The Bradford community stroke trial: results at six months

Efficacy of Caregivers Training in Rehabilitation of Stroke Survivors in Bangladesh: A Quasi-experimental Study

BACKGROUND

 A proper rehabilitation program may prevent post-stroke neurological, structural, and functional disabilities. We aimed to evaluate the efficacy of caregiver training in the rehabilitation of stroke survivors and compare rehabilitation interventions done by the therapist.

METHODS

 This quasi-experimental study was conducted among 67 stroke survivors divided into group A (home-based exercise by family caregivers; n=33) and group B (hospital-based supervised exercise by a physiotherapist; n=34). Family caregivers were trained according to "The London Stroke Carers Training Course." The functional independence measure (FIM) evaluated all patients after three months of physiotherapy.  Results: The mean age of the participants in group A and group B were 56.85 ± 11.49 and 58.65 ± 16.92 years, respectively, where most of the patients in both groups were male. In group A, 17 (51.5%) participants had left-sided involvement, while in group B, 17 (50.0%) participants had left-sided involvement. There was no significant statistical difference in FIM between groups A and B at baseline (p=0.532). At three months, the mean FIM of the participants in group A (98.54 ± 11.85) was significantly higher than in group B (89.85 ± 8.15) (p=0.001). A quasi-significant difference was observed between the right (18.41 ± 9.37) and the left (23.42 ± 11.68) hemisphere involvement regarding mean improvement of FIM (p=0.057).

CONCLUSION

 Therapeutic approach provided by trained caregivers was found to be more effective and efficient than that done by a physiotherapist.

Effect of home-based interventions on basic activities of daily living for patients who had a stroke: a systematic review with meta-analysis

OBJECTIVES

To investigate the effectiveness of home-based interventions in improving the ability to do basic activities of daily living in patients who had a stroke.

METHODS

Randomised controlled trials were searched through MEDLINE, Embase and CINAHL from their inception to 31 December 2021. We included studies involving home-based intervention prescribed by professionals and implemented at patients' homes. The characteristics of these studies were collected. Risk of bias of individual study was assessed by Physiotherapy Evidence Database scale. Meta-analyses were performed where studies reported comparable interventions and outcomes.

RESULTS

In total, 49 studies were included in the systematic review and 16 studies had sufficient data for meta-analyses. The short-term effect of home-based intervention showed no significant difference when compared with institution-based intervention (standardised mean difference (SMD)=0.24, 95% CI -0.15 to 0.62, I²=0%). No significant difference was found between home-based intervention and usual care for long-term effect (SMD=0.02; 95% CI -0.17 to 0.22; I²=0%). Home-based rehabilitation combined with usual care showed a significant short-term effect on the ability to do basic daily activities, compared with usual care alone (SMD=0.55; 95% CI 0.22 to 0.87; p=0.001; I²=3%).

CONCLUSION

Home-based rehabilitation with usual care, which varied from no therapy to inpatient or outpatient therapy, may have a short-term effect on the ability to do basic activities of daily living for patients who had a stroke compared with usual care alone. However, the evidence quality is low because of the limited number of studies and participants included in the meta-analysis and the possible publication bias. Future research is needed to investigate the effectiveness of home-based rehabilitation in groups with stratification by stroke severity and time since stroke onset, with elaboration of details of the home-based and the control interventions. Moreover, more high-quality studies are required to prove the cost-effectiveness of newly developed strategies like caregiver-mediated rehabilitation and telerehabilitation.

THE PRIMARY SOURCE OF FUNDING

The Medical Research Fund of Guangdong Province (No: A2021041).

Feasibility of a home-based physiotherapy intervention to promote post-stroke mobility: A randomized controlled pilot study

Objectives

Home-based physiotherapy interventions to improve post-stroke mobility are successful in high-income countries. These programs require less resources compared to center-based programs. However, feasibility of such an intervention in a low and middle-income setting remains unknown. Therefore, the SunRISe (Stroke Rehabilitation In Suriname) study aimed to assess feasibility and preliminary effectiveness of a home-based semi-supervised physiotherapy intervention to promote post-stroke mobility in a low resource setting.

Design

Prospective randomized controlled trial.

Methods

Chronic stroke patients were recruited and randomized into either an intervention group (IG (N = 20)) or a control group (CG (N = 10)). The IG received a 3-days-a-week home-based physiotherapy program that was supervised in the first 4 weeks and tele-supervised during the second 4 weeks. The physiotherapy program consisted of walking as well as functional and mobilization exercises. The CG received usual care. Feasibility outcome measures included adherence, patient satisfaction and safety. Efficacy measures included functional exercise tolerance (six-minute walking test (6MWT), functional balance (Berg Balance Score (BBS), upper extremity (UE) function (Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire), and UE strength ((non-)paretic handgrip (HG) strength). Two-way analysis of variance was used for data analysis.

Results

Thirty participants (61.8 ± 9.2 years old, 13 men) were enrolled in the study. The intervention was completed by 14 participants (70%). Adherence was affected by rainy season associated infrastructural problems (n = 2), the medical status of participants (n = 3) and insufficient motivation to continue the program without direct supervision (n = 1). No adverse events were noted and participants were satisfied with the program. Functional exercise tolerance (57.2 ± 67.3m, p = 0.02) and UE function (-9.8 ± 15.2, p = 0.04) improved in the IG compared to no change in the CG. HG strength was unaltered and a ceiling effect occurred for BBS.

Conclusion

Our home-based semi-supervised physiotherapy intervention seems safe, associated with moderate to high levels of engagement and patient satisfaction and results in functional improvements.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews

BACKGROUND

With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP).

METHODS

We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors).

RESULTS

Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP.

