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Williams NH, Roberts JL, Din NU, Charles JM, Totton N, Williams M, Mawdesley K, Hawkes CA, Morrison V, Lemmey A, Edwards RT, Hoare Z, Pritchard AW, Woods RT, Alexander S, Sackley C, Logan P, Wilkinson C, Rycroft-Malone J. Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR). Health Technol Assess 2018; 21:1-528. [PMID: 28836493 DOI: 10.3310/hta21440] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking. OBJECTIVES To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation. DESIGN Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study. SETTING Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge. PARTICIPANTS Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area. INTERVENTIONS Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions. MAIN OUTCOME MEASURES The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers. RESULTS Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported. CONCLUSIONS Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure. TRIAL REGISTRATION Current Controlled Trials ISRCTN22464643. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.
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Affiliation(s)
- Nefyn H Williams
- School of Healthcare Sciences, Bangor University, Bangor, UK.,Betsi Cadwaladr University Health Board, St Asaph, UK
| | | | - Nafees Ud Din
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | | | - Nicola Totton
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | | | - Kevin Mawdesley
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Claire A Hawkes
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Val Morrison
- School of Psychology, Bangor University, Bangor, UK
| | - Andrew Lemmey
- School of Sports, Health and Exercise Science, Bangor University, Bangor, UK
| | | | - Zoe Hoare
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | | | - Robert T Woods
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | | | - Catherine Sackley
- School of Health and Social Care Research, King's College London, London, UK
| | - Pip Logan
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Clare Wilkinson
- School of Healthcare Sciences, Bangor University, Bangor, UK
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Roberts JL, Din NU, Williams M, Hawkes CA, Charles JM, Hoare Z, Morrison V, Alexander S, Lemmey A, Sackley C, Logan P, Wilkinson C, Rycroft-Malone J, Williams NH. Development of an evidence-based complex intervention for community rehabilitation of patients with hip fracture using realist review, survey and focus groups. BMJ Open 2017; 7:e014362. [PMID: 29025824 PMCID: PMC5652569 DOI: 10.1136/bmjopen-2016-014362] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 08/16/2017] [Accepted: 08/23/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To develop an evidence and theory-based complex intervention for improving outcomes in elderly patients following hip fracture. DESIGN Complex-intervention development (Medical Research Council (MRC) framework phase I) using realist literature review, surveys and focus groups of patients and rehabilitation teams. SETTING North Wales. PARTICIPANTS Surveys of therapy managers (n=13), community and hospital-based physiotherapists (n=129) and occupational therapists (n=68) throughout the UK. Focus groups with patients (n=13), their carers (n=4) and members of the multidisciplinary rehabilitation teams in North Wales (n=13). RESULTS The realist review provided understanding of how rehabilitation interventions work in the real-world context and three programme theories were developed: improving patient engagement by tailoring the intervention to individual needs; reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living; and coordination of rehabilitation delivery. The survey provided context about usual rehabilitation practice; focus groups provided data on the experience, acceptability and feasibility of rehabilitation interventions. An intervention to enhance usual rehabilitation was developed to target these theory areas comprising: a physical component consisting of six additional therapy sessions; and a psychological component consisting of a workbook to enhance self-efficacy and a patient-held goal-setting diary for self-monitoring. CONCLUSIONS A realist approach may have advantages in the development of evidence-based interventions and can be used in conjunction with other established methods to contribute to the development of potentially more effective interventions. A rehabilitation intervention was developed which can be tested in a future randomised controlled trial (MRC framework phases II and III). TRIAL REGISTRATION NUMBER ISRCTN22464643, Pre-results.
