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Gittins M, Lugo-Palacios D, Vail A, Bowen A, Paley L, Bray B, Tyson S. Stroke impairment categories: A new way to classify the effects of stroke based on stroke-related impairments. Clin Rehabil 2021; 35:446-458. [PMID: 33131321 PMCID: PMC7944424 DOI: 10.1177/0269215520966473] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 09/25/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To create a classification system based on stroke-related impairments. DATA SOURCE All adults with stroke admitted for at least 72 hours in England, Wales and Northern Ireland from July 2013 to July 2015 extracted from the Sentinel Stroke National Audit Programme. ANALYSIS Impairments were defined using the National Institute of Health Stroke Scale scores at admission. Common combinations of impairments were identified based on geometric coding and expert knowledge. Validity of the classification was assessed using standard descriptive statistics to report and compare patients' characteristics, therapy received and outcomes in each group. RESULTS Data from 94,905 patients were extracted. The items of the National Institute of Health Stroke Scale (on admission) were initially grouped into four body systems: Cognitive, Motor, Sensory and Consciousness. Seven common combinations of these impairments were identified (in order of stroke severity); Patients with Loss of Consciousness (n = 6034, 6.4%); those with Motor + Cognitive + Sensory impairments (n = 28,226, 29.7%); Motor + Cognitive impairments (n = 16,967, 17.9%); Motor + Sensory impairments (n = 9882, 10.4%); Motor Only impairments (n = 20,471, 21.6%); Any Non-Motor impairments (n = 7498, 7.9%); and No Impairments (n = 5827, 6.1%). There was a gradation of age, premorbid disability, mortality and disability on discharge. People with the most and least severe categories were least likely to receive therapy, and received least therapy (-20 minutes/day of stay) compared to -35 minutes/day of stay for the moderately severe categories. CONCLUSIONS A classification system of seven Stroke Impairment Categories has been presented.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, School of Health Sciences University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David Lugo-Palacios
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, UK
| | - Andy Vail
- Centre for Biostatistics, School of Health Sciences University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Audrey Bowen
- Division of Neuroscience & Experimental Psychology, School of Biological Sciences University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College, London, UK
| | - Benjamin Bray
- School of Economics University Queensland, Brisbane, Australia
| | - Sarah Tyson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Gittins M, Lugo-Palacios D, Vail A, Bowen A, Paley L, Bray B, Gannon B, Tyson SF. Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Therapy is key to effective stroke care, but many patients receive little.
Objectives
To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.
Design
Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.
Setting
Stroke services in England, Wales and Northern Ireland.
Participants
A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.
Results
Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.
Limitations
Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.
Conclusions
Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David Lugo-Palacios
- Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Audrey Bowen
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Benjamin Bray
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Brenda Gannon
- School of Economics, The University of Queensland, Brisbane, QLD, Australia
| | - Sarah F Tyson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Jones S, Tyson S, Young M, Gittins M, Davis N. Patterns of moderate and severe injury in children after the introduction of major trauma networks. Arch Dis Child 2019; 104:366-371. [PMID: 30470686 PMCID: PMC6530074 DOI: 10.1136/archdischild-2018-315636] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To describe the demographics, mechanisms, presentation, injury patterns and outcomes for children with traumatic injuries. SETTING Data collected from the UK's Trauma and Audit Research Network. DESIGN AND PATIENTS The demographics, mechanisms of injury and outcomes were described for children with moderate and severe injuries admitted to the Major Trauma Network in England between 2012 and 2017. RESULTS Data regarding 9851 children were collected. Most (69%) were male. The median age was 6.4 (SD 5.2) years, but infants aged 0.1 year (36.5 days) were the most frequently injured of all ages (0-15 years); 447 (36.0%) of injuries in infants aged <1 year were from suspected child abuse. Most injuries occurred in the home, from falls <2 m, after school hours, at weekends and during the summer. The majority of injuries were of moderate severity (median Injury Severity Score 9.0, SD 8.7). The limbs and pelvis, followed by the head, were the most frequently and most severely injured body parts. Ninety-two per cent were discharged home and 72.8% made a 'good recovery' according to the Glasgow Outcome Scale. 3.1% of children died, their median age was 7.0 years (SD 5.8), but infants were the most commonly fatally injured group. CONCLUSIONS A common age of injury and mortality was infants aged <1 year. Accident prevention strategies need to focus on the prevention of non-accidental injuries in infants. Trauma services need to be organised to accommodate peak presentation times, which are after school, weekends and the summer.
