Model. Data were analyzed by content analysis. The results revealed that community care for survivors of stroke is mainly provided by family members. As well, our analysis revealed for survivors: 1) inadequate personal skills among caregivers and volunteers; 2) inefficient health services; 3) the lack of support for a caring system; 4) incomplete clinical information system; 5) no healthy public policy; and 6) lack of a supportive environment. We suggest that, to improve the care available to survivors of stroke, there needs to be: 1) development of supportive policies at both national and local government levels; 2) development and provision of guidelines for the care; and 3) a supportive caring system that includes health personnel, caregivers, and rehabilitation facilities, as well as support for the home and community-based environment. These results and suggestions will be useful to community nurses and stakeholders who are responsible to design caring for survivors of stroke.

Fundamental care guided by the Careful Nursing Philosophy and Professional Practice Model©

AIMS AND OBJECTIVES

To propose the Careful Nursing Philosophy and Professional Practice Model^© as a conceptual and practice solution to current fundamental nursing care erosion and deficits.

BACKGROUND

There is growing awareness of the crucial importance of fundamental care. Efforts are underway to heighten nurses' awareness of values that motivate fundamental care and thereby increase their attention to effective provision of fundamental care. However, there remains a need for nursing frameworks which motivate nurses to bring fundamental care values to life in their practice and strengthen their commitment to provide fundamental care.

DESIGN

This descriptive position paper builds on the Careful Nursing Philosophy and Professional Practice Model^© (Careful Nursing). Careful Nursing elaborates explicit nursing values and addresses both relational and pragmatic aspects of nursing practice, offering an ideal guide to provision of fundamental nursing care.

METHOD

A comparative alignment approach is used to review the capacity of Careful Nursing to address fundamentals of nursing care.

CONCLUSIONS

Careful Nursing provides a value-based comprehensive and practical framework which can strengthen clinical nurses' ability to articulate and control their practice and, thereby, more effectively fulfil their responsibility to provide fundamental care and measure its effectiveness.

RELEVANCE TO CLINICAL PRACTICE

This explicitly value-based nursing philosophy and professional practice model offers nurses a comprehensive, pragmatic and engaging framework designed to strengthen their control over their practice and ability to provide high-quality fundamental nursing care.

Centralisation of acute stroke services in London: Impact evaluation using two treatment groups

The bundling of clinical expertise in centralised treatment centres is considered an effective intervention to improve quality and efficiency of acute stroke care. In 2010, 8 London Trusts were converted into Hyper Acute Stroke Units. The intention was to discontinue acute stroke services in 22 London hospitals. However, in reality, provision of services declined only gradually, and 2 years later, 15% of all patients were still treated in Trusts without a Hyper Acute Stroke Unit. This study evaluates the impact of centralising London's stroke care on 7 process and outcome indicators using a difference-in-difference analysis with two treatment groups, Hyper Acute and discontinued London Trusts, and data on all stroke patients recorded in the hospital episode statistics database from April 2006 to April 2014. The policy resulted in improved thrombolysis treatment and lower rates of pneumonia in acute units. However, 6 indicators worsened in the Trusts that were meant to discontinue services, including deaths within 7 and 30 days, readmissions, brain scan rates, and thrombolysis treatment. The reasons for these results are difficult to uncover and could be related to differences in patient complexity, data recording, or quality of care. The findings highlight that actual implementation of centralisation policies needs careful monitoring and evaluation.

Exploring accounts of collaborative working between speech and language therapists and stroke association communication support coordinators following stroke

In the United Kingdom, speech and language therapists (SLTs) and Stroke Association communication support coordinators (CSCs) are both employed to provide services for people with communication difficulties following stroke. There is very little literature of this type of collaborative working. This research is unique because it explores collaborative working between SLTs who are employed by the National Health Service and CSCs who are employed by the Stroke Association. Five CSCs and seven SLTs from the East of England participated in a series of in-depth interviews. Data were analysed using thematic analysis informed by an interpretative phenomenological approach. The analysis suggested complex negotiation processes occur at a number of different levels. These levels include negotiation of individual relationships between SLTs and CSCs, negotiating the particular challenges involved in working across organisations and professions, and the need for both roles to negotiate and promote the value of their services at a societal level. The findings of this research are discussed in relation to existing theories and research within the field of collaborative working. Clinical applications are suggested for collaborative working within communication services. We propose that our findings may have relevance to other individuals and organisations delivering services collaboratively.

Qualitative investigation of the perceptions and experiences of nursing and allied health professionals involved in the implementation of an enriched environment in an Australian acute stroke unit

OBJECTIVE

An enriched environment embedded in an acute stroke unit can increase activity levels of patients who had stroke, with changes sustained 6 months post-implementation. The objective of this study was to understand perceptions and experiences of nursing and allied health professionals involved in implementing an enriched environment in an acute stroke unit.

DESIGN

A descriptive qualitative approach.

SETTING

An acute stroke unit in a regional Australian hospital.

PARTICIPANTS

We purposively recruited three allied health and seven nursing professionals involved in the delivery of the enriched environment. Face-to-face, semistructured interviews were conducted 8 weeks post-completion of the enriched environment study. One independent researcher completed all interviews. Voice-recorded interviews were transcribed verbatim and analysed by three researchers using a thematic approach to identify main themes.

RESULTS

Three themes were identified. First, staff perceived that 'the road to recovery had started' for patients. An enriched environment was described to shift the focus to recovery in the acute setting, which was experienced through increased patient activity, greater psychological well-being and empowering patients and families. Second, 'it takes a team' to successfully create an enriched environment. Integral to building the team were positive interdisciplinary team dynamics and education. The impact of the enriched environment on workload was diversely experienced by staff. Third, 'keeping it going' was perceived to be challenging. Staff reflected that changing work routines was difficult. Contextual factors such as a supportive physical environment and variety in individual enrichment opportunities were indicated to enhance implementation. Key to sustaining change was consistency in staff and use of change management strategies.