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Affiliation(s)
| | - Nafees Ud Din
- School of Healthcare Sciences, Bangor University, Bangor, Gwynedd, UK
| | - Michelle Williams
- School of Healthcare Sciences, Bangor University, Bangor, Gwynedd, UK
| | - Claire A Hawkes
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Joanna M Charles
- School of Healthcare Sciences, Bangor University, Bangor, Gwynedd, UK
| | - Zoe Hoare
- School of Healthcare Sciences, Bangor University, Bangor, Gwynedd, UK
| | - Val Morrison
- School of Psychology, Bangor University, Bangor, Gwynedd, UK
| | | | - Andrew Lemmey
- School of Sports, Health and Exercise Science, Bangor University, Bangor, Gwynedd, UK
| | - Catherine Sackley
- Division of Health and Social Care Research, King's College, London, UK
| | - Phillipa Logan
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Clare Wilkinson
- School of Healthcare Sciences, Bangor University, Bangor, Gwynedd, UK
| | - Jo Rycroft-Malone
- School of Healthcare Sciences, Bangor University, Bangor, Gwynedd, UK
| | - Nefyn H Williams
- School of Healthcare Sciences, Bangor University, Bangor, Gwynedd, UK
- Betsi Cadwaladr University Health Board, Bangor, Gwynedd, UK
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Knapp P, Campbell Burton CA, Holmes J, Murray J, Gillespie D, Lightbody CE, Watkins CL, Chun HY, Lewis SR. Interventions for treating anxiety after stroke. Cochrane Database Syst Rev 2017; 5:CD008860. [PMID: 28535332 PMCID: PMC6481423 DOI: 10.1002/14651858.cd008860.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Approximately 20% of stroke patients experience clinically significant levels of anxiety at some point after stroke. Physicians can treat these patients with antidepressants or other anxiety-reducing drugs, or both, or they can provide psychological therapy. This review looks at available evidence for these interventions. This is an update of the review first published in October 2011. OBJECTIVES The primary objective was to assess the effectiveness of pharmaceutical, psychological, complementary, or alternative therapeutic interventions in treating stroke patients with anxiety disorders or symptoms. The secondary objective was to identify whether any of these interventions for anxiety had an effect on quality of life, disability, depression, social participation, caregiver burden, or risk of death. SEARCH METHODS We searched the trials register of the Cochrane Stroke Group (January 2017). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2017, Issue 1: searched January 2017); MEDLINE (1966 to January 2017) in Ovid; Embase (1980 to January 2017) in Ovid; the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1937 to January 2017) in EBSCO; and PsycINFO (1800 to January 2017) in Ovid. We conducted backward citation searches of reviews identified through database searches and forward citation searches of included studies. We contacted researchers known to be involved in related trials, and we searched clinical trials registers for ongoing studies. SELECTION CRITERIA We included randomised trials including participants with a diagnosis of both stroke and anxiety for which treatment was intended to reduce anxiety. Two review authors independently screened and selected titles and abstracts for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. We performed a narrative review. We planned to do a meta-analysis but were unable to do so as included studies were not sufficiently comparable. MAIN RESULTS We included three trials (four interventions) involving 196 participants with stroke and co-morbid anxiety. One trial (described as a 'pilot study') randomised 21 community-dwelling stroke survivors to four-week use of a relaxation CD or to wait list control. This trial assessed anxiety using the Hospital Anxiety and Depression Scale and reported a reduction in anxiety at three months among participants who had used the relaxation CD (mean (standard deviation (SD) 6.9 (± 4.9) and 11.0 (± 3.9)), Cohen's d = 0.926, P value = 0.001; 19 participants analysed).The second trial randomised 81 participants with co-morbid anxiety and depression to paroxetine, paroxetine plus psychotherapy, or standard care. Mean levels of anxiety severity scores based on the Hamilton Anxiety Scale (HAM-A) at follow-up were 5.4 (SD ± 1.7), 3.8 (SD ± 1.8), and 12.8 (SD ± 1.9), respectively (P value < 0.01).The third trial randomised 94 stroke patients, also with co-morbid anxiety and depression, to receive buspirone hydrochloride or standard care. At follow-up, the mean levels of anxiety based on the HAM-A were 6.5 (SD ± 3.1) and 12.6 (SD ± 3.4) in the two groups, respectively, which represents a significant difference (P value < 0.01). Half of the participants receiving paroxetine experienced adverse events that included nausea, vomiting, or dizziness; however, only 14% of those receiving buspirone experienced nausea or palpitations. Trial authors provided no information about the duration of symptoms associated with adverse events. The trial of relaxation therapy reported no adverse events.The quality of the evidence was very low. Each study included a small number of participants, particularly the study of relaxation therapy. Studies of pharmacological agents presented details too limited to allow judgement of selection, performance, and detection bias and lack of placebo treatment in control groups. Although the study of relaxation therapy had allocated participants to treatment using an adequate method of randomisation, study recruitment methods might have introduced bias, and drop-outs in the intervention group may have influenced results. AUTHORS' CONCLUSIONS Evidence is insufficient to guide the treatment of anxiety after stroke. Further well-conducted randomised controlled trials (using placebo or attention controls) are required to assess pharmacological agents and psychological therapies.