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Affiliation(s)
- Samantha Jones
- Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, Manchester, UK,Department of Trauma and Orthopaedics, Manchester Foundation Trust, Royal Manchester Children’s Hospital, Manchester, UK,Research, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Tyson
- Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, Manchester, UK,Research, Manchester Academic Health Science Centre, Manchester, UK
| | - Michael Young
- Research, Manchester Academic Health Science Centre, Manchester, UK,Faculty of Biology, Medicine and Health, Trauma and Audit Research Network, University of Manchester, Manchester, UK
| | - Matthew Gittins
- Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, Manchester, UK,Research, Manchester Academic Health Science Centre, Manchester, UK
| | - Naomi Davis
- Department of Trauma and Orthopaedics, Manchester Foundation Trust, Royal Manchester Children’s Hospital, Manchester, UK,Research, Manchester Academic Health Science Centre, Manchester, UK
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Tyson SF, Woodward-Nutt K, Plant S. How are balance and mobility problems after stroke treated in England? An observational study of the content, dose and context of physiotherapy. Clin Rehabil 2018; 32:1145-1152. [DOI: 10.1177/0269215518777789] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To describe the dose, intensity and context of physiotherapy for balance and mobility problems after stroke. Design: Process mapping to describe the context and non-participant observation of therapy sessions to describe the dose and content of therapy. Setting: Four inpatient stroke units in North-West England. Participants: Therapy staff and previously mobile stroke survivors who were treating, or receiving treatment for balance and mobility problems in the participating units. Results: Two units were stand-alone rehabilitation units; two offered a service at the weekends. One had no access to community-based rehabilitation. All had dedicated treatment facilities but often did not use them because of lack of space and difficulty transporting patients. Twenty-two patients participated and 100 treatment sessions were observed. Practicing walking, sit-to-stand and transfers were the most frequent objectives and interventions usually with the therapist(s) physically facilitating the patient’s movements. The dose of practise was low; mean repetitions of sit-to-stand per session was 5 (SD 6.4); mean time spent upright per session was 11.24 (SD = 7) minutes, and mean number of steps per session was 202 (SD 118). The mean number of staff per patient was 2.1 (SD = 0.6, mode = 2), usually involving two qualified therapists. Falls prevention or management, wheelchair skills and bed mobility were not practised. Conclusion: Stroke physiotherapy for balance and mobility problems features low-dose, low-intensity therapist-led practice, mainly of walking and sit-to-stand. Staff:patient ratios were high. Therapists need to organize treatment sessions to maximize the intensity of functional task practice.