CONCLUSION

Investigating staff perceptions and experiences of an enrichment model in an acute stroke unit highlighted the need for effective teamwork. To facilitate staff in their new work practice, careful selection of change management strategies are critical to support clinical translation of an enriched environment.

TRIAL REGISTRATION NUMBER

ANZCTN12614000679684; Results.

Facial palsy: what can the multidisciplinary team do?

The functional and psychosocial impact of facial paralysis on the patient is significant. In response, a broad spectrum of treatment options exist and are provided by a multitude of health care practitioners. The cause and duration of the facial weakness can vary widely and the optimal care pathway varies. To optimize patient outcome, those involved in the care of patients with facial palsy should collaborate within comprehensive multidisciplinary teams (MDTs). At an international level, those involved in the care of patients with facial paralysis should aim to create standardized guidelines on which outcome domains matter most to patients to aid the identification of high quality care. This review summarizes the causes and treatment options for facial paralysis and discusses the subsequent importance of multidisciplinary care in the management of patients with this condition. Further discussion is given to the extended role of the MDT in determining what constitutes quality in facial palsy care to aid the creation of accepted care pathways and delineate best practice.

Cognitive Function and Prognosis of Multimodal Neuroimage-Guided Thrombectomy on Mild to Moderate Anterior Circulation Infarction Patients with Broadened Therapeutic Window: A Prospective Study

BACKGROUND AND OBJECTIVES

Endovascular mechanical thrombectomy is an important approach for acute ischemic stroke (AIS) treatment. Multimodal neuroimaging methods ideally provide the exact localization, extent, and metabolic activity of target tissues. Post-stroke cognitive impairment has recently been realized to be another major concern except for neurological function impairment. The aim of our study was to carry out a prospective study to compare neurological and cognitive functions after thrombectomy in mild to moderate anterior circulation infarction patients selected by multimodal neuroimaging.

METHODS

Ninety patients were recruited from January 2016 to March 2017 consecutively. Neurological function was assessed by NIHSS before thrombectomy, and 6 h, 24 h, 7 days, 90 days after mechanical thrombectomy. Cognitive functions were evaluated by Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and Hachinski Ischemic Scale.

RESULTS

Patients who received mechanical thrombectomy had significantly better neurological functions at 6 h (p < 0.001), 24 h (p < 0.001), 7 days (p < 0.001), and 90 days (p < 0.001), as well as cognitive functions evaluated by MoCA (26.23 ± 3.85 vs. 24.62 ± 2.25, p = 0.022, n = 85) and MMSE (26.65 ± 2.77 vs. 25.10 ± 2.36, p = 0.023, n = 85) compared to the standard therapy group.

CONCLUSIONS

The current prospective study demonstrated that mechanical thrombectomy can significantly improve neurological and cognitive functions in patients with mild to moderate AIS at broadened therapeutic window under multimodal CT and multimodal MRI imaging.

Stroke rehabilitation. A call to action in Saudi Arabia

Stroke is a major cause of death and other complications worldwide. In Saudi Arabia, stroke has become an emerging health issue leading to disability and death. However, stroke care including rehabilitation services, in Saudi Arabia lags behind developed countries. Stroke rehabilitation is an essential recovery option after stroke and should start as early as possible to avoid potential complications. The growing evidence on stroke rehabilitation effectiveness in different health care settings and outcome measures used widely are reviewed in this call to action paper.

Utilization of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan, Nigeria

OBJECTIVES

To investigate the pattern of referral for and utilisation of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan, Nigeria.

METHODS

Referral notes and medical records of patients admitted in the University College Hospital, Ibadan with a clinical diagnosis of stroke between January, 2009 and December, 2013 were retrospectively reviewed. Information on age, sex, type of stroke, length of hospital stay, referral for physiotherapy and utilisation of physiotherapy were retrieved. Data were summarised using descriptive statistics and analysed using Chi-square test.

RESULTS

A total of 783 patients with stroke were admitted in the hospital during the period under study. The in-patient mortality rate was 37.2%. The mean Length of Hospital Stay (LoHS) was 16.17±12.34 days. Referral rate for physiotherapy was high (75.8%) and the mean time from admission to referral for physiotherapy was three days. Majority of patients referred utilised physiotherapy (63.4%) and mean number of physiotherapy sessions received during in-patient care was 8.69±6.45. There was a significant association between LoHS and utilisation of in-patientphysiotherapy (p=0.02).

CONCLUSION

The referral rate of stroke patients for physiotherapy was relatively high. Utilisation of in-patient physiotherapy reduced length of hospital stay among patients with stroke. Utilisation of out-patient physiotherapy was low. Strategies to enhance out-patient utilisation should be explored.

Cell therapies administered in the chronic phase after stroke: a meta-analysis examining safety and efficacy

Aim: To assess the safety and efficacy of cell therapies for chronic stroke. Methodology: Five databases were searched for treatments administered >90 days post-stroke. Reporting quality, adherence to research guidelines, treatment safety (risk ratios/pooled incidence rates) and neurological/functional efficacy (Hedge’s g) were all evaluated. Results: Twenty-three studies examined 17 treatments. Reporting quality scores were medium to high, but adherence to recommended guidelines was lower. Three treatments resulted in serious adverse events; four improved outcomes more than standard care. However, many studies were under-powered and individual patients varied in their response to some treatments. Conclusion: Preliminary findings suggest that some cell therapies may be relatively safe and effective, but larger double-blinded placebo-controlled studies are needed to establish the long-term risks and benefits.