DISCUSSION

Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

Changes in social participation and life-space mobility in newly enrolled home-based rehabilitation users over 6 months

[Purpose] This study aimed to examine whether we were able to measure changes in social participation and life-space mobility of newly enrolled home-based rehabilitation (HR) users by using the activities and participation components of the International Classification of Functioning, Disability and Health (ICF) and Life-Space Assessment (LSA) over a 6-months period. [Participants and Methods] We enrolled 47 HR users who had suffered from a stroke or other condition within the previous year. A 6-month prospective cohort study was conducted. The performance qualifiers “d6 domestic life” and “d9 community, social and civic life” in the activities and participation components of the ICF and LSA were used. [Results] We observed significant improvements in the performance qualifier “d9 community, social and civic life” of the ICF over 3 months, and the LSA over a 6-months period. We also identified significant improvements in “d910 community life” and “d920 recreation and leisure” of the ICF. The LSA results showed that HR users had more frequent mobility within the neighborhood. [Conclusion] This study showed that newly enrolled HR users improved their social activities in the community, recreational activities, and life-space mobility over a 6-months period. These were measured using performance qualifiers from the ICF and LSA.

Orthoptic Home Visits for Stroke Survivors: Results from a UK Professional Practice Survey

Aim:

Orthoptists are perhaps the only allied health profession without a standard home visits service in the UK, although it could arguably be of benefit to many orthoptic patients. The aim of this survey was to identify whether home visits are being offered, or have the potential to be offered, within the orthoptic profession.

Method:

A survey of the orthoptic professional body (BIOS) for the UK and Ireland was developed and data collected between January and March 2016. Descriptive analysis was used to report the quantitative findings. A thematic analysis approach was undertaken for the written responses within the free-text boxes of the survey.

Results:

461 BIOS members responded to the survey (response rate of 30.7%). Ten hospital sites (3.7%) reported offering home visits, and 444 members (96.3%) reported that they do not offer home visits, with little desire or perceived need for such a service. Only certain patients reportedly meet requirements for an orthoptic home visit, including those unable to attend the hospital due to poor health, transport issues, reduced cognition, stroke and learning difficulties. Implementation barriers were reported including staff safety, assessment quality and cost.

Conclusion:

Home visits are infrequently conducted within the orthoptic profession. However, where offered, certain patient groups were suggested to benefit from this service when they cannot attend hospital and thus, home visits could present a viable means of providing equitable visual care. Future research is required to explore orthoptic home visits compared to other forms of rehabilitation, and address concerns from the orthoptic professional body.

Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: A cross-sectional survey

BACKGROUND

The greatest burden from stroke-related disability is borne by Low-and-Middle Income countries (LMICs) where access to rehabilitation after stroke is severely challenged. Tele-rehabilitation could be a viable avenue to address unmet rehabilitation needs in LMICs.

OBJECTIVES

To assess the burden of post-stroke physical deficits, rates of utilization of physiotherapy services, and perceptions of tele-rehabilitation among recent Ghanaian stroke survivors.

METHODS

Using a consecutive sampling strategy, 100 stroke survivors attending an outpatient Neurology clinic in a Ghanaian tertiary medical center were enrolled into this cross-sectional study. After collecting basic demographic data, clinical history on stroke type, severity and level of disability, we administered the validated 20-item Functional Independence Measure questionnaire to evaluate functional status of study participants and an 8-item questionnaire to assess participants' attitudes towards telemedicine administered rehabilitation intervention.

RESULTS

Mean±SD age of study participants was 57.2±13.3years of which 51.0% were males with a mean duration of stroke of 1.3±2.2years. 53% had Modified Rankin scores of ≥3, 57% were fully independent and only 27% reported utilizing any physiotherapy services. Barriers to access to physiotherapy included financial constraints due to cost of physiotherapy services and transportation as well as premature discharge from physiotherapy to avoid overburdening of available physiotherapy services. These factors led to the limited provision of rehabilitative therapy. Participants held positive views of the potential for tele-rehabilitation interventions (80-93%). However, while 85% owned mobile phones, only 35% had smart phones.

CONCLUSION

Despite, a high burden of residual disability, only about 1 out of 4 stroke patients in this Ghanaian cohort was exposed to post-stroke physiotherapy services, largely due to relatively high costs and limited health system resources. These Ghanaian stroke patients viewed the potential role of Tele-rehabilitation as positive, but this promising intervention needs to be formally tested for feasibility, efficacy and cost-effectiveness.

Management of post-stroke depression in the Middle East and North Africa: Too little is known

Stroke is among the most common disabilities among adults and most stroke victims live in developing countries. However, little is known about services delivered in these countries for post-stroke depression, a common comorbidity that influences functional outcomes of stroke. In this paper, a physician from Syria reviews the literature on post-stroke depression among patients living in countries of the Middle East and North Africa region in order to examine whether current practices can be improved. Studies of prevalence were found in six of the region's countries and only four studies described interventions for stroke patients with clinical depression. The limited studies on prevalence confirmed that stroke incidence and post-stroke depression are common although diagnosed depression appears to vary depending on the economic environment of the country. Hence, additional interventions in MENA countries may be warranted to increase recognition of depression in stroke patients and to ensure health professionals are prepared to deliver appropriate services to stroke patients and their family-caregivers for depression when it occurs.

Shared responsibility for ongoing rehabilitation: a new approach to home-based therapy after stroke

Objective: To assess the efficacy of a programme of continuing self-directed exercises for people discharged home after a stroke, supervised once a week by therapists.

Design: A randomized controlled trial of 100 patients discharged from hospital after a stroke, requiring ongoing therapy. The control group received outpatient or day hospital therapy; the experimental group were visited once a week by an occupational and/or physiotherapist who prescribed a programme of exercises and activities for the following week. Subjects were studied for the first three months after discharge from hospital.

Setting: A district general hospital, or the homes of subjects randomized to the experimental group, in New Zealand.

Main outcome measures: (1) Characteristics of the groups, (2) gait speed, limb function, activities of daily living, (3) time with therapists, (4) mood of both subjects and caregivers, (5) anticipation of outcome at entry, compared with perceived outcome at exit.

Results: No statistical differences between the control and experimental groups in characteristics, or in any outcomes measured, except that the contact time period, but not the number of visits, was longer in the experimental group (p = 0.003).

Conclusions: A supervised home-based programme is as effective as outpatient or day hospital therapy.