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Affiliation(s)
- Peter Knapp
- University of YorkDepartment of Health SciencesYorkUKYO10 5DD
| | | | - John Holmes
- Leeds and York Partnership NHS Foundation TrustHospital Mental Health Team for Older PeopleBasement Office, Beckett WingSt James University Hospital, Beckett StreetLeedsUKLS9 7TF
| | - Jenni Murray
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation TrustYorkshire Quality and Safety Research GroupTemple Bank House, Bradford Royal InfirmaryDuckworth LaneBradfordUKBD9 6RJ
| | - David Gillespie
- Astley Ainslie HospitalDepartment of Neuropsychology133 Grange LoanEdinburghUKEH9 2HL
| | - C. Elizabeth Lightbody
- University of Central LancashireCollege of Health and WellbeingPrestonUKPR1 2HE
- Australian Catholic UniversityNew South WalesAustralia
| | | | - Ho‐Yan Y Chun
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety Research DepartmentPointer Court 1, Ashton RoadLancasterUKLA1 4RP
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Forster A, Brown L, Smith J, House A, Knapp P, Wright JJ, Young J. Information provision for stroke patients and their caregivers. Cochrane Database Syst Rev 2012; 11:CD001919. [PMID: 23152210 PMCID: PMC6544775 DOI: 10.1002/14651858.cd001919.pub3] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Research shows that stroke patients and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues. OBJECTIVES To assess the effectiveness of information provision strategies in improving the outcome for stroke patients or their identified caregivers, or both. SEARCH METHODS For this update we searched the Cochrane Stroke Group Trials Register (June 2012), the Cochrane Central Register of Controlled trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the NHS Economic Evaluation Database (EED), and the Health Technology Assessment (HTA) Database (The Cochrane Library June, 2012), MEDLINE (1966 to June 2012), EMBASE (1980 to June 2012), CINAHL (1982 to June 2012) and PsycINFO (1974 to June 2012). We also searched ongoing trials registers, scanned bibliographies of relevant articles and books and contacted researchers. SELECTION CRITERIA Randomised trials involving patients or carers of patients with a clinical diagnosis of stroke or transient ischaemic attack (TIA) where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and methodological quality and extracted data. Primary outcomes were knowledge about stroke and stroke services, and impact on mood. MAIN RESULTS We have added four new trials to this update. This review now includes 21 trials involving 2289 patient and 1290 carer participants. Nine trials evaluated a passive and 12 trials an active information intervention. Meta-analyses showed a significant effect in favour of the intervention on patient knowledge (standardised mean difference (SMD) 0.29, 95% confidence interval (CI) 0.12 to 0.46, P < 0.001), carer knowledge (SMD 0.74, 95% CI 0.06 to 1.43, P = 0.03), one aspect of patient satisfaction (odds ratio (OR) 2.07, 95% CI 1.33 to 3.23, P = 0.001), and patient depression scores (mean difference (MD) -0.52, 95% CI -0.93 to -0.10, P = 0.01). There was no significant effect (P > 0.05) on number of cases of anxiety or depression in patients, carer mood or satisfaction, or death. Qualitative analyses found no strong evidence of an effect on other outcomes. Post-hoc subgroup analyses showed that active information had a significantly greater effect than passive information on patient mood but not on other outcomes. AUTHORS' CONCLUSIONS There is evidence that information improves patient and carer knowledge of stroke, aspects of patient satisfaction, and reduces patient depression scores. However, the reduction in depression scores was small and may not be clinically significant. Although the best way to provide information is still unclear there is some evidence that strategies that actively involve patients and carers and include planned follow-up for clarification and reinforcement have a greater effect on patient mood.
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Affiliation(s)
- Anne Forster
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford, UK.