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Affiliation(s)
- Sarah F Tyson
- Stroke Research Centre, The University of Manchester, Manchester, UK
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Kate Woodward-Nutt
- Stroke Research Centre, The University of Manchester, Manchester, UK
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Plant
- Stroke Research Centre, The University of Manchester, Manchester, UK
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
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Abstract
High quality up-to-date systematic reviews are essential in order to help healthcare practitioners and researchers keep up-to-date with a large and rapidly growing body of evidence. Systematic reviews answer pre-defined research questions using explicit, reproducible methods to identify, critically appraise and combine results of primary research studies. Key stages in the production of systematic reviews include clarification of aims and methods in a protocol, finding relevant research, collecting data, assessing study quality, synthesizing evidence, and interpreting findings. Systematic reviews may address different types of questions, such as questions about effectiveness of interventions, diagnostic test accuracy, prognosis, prevalence or incidence of disease, accuracy of measurement instruments, or qualitative data. For all reviews, it is important to define criteria such as the population, intervention, comparison and outcomes, and to identify potential risks of bias. Reviews of the effect of rehabilitation interventions or reviews of data from observational studies, diagnostic test accuracy, or qualitative data may be more methodologically challenging than reviews of effectiveness of drugs for the prevention or treatment of stroke. Challenges in reviews of stroke rehabilitation can include poor definition of complex interventions, use of outcome measures that have not been validated, and poor generalizability of results. There may also be challenges with bias because the effects are dependent on the persons delivering the intervention, and because masking of participants and investigators may not be possible. There are a wide range of resources which can support the planning and completion of systematic reviews, and these should be considered when planning a systematic review relating to stroke.
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Affiliation(s)
- Alex Pollock
- 1 Nursing Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Eivind Berge
- 2 Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
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Haarman JAM, Maartens E, van der Kooij H, Buurke JH, Reenalda J, Rietman JS. Manual physical balance assistance of therapists during gait training of stroke survivors: characteristics and predicting the timing. J Neuroeng Rehabil 2017; 14:125. [PMID: 29197402 PMCID: PMC5712141 DOI: 10.1186/s12984-017-0337-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 11/23/2017] [Indexed: 11/25/2022] Open
Abstract
Background During gait training, physical therapists continuously supervise stroke survivors and provide physical support to their pelvis when they judge that the patient is unable to keep his balance. This paper is the first in providing quantitative data about the corrective forces that therapists use during gait training. It is assumed that changes in the acceleration of a patient’s COM are a good predictor for therapeutic balance assistance during the training sessions Therefore, this paper provides a method that predicts the timing of therapeutic balance assistance, based on acceleration data of the sacrum. Methods Eight sub-acute stroke survivors and seven therapists were included in this study. Patients were asked to perform straight line walking as well as slalom walking in a conventional training setting. Acceleration of the sacrum was captured by an Inertial Magnetic Measurement Unit. Balance-assisting corrective forces applied by the therapist were collected from two force sensors positioned on both sides of the patient’s hips. Measures to characterize the therapeutic balance assistance were the amount of force, duration, impulse and the anatomical plane in which the assistance took place. Based on the acceleration data of the sacrum, an algorithm was developed to predict therapeutic balance assistance. To validate the developed algorithm, the predicted events of balance assistance by the algorithm were compared with the actual provided therapeutic assistance. Results The algorithm was able to predict the actual therapeutic assistance with a Positive Predictive Value of 87% and a True Positive Rate of 81%. Assistance mainly took place over the medio-lateral axis and corrective forces of about 2% of the patient’s body weight (15.9 N (11), median (IQR)) were provided by therapists in this plane. Median duration of balance assistance was 1.1 s (0.6) (median (IQR)) and median impulse was 9.4Ns (8.2) (median (IQR)). Although therapists were specifically instructed to aim for the force sensors on the iliac crest, a different contact location was reported in 22% of the corrections. Conclusions This paper presents insights into the behavior of therapists regarding their manual physical assistance during gait training. A quantitative dataset was presented, representing therapeutic balance-assisting force characteristics. Furthermore, an algorithm was developed that predicts events at which therapeutic balance assistance was provided. Prediction scores remain high when different therapists and patients were analyzed with the same algorithm settings. Both the quantitative dataset and the developed algorithm can serve as technical input in the development of (robot-controlled) balance supportive devices.