Results of the Belgian Sentinel Network of General Practitioners on the Involvement of Therapists in Stroke Rehabilitation

This study examines which therapists are involved in the rehabilitation of stroke survivors in Belgium at different points in time. A nationwide registration of stroke patients was provided by 199 and 189 family physicians working in sentinel practices for the years 2009 and 2010 respectively. 326 patients who were diagnosed with stroke were included. Patients with paralysis/paresis received significant more physiotherapy after one month (63%) compared to non-paralysed patients (38%) (P = 0.005). Residing in a nursing home was associated with higher proportions of patients receiving physiotherapy, both after one (P = 0.003) and six (P = 0.002) months. 31% of patients with aphasia were treated by a speech and language therapist after one month, which decreased after six months to 20%. After six months, the patients in a nursing home received significant more often speech and language therapy (P = 0.004), compared to patients living at home. The proportion of patients receiving stroke rehabilitation services provided by physiotherapists, speech/language therapists and occupational therapists is rather low, especially 6 months after the critical event.

Evaluating Health Interventions for Older People

In recent years there has been a growing emphasis on evidencebased medicine and measuring outcomes of health care. The evaluation of health interventions for older people has increasingly relied upon the use of standardized assessment instruments, which are seen as providing detailed, holistic and patient-centred information. This article argues that such an approach has several drawbacks which may have serious implications for the evaluation and provision of health care. Standardized assessment instruments ignore the social dimensions of interviewing, decontextualize scores and contain an implicitly individualistic biomedical ideology of health. These factors undermine the effective evaluation of interventions. This is particularly significant when health care is purchased on the basis of delivering demonstrable gains. Provision for older people may be under threat if methods of evaluating its efficacy are inadequate.

Barthel ADL Index: a comparison of administration methods

The Barthel ADL Index is routinely used to assess elderly patients after discharge from hospital. Its inter-rater reliability and criterion validity have been well established. However, the inter-method reliability in administering this scale has not been sufficiently documentated. This study compares post, telephone and interview (visit) methods of administration to investigate their agreement. The index was administered by the three methods in random order after patients were discharged from acute geriatric wards. Results suggest that these three methods are reliable and agree well with each other in the total scores obtained. Analyses of individual item scores indicate poor agreement on one item (stairs). Suggestions on improving the guidelines for this item are outlined.

Survey of a domiciliary stroke rehabilitation service

A previous randomized controlled comparison of hospital-based and domiciliary rehabilitation for stroke patients discharged from hospital (the DOMINO study) found home therapy to be beneficial in a subgroup who had been in hospital on a stroke unit before entering the trial, whereas no benefit was seen in patients who had been on ordinary geriatric or general medical wards. In this study, to explain the findings of the DOMINO study further, the therapy records kept during the DOMINO study of the amount and type of rehabilitation provided by the domiciliary rehabilitation team were examined.

More patients who had been on the stroke unit before entering the trial received therapy and they received more and longer visits than those who had been on geriatric or medical wards. The group from the stroke unit were more likely to receive practice in activities of daily living (ADL), assessment for and instruction in the use of aids and appliances, gait re-education, mobility practice and facilitation of normal muscle tone.

One possible deduction is that home rehabilitation services should aim to deliver an average of 15-20 visits in six months, since only this amount of therapy was associated with a measurable benefit. The active components of home therapy may be ADL practice, assessment for and instruction in the use of aids and appliances, gait re-education, mobility, mobility practice and facilitation of normal muscle tone.

A randomized controlled trial to evaluate intensity of community-based rehabilitation provision following stroke or hip fracture in old age

Objective: To compare intensive with non-intensive home-based rehabilitation provision following stroke or hip fracture in old age (65 years).

Design: Parallel single-blind randomized control trial.

Setting: Domiciliary provided multidisciplinary rehabilitation.

Subjects: One hundred and sixty patients aged 65 or over recently discharged from hospital after suffering a stroke or hip fracture.

Intervention: Patients assigned to receive six or more face-to-face contacts or three or less face-to-face contacts from members of a multidisciplinary rehabilitation team.

Main measures: Patients assessed using the Barthel Index, Therapy Outcome Measure, Euroqol 5D (EQ-5D), Hospital Anxiety and Depression Scale (HADS) and Frenchay Activities Index (FAI) at three months. All follow-up assessments were conducted blind to allocation.

Results: Subgroup analysis was conducted on the basis of incident condition (stroke or hip fracture). Significant differences were detected for the stroke subgroup at three months [Therapy Outcome Measure Handicap (median difference 0.5 ( P < 0.05)) and EQ-5D (median difference 0.17 ( P < 0.05))] and in change at three months [Therapy Outcome Measure (mean difference 0.52 (SD 0.85) 95% CI (0.16, 0.88)) and EQ-5D (mean difference 0.15 (SD 0.25) 95% CI (0.05, 0.26))]. No significant differences were detected between the two arms of the study for the hip fracture subgroup.

Conclusion: Following stroke older people who receive a more intensive communitybased multidisciplinary rehabilitation service may experience short-term benefit in relation to social participation and some aspects of health-related quality of life. A more intensive service after discharge from hospital following a hip fracture is unlikely to result in similar patient benefit.

Combined analysis of two randomized trials of community physiotherapy for patients more than one year post stroke

Background: Some patients continue to have mobility problems as a long-term consequence of stroke and it is unclear whether routine, further contact with a physiotherapy service is beneficial. Two single-centre, randomized controlled trials of physiotherapy for patients more than one year post stroke have been undertaken in Oxford and Bradford in the UK and the results from these two trials have been combined to give a more precise estimate of effectiveness.

Method: The computerized databases from both trials were combined for a joint analysis. Outcome measures common to both trials were: Rivermead Mobility Index; gait speed measured over 10 metres; Barthel Index; Frenchay Activities Index; Hospital Anxiety and Depression Scale.

Results: There were 264 patients available for the combined analysis (Oxford= 94; Bradford= 170). There was a significant but clinically small improvement in mobility at three months in the combined treatment group measured by the Rivermead Mobility Index (median of the differences= 0 (95% confidence interval (CI) 0, 1); interpolated values= 0.43 (95% CI 0.08, 0.80)) and gait speed (treatment effect 2.7 m/min (95% CI 0.94, 4.46)). There were no other significant differences. Intervention given in both studies was at the discretion of the physiotherapists and was of similar and low intensity (mean visits Oxford= 4 (SD 2.5); Bradford= 5 (SD 4.5)).