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Jones F, Riazi A, Norris M. Self-management after stroke: time for some more questions? Disabil Rehabil 2012; 35:257-64. [DOI: 10.3109/09638288.2012.691938] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Campbell Burton CA, Holmes J, Murray J, Gillespie D, Lightbody CE, Watkins CL, Knapp P. Interventions for treating anxiety after stroke. Cochrane Database Syst Rev 2011:CD008860. [PMID: 22161439 DOI: 10.1002/14651858.cd008860.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Approximately 20% of stroke patients experience anxiety at some point after stroke. OBJECTIVES To determine if any treatment for anxiety after stroke decreases the proportion of patients with anxiety disorders or symptoms, and to determine the effect of treatment on quality of life, disability, depression, social participation, risk of death or caregiver burden. SEARCH METHODS We searched the trials register of the Cochrane Stroke Group (October 2010), CENTRAL (The Cochrane Library 2010, Issue 4), MEDLINE (1950 to October 2010), EMBASE (1947 to October 2010), PsycINFO (1806 to October 2010), Allied and Complementary Medicine database (AMED) (1985 to October 2010), Cumulative Index to Nursing and Allied Health (CINAHL) (1982 to October 2010), Proquest Digital Dissertations (1861 to October 2010), and Psychological Database for Brain Impairment Treatment Efficacy (PsycBITE) (2004 to October 2010). In an effort to identify further published, unpublished and ongoing trials, we searched trial registries and major international stroke conference proceedings, scanned reference lists, and contacted select individuals known to the review team who are actively involved in psychological aspects of stroke research, and the Association of the British Pharmaceutical Industry. SELECTION CRITERIA Two review authors independently screened and selected titles and abstracts for inclusion in the review. Randomised trials of any intervention in patients with stroke where the treatment of anxiety was an outcome were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data for analysis. We performed a narrative review. A meta-analysis was planned but not carried out as studies were not of sufficient quality to warrant doing so. MAIN RESULTS We included two trials (three interventions) involving 175 participants with co-morbid anxiety and depression in the review. Both trials used the Hamilton Anxiety Scale (HAM-A) to assess anxiety, and neither included a placebo control group. One trial randomised 81 patients to paroxetine, paroxetine plus psychotherapy or standard care. Mean level of anxiety severity scores were 58% and 71% lower in the paroxetine, and paroxetine plus psychotherapy groups respectively compared with those in standard care at follow-up (P < 0.01). The second trial randomised 94 stroke patients, also with co-morbid anxiety and depression, to receive buspirone hydrochloride or standard care. At follow-up, the mean level of anxiety was significantly lower for those receiving buspirone relative to controls (P < 0.01). Half of the participants receiving paroxetine experienced adverse events that included nausea, vomiting or dizziness; however, only 14% of those receiving buspirone experienced nausea or palpitations. No information was provided about the duration of symptoms associated with adverse events. AUTHORS' CONCLUSIONS There is insufficient evidence to guide the treatment of anxiety after stroke. The data available suggest that pharmaceutical therapy (paroxetine and buspirone) may be effective in reducing anxiety symptoms in stroke patients with co-morbid anxiety and depression. No information was available for stroke patients with anxiety only. Randomised placebo controlled trials are needed.