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Affiliation(s)
- Juliet A M Haarman
- Roessingh Research and Development, Roessinghsbleekweg 33b, 7522 AH, Enschede, the Netherlands. .,Department of Biomechanical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands. .,Roessingh Research and Development, Roessinghsbleekweg 33b, PO Box 310, 7500 AH, Enschede, the Netherlands.
| | - Erik Maartens
- Roessingh Research and Development, Roessinghsbleekweg 33b, 7522 AH, Enschede, the Netherlands.,Department of Biomechanical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands
| | - Herman van der Kooij
- Department of Biomechanical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands
| | - Jaap H Buurke
- Roessingh Research and Development, Roessinghsbleekweg 33b, 7522 AH, Enschede, the Netherlands.,Department of Biomechanical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands
| | - Jasper Reenalda
- Roessingh Research and Development, Roessinghsbleekweg 33b, 7522 AH, Enschede, the Netherlands.,Department of Biomechanical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands
| | - Johan S Rietman
- Roessingh Research and Development, Roessinghsbleekweg 33b, 7522 AH, Enschede, the Netherlands.,Department of Biomechanical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands
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7
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de Jong LD, van Wijck F, Stewart RE, Geurts ACH, Dijkstra PU. Content of conventional therapy for the severely affected arm during subacute rehabilitation after stroke: An analysis of physiotherapy and occupational therapy practice. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2017; 23. [PMID: 28092139 DOI: 10.1002/pri.1683] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/15/2016] [Accepted: 08/19/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE Physiotherapy (PT) and occupational therapy (OT) are key professions providing treatment for the arm after stroke; however, knowledge about the content of these treatments is scant. Detailed data are needed to replicate interventions, evaluate their effective components, and evaluate PT and OT practice. This paper describes PT and OT treatment for the severely affected arm in terms of duration, content according to components and categories of the International Classification of Human Functioning, Disability and Health, and to analyze differences between professions. METHODS Design: This is a retrospective analysis of randomized trial data. PARTICIPANTS 46 patients after stroke with poor arm motor control recruited from inpatient neurological units from three rehabilitation centers in the Netherlands. PROCEDURE PTs and OTs recorded duration and content of arm treatment interventions for 8 weeks using a bespoke treatment schedule with 15 International Classification of Human Functioning, Disability and Health categories. RESULTS PTs and OTs spent on average 4-7 min per treatment session (30 min) on arm treatment. OTs spent significantly more time providing arm treatment and treatment at the activities level than PTs. PTs spent 79% of their arm treatment time on body functions, OTs 41%. OTs spent significantly more time on "moving around using transportation," "self care," and "household tasks" categories. CONCLUSIONS Patients after stroke with a severely affected arm and an unfavorable prognosis for arm motor recovery receive little arm-oriented PT and OT. Therapists spent most arm treatment time on body functions. There was a considerable overlap in the content of PT and OT in 12 of the 15 categories. Results can be generalized only to patients with poor arm motor control and may not represent practice in other countries.