Conclusion: A more effective physiotherapy intervention is required for stroke patients with persisting mobility problems after stroke.

Post-stroke care: an alternative model to reduce stroke related morbidity in sub-Saharan Africa

Stroke is a leading cause of death and disability in adults in sub-Saharan Africa (SSA). Despite its considerable burden, there has been limited progress to properly cater for and rehabilitate stroke survivors. Scarcity of rehabilitation services and grossly inadequate skilled personnel for post stroke care are distressing realities for stroke victims in SSA. There is growing evidence suggesting that home-based rehabilitation for stroke can have functional outcomes similar to patients who receive inpatient neuro-rehabilitation. The acute phase of treatment during hospitalization could be an opportunity to educate families and caregivers on how to care for stroke victims at home and provide home-based rehabilitation and care tailored to their disability. Interventions to vulgarize home-based post-stroke care could be more acceptable, affordable and accessible for victims and families. This could go a long way to palliate to the scarcity of rehabilitation services and reduce stroke related morbidity. We suggest that further research be carried out to ascertain the feasibility of this model in SSA settings, with greater emphasis on the cost effectiveness and sustainability arms of such an intervention.

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

Stroke is a leading cause of serious, long-term disability, the effects of which may be prolonged with physical, emotional, social, and financial consequences not only for those affected but also for their family and friends. Evidence for the effectiveness of stroke unit care and the benefits of thrombolysis have transformed treatment for people after stroke. Previously viewed nihilistically, stroke is now seen as a medical emergency with clear evidence-based care pathways from hospital admission to discharge. However, stroke remains a complex clinical condition that requires health professionals to work together to bring to bear their collective knowledge and specialist skills for the benefit of stroke survivors. Multidisciplinary team working is regarded as fundamental to delivering effective care across the stroke pathway. This paper discusses the contribution of team working in improving recovery at key points in the post-stroke pathway.

Medical day hospital care for older people versus alternative forms of care

BACKGROUND

The proportion of the world's population aged over 60 years is increasing. Therefore, there is a need to examine different methods of healthcare provision for this population. Medical day hospitals provide multidisciplinary health services to older people in one location.

OBJECTIVES

To examine the effectiveness of medical day hospitals for older people in preventing death, disability, institutionalisation and improving subjective health status.

SEARCH METHODS

Our search included the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register of Studies, CENTRAL (2013, Issue 7), MEDLINE via Ovid (1950-2013 ), EMBASE via Ovid (1947-2013) and CINAHL via EbscoHost (1980-2013). We also conducted cited reference searches, searched conference proceedings and trial registries, hand searched select journals, and contacted relevant authors and researchers to inquire about additional data.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing medical day hospitals with alternative care for older people (mean/median > 60 years of age).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias and extracted data from included trials. We used standard methodological procedures expected by the Cochrane Collaboration. Trials were sub-categorised as comprehensive care, domiciliary care or no comprehensive care.

MAIN RESULTS

Sixteen trials (3689 participants) compared day hospitals with comprehensive care (five trials), domiciliary care (seven trials) or no comprehensive care (four trials). Overall there was low quality evidence from these trials for the following results.For the outcome of death, there was no strong evidence for or against day hospitals compared to other treatments overall (odds ratio (OR) 1.05; 95% CI 0.85 to 1.28; P = 0.66), or to comprehensive care (OR 1.26; 95% CI 0.87 to 1.82; P = 0.22), domiciliary care (OR 0.97; 95% CI 0.61 to 1.55; P = 0.89), or no comprehensive care (OR 0.88; 95% CI 0.63 to 1.22; P = 0.43).For the outcome of death or deterioration in activities of daily living (ADL), there was no strong evidence for day hospital attendance compared to other treatments (OR 1.07; 95% CI 0.76 to 1.49; P = 0.70), or to comprehensive care (OR 1.18; 95% CI 0.63 to 2.18; P = 0.61), domiciliary care (OR 1.41; 95% CI 0.82 to 2.42; P = 0.21) or no comprehensive care (OR 0.76; 95% CI 0.56 to 1.05; P = 0.09).For the outcome of death or poor outcome (institutional care, dependency, deterioration in physical function), there was no strong evidence for day hospitals compared to other treatments (OR 0.92; 95% CI 0.74 to 1.15; P = 0.49), or compared to comprehensive care (OR 1.05; 95% CI 0.79 to 1.40; P = 0.74) or domiciliary care (OR 1.08; 95% CI 0.67 to 1.74; P = 0.75). However, compared with no comprehensive care there was a difference in favour of day hospitals (OR 0.72; 95% CI 0.53 to 0.99; P = 0.04).For the outcome of death or institutional care, there was no strong evidence for day hospitals compared to other treatments overall (OR 0.85; 95% CI 0.63 to 1.14; P = 0.28), or to comprehensive care (OR 1.00; 95% CI 0.69 to 1.44; P = 0.99), domiciliary care (OR 1.05; 95% CI 0.57 to1.92; P = 0. 88) or no comprehensive care (OR 0.63; 95% CI 0.40 to 1.00; P = 0.05).For the outcome of deterioration in ADL, there was no strong evidence that day hospital attendance had a different effect than other treatments overall (OR 1.11; 95% CI 0.68 to 1.80; P = 0.67) or compared with comprehensive care (OR 1.21; 0.58 to 2.52; P = 0.61), or domiciliary care (OR 1.59; 95% CI 0.87 to 2.90; P = 0.13). However, day hospital patients showed a reduced odds of deterioration compared with those receiving no comprehensive care (OR 0.61; 95% CI 0.38 to 0.97; P = 0.04) and significant subgroup differences (P = 0.04).For the outcome of requiring institutional care, there was no strong evidence for day hospitals compared to other treatments (OR 0.84; 95% CI 0.58 to 1.21; P = 0.35), or to comprehensive care (OR 0.91; 95% CI 0.70 to 1.19; P = 0.49), domiciliary care (OR 1.49; 95% CI 0.53 to 4.25; P = 0.45), or no comprehensive care (OR 0.58; 95% CI 0.28 to 1.20; P = 0.14).