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Ellis G, Mant J, Langhorne P, Dennis M, Winner S. Stroke liaison workers for stroke patients and carers: an individual patient data meta-analysis. Cochrane Database Syst Rev 2010; 2010:CD005066. [PMID: 20464736 PMCID: PMC6464840 DOI: 10.1002/14651858.cd005066.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Many patients experience depression, social isolation and anxiety post stroke. These are associated with a poorer outcome. Ameliorating these problems may improve patient wellbeing. OBJECTIVES To evaluate the impact of a healthcare worker or volunteer whose multi-dimensional roles have been grouped under the title 'stroke liaison worker'. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (searched February 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2009), MEDLINE (1966 to 2009), EMBASE (1980 to 2009) and four other databases. We performed a cited reference search, searched conference proceedings and trials registers, checked reference lists and contacted authors and trial investigators. SELECTION CRITERIA Randomised controlled trials investigating the impact of a stroke liaison worker versus usual care. DATA COLLECTION AND ANALYSIS We invited trialists to participate in a review of individual patient data. Primary outcomes for patients were subjective health status and extended activities of daily living. Primary outcomes for carers were subjective health status including measures of carer strain. MAIN RESULTS We included 16 trials involving 4759 participants. Analysis did not show a significant overall difference for subjective health status (standardised mean difference (SMD) -0.03, 95% confidence interval (CI) -0.11 to 0.04, P = 0.34) or extended activities of daily living (SMD 0.04, 95% CI -0.03 to 0.11, P = 0.22). There was no overall significant effect for the outcome of carer subjective health status (SMD 0.04, 95% CI -0.05 to 0.14, P = 0.37). Patients with mild to moderate disability (Barthel 15 to 19) had a significant reduction in dependence (odds ratio (OR) 0.62, 95% CI 0.44 to 0.87, P = 0.006). This would equate to 10 fewer dependent patients (95% CI 17 fewer to 4 fewer) for every 100 patients seen by the stroke liaison worker. Similar results were seen for the outcome of death or dependence for the subgroup with Barthel 15 to 19 (OR 0.55, 95% CI 0.38 to 0.81, P = 0.002). This risk difference equates to 11 fewer dead or dependent patients (95% CI 17 fewer to 4 fewer) for every 100 patients seen by the stroke liaison worker. AUTHORS' CONCLUSIONS There is no evidence for the effectiveness of this multifaceted intervention in improving outcomes for all groups of patients or carers. Patients with mild to moderate disability benefit from a reduction in death and disability. Patients and carers do report improved satisfaction with some aspects of service provision.
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Affiliation(s)
- Graham Ellis
- Monklands HospitalMedicine for the ElderlyMonkscourt AvenueAirdrieUKML6 0JS
| | - Jonathan Mant
- University of CambridgeGeneral Practice & Primary Care Research Unit, Department of Public Health & Primary CareForvie SiteAddenbrookes HospitalCambridgeUKCB2 0SR
| | - Peter Langhorne
- University of GlasgowAcademic Section of Geriatric Medicine3rd Floor, Centre BlockRoyal InfirmaryGlasgowUKG4 0SF
| | - Martin Dennis
- University of EdinburghDivision of Clinical NeurosciencesWestern General HospitalCrewe RoadEdinburghUKEH4 2XU
| | - Simon Winner
- Radcliffe InfirmaryDepartment of Clinical GeratologyOxfordUKOX2 6HE
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Smith J, Forster A, House A, Knapp P, Wright J, Young J. Information provision for stroke patients and their caregivers. Cochrane Database Syst Rev 2008:CD001919. [PMID: 18425877 DOI: 10.1002/14651858.cd001919.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Research shows that stroke patients and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues. OBJECTIVES To assess the effectiveness of information provision strategies in improving the outcome for stroke patients and/or their identified caregivers. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched May 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2007), MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007), CINAHL (1982 to March 2007), PsycINFO (1974 to March 2007), Science Citation Index and Social Science Citation Index (1981 to March 2007), Assia (1987 to March 2007), Index to UK theses (1970 to March 2007), Dissertation Abstracts (1961 to March 2007), ongoing trials and research registers, bibliographies of retrieved papers, relevant articles and books, and the Journal of Advanced Nursing. We also contacted researchers for additional information. SELECTION CRITERIA Randomised trials involving patients or carers of patients with a clinical diagnosis of stroke or transient ischaemic attack (TIA) where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and methodological quality and extracted data. Primary outcomes were knowledge about stroke and stroke services, and impact on mood. MAIN RESULTS Seventeen trials involving 1773 patient and 1058 carer participants were included. Eight evaluated a passive and nine an active information intervention. Meta-analyses showed a significant effect in favour of the intervention on patient and carer knowledge, one aspect of patient satisfaction, and patient depression scores. There was no significant effect on number of cases of anxiety or depression in patients, carer mood or satisfaction, or death. Qualitative analyses found no strong evidence of an effect on other outcomes. Post-hoc subgroup analyses showed that active information had a significantly greater effect than passive information on patient mood but not on other outcomes. AUTHORS' CONCLUSIONS There is evidence that information improves patient and carer knowledge of stroke, aspects of patient satisfaction, and reduces patient depression scores. However, the reduction in depression scores was small and probably clinically insignificant. Although the best way to provide information is still unclear there is some evidence that strategies that actively involve patients and carers and include planned follow up for clarification and reinforcement have a greater effect on patient mood.
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Affiliation(s)
- J Smith
- University of Leeds, Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK, BD9 6RJ.