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Affiliation(s)
- Lex D de Jong
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, The Netherlands.,Institute for Applied Health Research, School for Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Frederike van Wijck
- Institute for Applied Health Research, School for Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Roy E Stewart
- Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Alexander C H Geurts
- Department of Rehabilitation, Donders Center for Neuroscience, Radboud University Medical Center Nijmegen, The Netherlands
| | - Pieter U Dijkstra
- Department of Rehabilitation Medicine, and Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, The Netherlands
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Thomas N, Plant S, Woodward-Nutt K, Prior Y, Tyson S. Health care professionals' views of the factors influencing the decision to refer patients to a stroke rehabilitation trial. Trials 2015; 16:577. [PMID: 26680020 PMCID: PMC4683768 DOI: 10.1186/s13063-015-1115-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 12/09/2015] [Indexed: 11/23/2022] Open
Abstract
Background Effective recruitment is an essential element of successful research but notoriously difficult to achieve. This article examines health care professionals’ views on the factors influencing decision-making regarding referral to a stroke rehabilitation trial. Methods Semi-structured interviews and a card-sorting task were undertaken with stroke service staff in acute and community hospital trusts. Data analysis used a thematic framework approach. Results Twenty-seven qualified health care professionals from 12 (6 acute and 6 community) hospital trusts and one charity participated. Four main factors emerged: patient-related, professional views, the organisation and research logistics, which all contributed to staff’s decision about whether to refer patients to a trial. Clinicians identified patient-related factors as the most frequent influence and considered themselves the patients’ advocate. They used their knowledge of the patient to anticipate the patients’ reaction to possible participation and tended to only refer those whom they perceived would respond positively. Participants also identified experience of research, a sense of ownership of the project and a positive view of the intervention being evaluated as factors influencing referral. The need to prioritise clinical matters, meet managerial demands and cope with constant change were organisational factors impacting negatively on referral. Staff often simply forgot about recruitment in the face of other higher priorities. Quick, simple, flexible research processes that were closely aligned with existing ways of working were felt to facilitate recruitment. Conclusions Patient- and professional-related factors were the most frequent influence on clinicians’ recruitment decisions, which often had a ‘gate-keeping’ effect. Managerial and clinical responsibility to juggle multiple (often higher) priorities was also an important factor. To facilitate recruitment, researchers need to develop strategies to approach potential participants as directly as possible to enable them to make their own decisions about participation; ensure that research processes are as quick and simple as possible; align with existing clinical pathways and systems; and give regular reminders and ongoing support to promote recruitment. Trial registration ISRCTN, 98287938. Registered 6 May 2015 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1115-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nessa Thomas
- Salford Royal NHS Foundation Trust, Salford, UK.
| | - Sarah Plant
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK.
| | - Kate Woodward-Nutt
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK.
| | - Yeliz Prior
- Centre for Health Sciences Research, University of Salford, Salford, UK. .,Mid Cheshire Hospitals NHS Foundation Trust, Cheshire, UK.
| | - Sarah Tyson
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK. .,Stroke Research Centre, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
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Miller KJ, Hunt MA, Pollock CL, Bryant D, Garland SJ. Protocol for a randomized controlled clinical trial investigating the effectiveness of Fast muscle Activation and Stepping Training (FAST) for improving balance and mobility in sub-acute stroke. BMC Neurol 2014; 14:187. [PMID: 25300433 PMCID: PMC4207320 DOI: 10.1186/s12883-014-0187-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 09/17/2014] [Indexed: 11/14/2022] Open
Abstract
Background Following stroke, many people have difficulty activating their paretic muscles quickly and with sufficient power to regain their balance by taking quick and effective steps. Reduced dynamic balance and mobility following stroke, or ‘walking balance’, is associated with reduced self-efficacy and restrictions in daily living activities, community integration, and quality of life. Targeted training of movement speeds required to effectively regain balance has been largely overlooked in post-stroke rehabilitation. The Fast muscle Activation and Stepping Training (FAST) program incorporates fast functional movements known to produce bursts of muscle activation essential for stepping and regaining standing balance effectively. The purpose of this study is to: 1) compare the effectiveness of an outpatient FAST program to an active control outpatient physiotherapy intervention in improving walking balance following stroke, and 2) explore potential mechanisms associated with improvements in walking balance. Methods/Design This will be an assessor-blinded, parallel group randomized controlled trial design. Sixty participants (30 per group) who have sustained a stroke within the previous six months will be randomly assigned with stratification for lower limb motor recovery to receive twelve 45-minute 1:1 physiotherapy intervention sessions over 6 – 10 weeks in an outpatient setting of either: 1) FAST intervention - systematic and progressive practice of fast squatting and stepping exercises, or 2) active control - conventional physiotherapy directed at improving balance and mobility that includes no targeted fast movement training. The same blinded research physiotherapist will assess outcomes at three time points: 1) baseline (prior to intervention), 2) follow up (within one week post-intervention); and 3) retention (one month post-intervention). The primary outcome is dynamic balance assessed using the Community Balance and Mobility Scale. We will also assess fast and self-selected walking speed, balance self-efficacy, and the ability to respond to internal and external perturbations to balance and associated changes in postural muscle activation. Discussion The targeted training of fast functional movements in the FAST program is expected to improve walking balance following stroke compared to the active control intervention. Unique to this study is the investigation of potential mechanisms associated with improvements in walking balance. Trial registration NCT01573585 Electronic supplementary material The online version of this article (doi:10.1186/s12883-014-0187-y) contains supplementary material, which is available to authorized users.