AUTHORS' CONCLUSIONS

There is low quality evidence that medical day hospitals appear effective compared to no comprehensive care for the combined outcome of death or poor outcome, and for deterioration in ADL. There is no clear evidence for other outcomes, or an advantage over other medical care provision.

The effect of post-stroke depression on rehabilitation outcome and the impact of caregiver type as a factor of post-stroke depression

OBJECTIVE

To evaluate the effect of post-stroke depression (PSD) on rehabilitation outcome and to investigate the risk factors of PSD, especially, the role of caregivers type (family or professional) in subacute stroke patients.

METHODS

Two hundred twenty-six stroke patients were enrolled retrospectively. All the subjects' basic characteristics, Korean version of the Beck Depression Inventory (K-BDI), Korean version of the Modified Barthel Index (K-MBI), and the modified Rankin Scale (mRS) were recorded when the patient was transferred into the Department of Rehabilitation Medicine and at the time of discharge. The results were statistically analyzed by using SPSS ver. 20.0.

RESULTS

The patients' K-BDI score showed a significantly negative association with K-MBI at discharge (β=-0.473, p<0.001) and a significantly positive association with the mRS score at discharge (β=0.316, p<0.001). Patients with lesions on the left hemisphere (odds ratio [OR], 3.882; 95% confidence interval [CI], 1.726-8.733) and professional caregiver support (OR, 0.028; 95% CI, 0.012-0.065) had a higher rate of depression.

CONCLUSION

Depression was prevalent in stroke patients, and it had a negative effect on patients' functional outcome. Patients who had a lesion on the right hemisphere had less depression. The type of caregiver was related to the incidence of subacute PSD, and family caregivers were found to lower the frequency of stroke patients' depression.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Evidence-Based Practice and Setting Basic Standards for Stroke Rehabilitation in Canada

It is a concern that the consistency of care in stroke rehabilitation appears to vary significantly among practice settings within Canada. Based upon an evidence-based review of stroke rehabilitation, a group of physiatrists from across Canada agreed to some basic standards for stroke rehabilitation. The following standards were deemed to be critical to providing effective stroke rehabilitation care: early assessment and quick access to specialized interdisciplinary rehabilitation, appropriate intensity of therapies, availability of outpatient therapy, appropriate community supports, and careful attention to secondary prevention of stroke. Providing stroke rehabilitation care consistently within these standards remains a challenge, particularly given the potential initial costs, despite significant improvements in patient outcomes and quality of life. Nevertheless, these standards should be the expectation of stroke patients, essentially forming a stroke rehabilitation "bill of rights."

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

BACKGROUND

Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

METHODS AND FINDINGS

Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

CONCLUSIONS

There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.

Effectiveness of a video-based therapy program at home after acute stroke: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of an intervention using video to deliver therapy at home for patients with stroke.

DESIGN

Randomized controlled trial.

SETTING

The neurology ward and rehabilitation medicine department of a tertiary hospital.

PARTICIPANTS

Patients with stroke (N=90). There were 44 patients in the intervention group and 46 patients in the control group.

INTERVENTIONS

The intervention group received a combination of at-home rehabilitation guided by a digital videodisk containing therapy techniques and twice-monthly outpatient follow-up for 3 months. The conventional therapy group (control) attended weekly outpatient therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the modified Barthel Index (MBI) score. The secondary measures were the incidence of poststroke complications and the Caregiver Strain Index.

RESULTS

At 3 months, there were no significant differences with regard to the number of patients with improved MBI score, complication rate, or Caregiver Strain Index score between the 2 groups. Both groups had significant increases in the MBI score at 3 months (P<.001 for both groups). Regression analysis revealed that only stroke severity significantly influenced the MBI score (P<.001), complication rate (P<.01), and caregiver stress level (P<.05).

CONCLUSIONS

Video-based therapy at home for post-acute stroke patients is safe, does not negatively impact independence, and is not stressful for caregivers.

[Therapeutic strategies in stroke aftercare. Contents and effects]

No generally accepted guidelines for stroke aftercare exist in Germany. This literature review summarizes the current evidence regarding the content and the effectiveness of aftercare strategies (exercise therapy, physiotherapy, occupational therapy) and their specific dose (intensity, duration, frequency). Exercise therapy (inter alia physiotherapy, resistance, endurance and gait training) has been shown to be effective for improving physical performance (strength, cardiopulmonary fitness, motor function) resulting in beneficial effects on gait, mobility and activities of daily living (ADL). As for the restoration of ADL and the resumption of social and leisure activities occupational therapy proved to be particularly effective. More research is needed to identify the specific effects of different aftercare strategies and their dose-response relationship to provide physicians a better foundation for therapy prescriptions.

Rehabilitation of older patients: day hospital compared with rehabilitation at home. Clinical outcomes

OBJECTIVES

to test the hypothesis that older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day hospital rehabilitation (DHR).

DESIGN

pragmatic randomised controlled trial.

SETTING

four geriatric day hospitals and four home rehabilitation teams in England.

PARTICIPANTS

eighty-nine patients referred for multidisciplinary rehabilitation. The target sample size was 460.

INTERVENTION

multidisciplinary rehabilitation either in the home or in the day hospital.

MEASUREMENTS

the primary outcome measure was the Nottingham extended activities of daily living scale (NEADL). Secondary outcome measures included EQ-5D, hospital anxiety and depression scale, therapy outcome measures, hospital admissions and the General Health Questionnaire for carers.

RESULTS

at the primary end point of 6 months NEADL scores were not significantly in favour of HBR cf. DHR; mean difference -2.139 (95% confidence interval -6.87 to 2.59, P = 0.37). A post hoc analysis suggested non-inferiority for HBR for NEADL but there was considerable statistical uncertainty.

CONCLUSION

taken together the statistical analyses and lack of power of the trial outcomes do not provide sufficient evidence to conclude that patients in receipt of HBR are disadvantaged compared with those receiving DHR.

Interprofessional stroke rehabilitation for stroke survivors using home care

OBJECTIVE

To compare a specialized interprofessional team approach to community-based stroke rehabilitation with usual home care for stroke survivors using home care services.