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Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Rev 2014; 2014:CD001920. [PMID: 24756870 PMCID: PMC6465059 DOI: 10.1002/14651858.cd001920.pub3] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches. OBJECTIVES To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation. SELECTION CRITERIA Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches. DATA COLLECTION AND ANALYSIS Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data. MAIN RESULTS We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions. AUTHORS' CONCLUSIONS Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.
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Affiliation(s)
- Alex Pollock
- Glasgow Caledonian UniversityNursing, Midwifery and Allied Health Professions Research UnitBuchanan HouseCowcaddens RoadGlasgowUKG4 0BA
| | - Gillian Baer
- Queen Margaret UniversityDepartment of PhysiotherapyQueen Margaret University DriveEdinburghUKEH21 6UU
| | - Pauline Campbell
- Glasgow Caledonian UniversityNursing, Midwifery and Allied Health Professions Research UnitBuchanan HouseCowcaddens RoadGlasgowUKG4 0BA
| | - Pei Ling Choo
- Glasgow Caledonian UniversitySchool of Health & Life SciencesGlasgowUK
| | - Anne Forster
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationTemple Bank House, Bradford Royal InfirmaryDuckworth LaneBradfordUKBD9 6RJ
| | - Jacqui Morris
- University of DundeeSchool of Nursing and Midwifery11 Airlie PlaceDundeeUKDD1 4HJ
| | - Valerie M Pomeroy
- University of East AngliaSchool of Rehabilitation SciencesNorwichUKNR4 7TJ
| | - Peter Langhorne
- University of GlasgowAcademic Section of Geriatric Medicine3rd Floor, Centre BlockRoyal InfirmaryGlasgowUKG4 0SF
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Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Hippokratia 2014. [PMID: 24756870 DOI: 10.1002/14651858.cd001920.pub3#sthash.keppcclr.dpuf] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches. OBJECTIVES To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation. SELECTION CRITERIA Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches. DATA COLLECTION AND ANALYSIS Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data. MAIN RESULTS We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions. AUTHORS' CONCLUSIONS Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.
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Affiliation(s)
- Alex Pollock
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Buchanan House, Cowcaddens Road, Glasgow, UK, G4 0BA
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Shinohara T, Usuda S. Are contents of physical therapy in nine Japanese hospitals for inpatients with stroke related to inpatients' and physical therapists' characteristics? J Phys Ther Sci 2013; 25:641-7. [PMID: 24259820 PMCID: PMC3804984 DOI: 10.1589/jpts.25.641] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/22/2013] [Indexed: 11/24/2022] Open
Abstract
[Purpose] This study investigated the factors that influence activities provided during
physical therapy for stroke. [Subjects] Data were collected from 85 physical therapists
and 216 inpatients with stroke. [Methods] Time spent on specific functional activities
provided to inpatients with stroke was recorded at nine rehabilitation facilities. These
were used as dependent variables. Physical therapists’ characteristics, including years
since acquiring a license, gender, and treatment concepts influencing physical therapy for
stroke, were recorded. Inpatients’ characteristics, including age, gender, affected side,
days post stroke, score on the Modified Rankin Scale (mRS), and gait ability measured by
the Functional Independence Measure (FIM gait), were also recorded. Physical therapists’
and inpatients’ characteristics were used as independent variables. The t-test,
correlation coefficients, and analysis of covariance were used to investigate which
independent variables correlated with which dependent variables. [Results] Pre-gait,
advanced gait, and community mobility were significantly correlated with mRS and FIM gait
(|rs| = 0.32–0.62). Time spent on other functional activities had a weak
correlation with inpatients’ characteristics. Time spent on functional activities had no
or few correlations with physical therapists’ characteristics. [Conclusion] Relationships
between time spent on specific functional activities and physical therapists’
characteristics were weaker than those for inpatients’ characteristics. Physical therapy
for stroke includes many factors.
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Affiliation(s)
- Tomoyuki Shinohara
- Acute Rehabilitation Center, Hidaka Hospital ; Graduate School of Health Sciences, Gunma University
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Askim T, Indredavik B, Engen A, Roos K, Aas T, Mørkved S. Physiotherapy after stroke: to what extent is task-oriented practice a part of conventional treatment after hospital discharge? Physiother Theory Pract 2012; 29:343-50. [PMID: 23098358 DOI: 10.3109/09593985.2012.734008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Research has shown that motor training after stroke should be task-oriented. It is still unknown whether the task-oriented approach is implemented into clinical practice. The purpose of the present study was to survey to which extent task-specific training was a part of conventional physiotherapy practice given to stroke patients after discharge from hospital. This cross-sectional survey was a sub-study of a randomized controlled trial. Physiotherapists treating patients included in the trial were asked to register their choice of treatment according to 11 predefined activity categories during the second week after discharge from hospital. Nineteen physiotherapists treating 46 patients suffering from mild-to-moderate stroke were included. The activities chosen in most patients were sit-to-stand (60.9%), balance in standing position (65.2%), walking on even ground (78.3%), and stair climbing (56.5%). Only two patients (4.3%) practiced transfers or balance related to activities of daily living (ADL), such as washing, dressing, and toileting. This study shows that conventional physiotherapy practice for a selected group of Norwegian stroke patients was mainly based on a task-oriented approach, although with very little emphasis on training in relation to ADL. Future research is needed to ensure that evidence-based treatment is given to all stroke patients.
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Affiliation(s)
- Torunn Askim
- Department of Neuroscience, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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Kunkel D, Pickering RM, Burnett M, Littlewood J, Burridge JH, Ashburn A. Functional electrical stimulation with exercises for standing balance and weight transfer in acute stroke patients: a feasibility randomized controlled trial. Neuromodulation 2012; 16:168-77. [PMID: 22861816 DOI: 10.1111/j.1525-1403.2012.00488.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To test parameters needed for the design of a larger trial including the following: 1) identifying eligible participants, recruitment, and retention rates; 2) the feasibility and acceptability of delivering functional electrical stimulation (FES) to the gluteus maximus and quadriceps femoris for acute stroke patients in a hospital rehabilitation setting; 3) the outcome measures; 4) obtaining initial estimates of effect size; and 5) clarifying the relevant control group. MATERIALS AND METHODS Twenty-one people with acute stroke-mean age = 68 (min to max: 33-87) years; weeks postonset = 4.6 (min to max: 1-14)-were randomized to three groups to receive two weeks of balance training with FES, balance training alone, or usual care. Symmetry in normal standing, weight transfer onto the affected limb, balance, mobility, and speed of walking were assessed before, shortly after the end of training, and two weeks later by a blinded assessor. RESULTS 1) FES was successfully delivered but not with the planned eight sessions; 2) no trends in favor of FES were found; and 3) 4% of those screened took part but approaching 20% might be recruited in the future, no single outcome measure was suitable for all participants, and more routine physiotherapy was delivered to the control group. CONCLUSIONS FES is feasible in this patient group but further feasibility and definitive trials are required.
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Affiliation(s)
- Dorit Kunkel
- Faculty of Health Sciences, Southampton General Hospital, University of Southampton, Southampton, UK.
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