METHODS

Randomized controlled trial of 101 community-living stroke survivors (<18 months post-stroke) using home care services. Subjects were randomized to intervention (n=52) or control (n=49) groups. The intervention was a 12-month specialized, evidence-based rehabilitation strategy involving an interprofessional team. The primary outcome was change in health-related quality of life and functioning (SF-36) from baseline to 12 months. Secondary outcomes were number of strokes during the 12-month follow-up, and changes in community reintegration (RNLI), perceived social support (PRQ85-Part 2), anxiety and depressive symptoms (Kessler-10), cognitive function (SPMSQ), and costs of use of health services from baseline to 12 months.

RESULTS

A total of 82 subjects completed the 12-month follow-up. Compared with the usual care group, stroke survivors in the intervention group showed clinically important (although not statistically significant) greater improvements from baseline in mean SF-36 physical functioning score (5.87, 95% CI -3.98 to 15.7; p=0.24) and social functioning score (9.03, CI-7.50 to 25.6; p=0.28). The groups did not differ for any of the secondary effectiveness outcomes. There was a higher total per-person costs of use of health services in the intervention group compared to usual home care although the difference was not statistically significant (p=0.76).

CONCLUSIONS

A 12-month specialized, interprofessional team is a feasible and acceptable approach to community-based stroke rehabilitation that produced greater improvements in quality of life compared to usual home care. Clinicaltrials.gov identifier: NCT00463229.

Rehabilitation for Community-Dwelling People with Stroke: Home or Centre Based? a Systematic Review

Stroke rehabilitation for people living in the community is commonly delivered either in a centre, outpatient or day hospital setting. More recently, services may be offered in the actual home of the person as home-based or domiciliary rehabilitation. There are differing reports of the benefits and barriers of home-based vs. centre-based community rehabilitation. This systematic review sought to pool data from all retrieved studies that compared the functional benefits of home-based vs. centre for community-dwelling people with stroke. A comprehensive search strategy was implemented in all major databases (Cochrane library, Medline, AMED, Embase, Ageline, Cinahl, PEDro) for randomised controlled trials investigating this question in relation to functional benefits as a primary outcome and carer, cost or other benefits as secondary outcomes. There were no language or date limits. Eleven trials were found and results pooled for the Barthel Index, the measure of functional independence used consistently across the majority of retrieved studies. There was a significant effect in favour of home-based rehabilitation at 6 weeks ( P = 0·03) and 3–6 months ( P = 0·01). The effects were less clear at 6 months, although this was using the less sensitive version of the Barthel Index ( P = 0·27 or adjusted P = 0·04). Individual studies reported cost benefits and increased carer satisfaction in favour of home-based rehabilitation. The provision of rehabilitation for people living in the community should trend towards home-based. Further research is required into adverse events and the experiences of all stakeholders.

Design and Usability of a Home Telerehabilitation System to Train Hand Recovery Following Stroke

Current theories of stroke rehabilitation point toward paradigms of intense concentrated use of the afflicted limb as a means for motor program reorganization and partial function restoration. A home-based system for stroke rehabilitation that trains recovery of hand function by a treatment of concentrated movement was developed and tested. A wearable goniometer measured finger and wrist motions in both hands. An interface box transmitted sensor measurements in real-time to a laptop computer. Stroke patients used joint motion to control the screen cursor in a one-dimensional tracking task for several hours a day over the course of 10–14 days to complete a treatment of 1800 tracking trials. A telemonitoring component enabled a therapist to check in with the patient by video phone to monitor progress, to motivate the patient, and to upload tracking data to a central file server. The system was designed for use at home by patients with no computer skills. The system was placed in the homes of 20 subjects with chronic stroke and impaired finger motion, ranging from 2–305 mi away from the clinic, plus one that was a distance of 1057 miles. Fifteen subjects installed the system at home themselves after instruction in the clinic, while nine required a home visit to install. Three required follow-up visits to fix equipment. A post-treatment telephone survey was conducted to assess ease of use and most responded that the system was easy to use. Functional improvements were seen in the subjects enrolled in the formal treatment study, although the treatment period was too short to trigger cortical reorganization. We conclude that the system is feasible for home use and that tracking training has promise as a treatment paradigm.

Overground physical therapy gait training for chronic stroke patients with mobility deficits

BACKGROUND

Overground gait training forms a major part of physical therapy services for chronic stroke patients in almost every setting. Overground gait training refers to physical therapists' observation and cueing of the patient's walking pattern along with related exercises, but does not include high-technology aids such as functional electrical stimulation or body weight support.

OBJECTIVES

To assess the effects of overground physical therapy gait training on walking ability for chronic stroke patients with mobility deficits.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched March 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2008), MEDLINE (1966 to May 2008), EMBASE (1980 to May 2008), CINAHL (1982 to May 2008), AMED (1985 to March 2008), Science Citation Index Expanded (1981 to May 2008), ISI Proceedings (Web of Science, 1982 to May 2006), Physiotherapy Evidence Database (http://www.pedro.org.au/) (May 2008), REHABDATA (http://www.naric.com/research/rehab/) (1956 to May 2008), http://www.clinicaltrials.gov (May 2008), http://www.controlled-trials.com/ (May 2008), and http://www.strokecenter.org/ (May 2008). We also searched reference lists of relevant articles, and contacted authors and trial investigators.

SELECTION CRITERIA

Randomised controlled trials comparing overground physical therapy gait training with a placebo intervention or no treatment for chronic stroke patients with mobility deficits.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently selected trials. Three authors independently extracted data and assessed quality. We contacted study authors for additional information.

MAIN RESULTS

We included nine studies involving 499 participants. We found no evidence for a benefit on the primary variable, post-test gait function, based on three studies with 269 participants. Uni-dimensional performance variables did show significant effects post-test. Gait speed increased by 0.07 metres per second (95% confidence interval (CI) 0.05 to 0.10) based on seven studies with 396 participants, timed up-and-go (TUG) test improved by 1.81 seconds (95% CI -2.29 to -1.33), and six-minute-walk test (6MWT) increased by 26.06 metres (95% CI 7.14 to 44.97) based on four studies with 181 participants. We found no significant differences in deaths/disabilities or in adverse effects, based on published reports or personal communication from all of the included studies.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine if overground physical therapy gait training benefits gait function in patients with chronic stroke, though limited evidence suggests small benefits for uni-dimensional variables such as gait speed or 6MWT. These findings must be replicated by large, high quality studies using varied outcome measures.

Medical day hospital care for the elderly versus alternative forms of care

BACKGROUND

The proportion of the world's population aged 60 or over is increasing. This review sets out to examine the effectiveness and resource implications of geriatric medical day hospital attendance for elderly people. This is an update of a Cochrane review first published in 1999.

OBJECTIVES

To examine the effectiveness of attendance at a medical day hospital for elderly people in preventing death, disability, and institutionalisation and improving subjective health status.

SEARCH STRATEGY

We searched the EPOC group specialist register (March 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2008), MEDLINE (1996 to January 2008), EMBASE (1996 to 2008 week 5), and other databases.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing attendance at a geriatric medical day hospital with alternative forms of care for elderly medical patients (usually > 60 years).

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed research reports to determine eligibility, categorise trial type and extract data.

MAIN RESULTS

Thirteen trials involving 3007 participants were included. These compared day hospital with a) comprehensive elderly care (five trials), b) domiciliary care (five trials), or c) no comprehensive elderly care (three trials).There were no significant differences between day hospital attendance and the sub-categories of comparison treatments for the outcomes of death, death or requiring institutional care, death or deterioration in ADL. When death or a 'poor' outcome at follow up was examined there was a significant difference in favour of day hospital attendance when compared to no comprehensive elderly care (odds ratio (OR) 0.73; 95% confidence interval (CI) 0.53 to 1.00; P < 0.05).Dependency was measured in 12 trials using a variety of ADL measures; two described short-term improvement for the day hospital group, one reported improved outcome for the comparison group, while in the remaining trials there was no statistically significant difference. Using the outcome of deterioration in ADL among survivors, day hospital patients showed a reduced odds of deterioration when compared with those receiving no comprehensive elderly care (OR 0.60; 95% CI 0.38 to 0.97; P < 0.05).When resource use was examined the day hospital group showed trends towards reductions in hospital bed use and placement of survivors in institutional care.

AUTHORS' CONCLUSIONS

Medical day hospital care for the elderly appears to be more effective than no intervention but may have no clear advantage over other forms of comprehensive elderly medical services.

Interventions for treating depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet is often not detected or inadequately treated. This is an update of a Cochrane review first published in 2004.

OBJECTIVES

To determine whether pharmaceutical, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome.

SEARCH STRATEGY

We searched the trials registers of the Cochrane Stroke Group (last searched October 2007) and the Cochrane Depression Anxiety and Neurosis Group (last searched February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006) and other databases. We also searched reference lists, clinical trials registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or various forms of psychotherapy or ECT with standard care (or attention control), in patients with stroke, with the intention of treating depression.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion and assessed methodological quality; three review authors extracted, cross-checked and entered data. Primary analyses were the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Sixteen trials (17 interventions), with 1655 participants, were included in the review. Data were available for 13 pharmaceutical agents, and four trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was some evidence of benefit of pharmacotherapy in terms of a complete remission of depression and a reduction (improvement) in scores on depression rating scales, but there was also evidence of an associated increase in adverse events. There was no evidence of benefit of psychotherapy.

AUTHORS' CONCLUSIONS

A small but significant effect of pharmacotherapy (not psychotherapy) on treating depression and reducing depressive symptoms was found, as was a significant increase in adverse events. More research is required before recommendations can be made about the routine use of such treatments.

Interventions for preventing depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet often is not detected or is inadequately treated.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent depression and improve physical and psychological outcomes in patients with stroke.

SEARCH STRATEGY

We searched the Trials Registers of the Cochrane Stroke Group (October 2007) and the Cochrane Depression Anxiety and Neurosis Group (February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006), Applied Science and Technology Plus (1986 to May 2006), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), BIOSIS Previews (2002 to May 2006), General Science Plus (1994 to September 2002), Science Citation Index (1992 to May 2006), Social Sciences Citation Index (1991 to May 2006), SocioFile (1974 to May 2006) ISI Web of Science (2002 to February 2008), reference lists, trial registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or psychotherapy against standard care (or attention control) to prevent depression in patients with stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed trial quality. Primary analyses were the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow up. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Fourteen trials involving 1515 participants were included. Data were available for 10 pharmaceutical trials (12 comparisons) and four psychotherapy trials. The time from stroke to entry ranged from a few hours to seven months, but most patients were recruited within one month of acute stroke. The duration of treatment ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or other endpoints. A significant improvement in mood and the prevention of depression was evident for psychotherapy, but the treatment effects were small.

AUTHORS' CONCLUSIONS

A small but significant effect of psychotherapy on improving mood and preventing depression was identified. More evidence is required before recommendations can be made about the routine use of such treatments after stroke.

Therapy-based rehabilitation services for patients living at home more than one year after stroke

BACKGROUND

Current practice of rehabilitation intervention mainly concentrates on the first six months of stroke. At present, there is no agreed consensus about the benefits of such a service more than one year after stroke.

OBJECTIVES

To ascertain whether therapy-based rehabilitation services can influence outcome one year or more after stroke.

SEARCH STRATEGY

We searched the trials registers of the following Cochrane Review Groups: Stroke Group (last searched September 2007), Effective Practice and Organisation of Care Group (last searched October 2006) and Dementia and Cognitive Improvement Group (last searched October 2006). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2006), MEDLINE (1966 to October 2006), EMBASE (1980 to October 2006), CINAHL (1982 to October 2006), AMED (1985 to October 2006), PEDro (1952 to October 2006), British Nursing Index (1993 to October 2006), DARE (1994 to October 2006), HMIC (1979 to October 2006) and NHS EED (1991 to October 2006). We also searched dissertation databases and ongoing trials and research registers, scanned reference lists and contacted researchers and experts in the field.

SELECTION CRITERIA

All randomised controlled trials of community-based stroke patients, in which at least 75% were recruited one year after stroke and received a therapy-based rehabilitation intervention that was compared with conventional care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data on a number of pre-specified outcomes. The primary outcomes were the proportion of participants who had deteriorated or were dependent in personal activities of daily living at the end of scheduled follow up.

MAIN RESULTS

We identified five trials of 487 participants that were eligible for the review. Overall, there was inconclusive evidence as to whether therapy-based rehabilitation intervention one year after stroke was able to influence any relevant patient or carer outcome. Trials varied in design, type of interventions provided, quality, and outcomes assessed.

AUTHORS' CONCLUSIONS

This review highlights the dearth of evidence investigating long-term therapy-based rehabilitation interventions for patients with stroke.

Rehabilitation needs for older adults with stroke living at home: perceptions of four populations

BACKGROUND

Many people who have suffered a stroke require rehabilitation to help them resume their previous activities and roles in their own environment, but only some of them receive inpatient or even outpatient rehabilitation services. Partial and unmet rehabilitation needs may ultimately lead to a loss of functional autonomy, which increases utilization of health services, number of hospitalizations and early institutionalization, leading to a significant psychological and financial burden on the patients, their families and the health care system. The aim of this study was to explore partially met and unmet rehabilitation needs of older adults who had suffered a stroke and who live in the community. The emphasis was put on needs that act as obstacles to social participation in terms of personal factors, environmental factors and life habits, from the point of view of four target populations.

METHODS

Using the focus group technique, we met four types of experts living in three geographic areas of the province of Québec (Canada): older people with stroke, caregivers, health professionals and health care managers, for a total of 12 groups and 72 participants. The audio recordings of the meetings were transcribed and NVivo software was used to manage the data. The process of reducing, categorizing and analyzing the data was conducted using themes from the Disability Creation Process model.

RESULTS

Rehabilitation needs persist for nine capabilities (e.g. related to behaviour or motor activities), nine factors related to the environment (e.g. type of teaching, adaptation and rehabilitation) and 11 life habits (e.g. nutrition, interpersonal relationships). The caregivers and health professionals identified more unmet needs and insisted on an individualized rehabilitation. Older people with stroke and the health care managers had a more global view of rehabilitation needs and emphasized the availability of resources.

CONCLUSION

Better knowledge of partially met or unmet rehabilitation needs expressed by the different types of people involved should lead to increased attention being paid to education for caregivers, orientation of caregivers towards resources in the community, and follow-up of patients' needs in terms of adjustment and rehabilitation, whether for improving their skills or for carrying out their activities of daily living.

Can we improve the statistical analysis of stroke trials? Statistical reanalysis of functional outcomes in stroke trials

BACKGROUND AND PURPOSE

Most large acute stroke trials have been neutral. Functional outcome is usually analyzed using a yes or no answer, eg, death or dependency versus independence. We assessed which statistical approaches are most efficient in analyzing outcomes from stroke trials.

METHODS

Individual patient data from acute, rehabilitation and stroke unit trials studying the effects of interventions which alter functional outcome were assessed. Outcomes included modified Rankin Scale, Barthel Index, and "3 questions". Data were analyzed using a variety of approaches which compare 2 treatment groups. The results for each statistical test for each trial were then compared.

RESULTS

Data from 55 datasets were obtained (47 trials, 54,173 patients). The test results differed substantially so that approaches which use the ordered nature of functional outcome data (ordinal logistic regression, t test, robust ranks test, bootstrapping the difference in mean rank) were more efficient statistically than those which collapse the data into 2 groups (chi(2); ANOVA, P<0.001). The findings were consistent across different types and sizes of trial and for the different measures of functional outcome.

CONCLUSIONS

When analyzing functional outcome from stroke trials, statistical tests which use the original ordered data are more efficient and more likely to yield reliable results. Suitable approaches included ordinal logistic regression, t test, and robust ranks test.

Domiciliary therapy during inpatient rehabilitation treatment for patients with an acquired brain injury: a preliminary study

The objective was to assess the feasibility of additional domiciliary treatment for patients with an acquired brain injury while they are still inpatients at a rehabilitation centre. This cohort study included 22 patients with an acquired brain injury (mainly stroke) and with moderate to severe neuropsychological deficits. After two observational home visits for goal setting to determine the aim of the treatment, domiciliary treatment was given once a week in addition to the therapy at the rehabilitation centre. The number of home visits depended on the time interval between admission and time of inclusion in the study. The main outcome measures were (1) a semi-structured interview with patients and partners or children, (2) a questionnaire filled in by the attending therapist(s) before and after each therapeutic home visit and (3) the functional level of the patient. All but one of the patients and all partners and therapists were satisfied with the domiciliary treatment. Most of the main goals were attained during the treatment. The main goals during the domiciliary treatment were in the domains of domestic activities and leisure. A 90--120 min duration of the treatment sessions seems most feasible. It was concluded that domiciliary treatment for inpatients is feasible and seems useful for patients with moderate to severe cognitive impairments.

An exploration looking at the impact of domiciliary and day hospital delivery of stroke rehabilitation on informal carers

OBJECTIVES

To explore the impact of two methods of post-hospital stroke rehabilitation on both carers' perceptions of the health services offered and their quality of life.

SETTING

East Dorset Health Authority.

SUBJECTS

Forty-six informal carers were recruited from a sample of 106, initially identified from stroke patients participating in a larger randomized controlled trial.

DESIGN

Qualitative methods.

METHODS

Semi-structured interviews were used at baseline and six months to explore carers' perception of a good therapy, the advantages and disadvantages of the different services and their fulfilment with the services. In-depth thematic analysis was carried out to explore the impact of the two different methods of service delivery on carers' quality of life.

RESULTS

Day hospitals provided carers with respite opportunities, whilst domiciliary stroke teams provided carers with better educational opportunities to be involved in therapy. No qualitative difference was found in the impact that the different services had on carers' quality of life, which were influenced by factors such as the degree of disruption that caring had on their lives, the loss of a shared life and the availability of social support. Ultimately, carers saw the services as providing benefit for survivors and not themselves.

CONCLUSIONS

Domiciliary stroke teams provided informal stroke carers with skills that could help improve postdischarge stroke rehabilitation amongst stroke survivors. Informal carers also benefited from the respite elements of day hospital. A mixed model using both domiciliary care and day hospital care, could provide carers with the benefits of education, convenience and respite.