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Johnston M, Bonetti D, Joice S, Pollard B, Morrison V, Francis JJ, Macwalter R. Recovery from disability after stroke as a target for a behavioural intervention: results of a randomized controlled trial. Disabil Rehabil 2007; 29:1117-27. [PMID: 17612998 DOI: 10.1080/03323310600950411] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Disability following stroke is highly prevalent and is predicted by psychological variables such as control cognitions and emotions, in addition to clinical variables. This study evaluated the effectiveness of a workbook-based intervention, designed to change cognitions about control, in improving outcomes for patients and their carers. METHOD At discharge, stroke patients were randomly allocated (with their carers) to a 5-week intervention (n = 103) or control (normal care: n = 100). The main outcome (at 6 months) was recovery from disability using a performance measure, with distress and satisfaction as additional outcomes. RESULTS The intervention group showed significantly better disability recovery, allowing for initial levels of disability, than those in the control group, F(1,201) = 5.61, p = 0.019. Groups did not differ in distress or satisfaction with care for patients or carers. The only psychological process variable improved by the intervention was Confidence in Recovery but this did not mediate the effects on recovery. CONCLUSIONS A large proportion of intervention participants did not complete the workbook tasks. This was perhaps associated with the fairly low level of personal contact with workbook providers. The modest success of this intervention suggests that it may be possible to develop effective behavioural interventions to enhance recovery from disability in stroke patients.
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Andersen HE, Eriksen K, Brown A, Schultz-Larsen K, Forchhammer BH. Follow-up services for stroke survivors after hospital discharge--a randomized control study. Clin Rehabil 2002; 16:593-603. [PMID: 12392333 DOI: 10.1191/0269215502cr528oa] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate whether follow-up services for stroke survivors could improve functional outcome and reduce readmission rate. In this paper results of functional outcome are reported. DESIGN Randomized controlled trial allocating patients to one of three different types of aftercare: (1) follow-up home visits by a physician, (2) physiotherapist instruction in the patient's home, or (3) standard aftercare. SUBJECTS Stroke patients with persisting impairment and disability who, after completing inpatient rehabilitation, were discharged to their homes. OUTCOME MEASURES Six months after discharge, functional outcome was assessed with Functional Quality of Movement, Barthel Index, Frenchay Activity Index and Index of Extended Activites of Daily Living. RESULTS One-hundred and fifty-five stroke patients were included in the study. Fifty-four received follow-up home visits by a physician, 53 were given instructions by a physiotherapist in their home and 48 received standard aftercare only. No statistically significant differences in functional outcome six months after discharge were demonstrated between the three groups. However, all measurements showed a tendency towards higher scores indicating better function in both interventions groups compared with the control group. CONCLUSION Follow-up services after stroke may be a way of improving functional outcome. The results of the present study should be evaluated in future trials. More research in this field is needed, especially studies of how to support stroke survivors to resume social and leisure activities.
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Forster A, Smith J, Young J, Knapp P, House A, Wright J. Information provision for stroke patients and their caregivers. Cochrane Database Syst Rev 2001:CD001919. [PMID: 11687003 DOI: 10.1002/14651858.cd001919] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The provision of information has been recommended as a key component of service provision after stroke. However, research suggests that patients' understanding of stroke and associated issues remains poor. We determined to undertake a systematic review of information provision strategies for patients and their carers after stroke. OBJECTIVES To examine the effectiveness of an information and/or education strategy to improve the outcome of stroke patients and/or their identified caregivers. SEARCH STRATEGY Relevant trials were identified in the Cochrane Stroke Group Specialised Trials Register (last searched: June 2000). Additional intervention-based search strategies were developed for: The Cochrane Controlled Trials Register (CENTRAL/CCTR) Medline; Embase; CINAHL; ISI citation index; Science and Social Science Citation Indexes; ISI Web of Science Service; Aslib Index to UK theses; Dissertation Abstracts International, ASSIA and Psychlit/PsycINFO. We also searched the Journal of Advanced Nursing, bibliographies of retrieved papers, relevant articles and books. SELECTION CRITERIA Two or three investigators independently assessed trials and abstracts identified for eligibility, methodological quality and other participant characteristics. DATA COLLECTION AND ANALYSIS Data were extracted independently using piloted data extraction forms. The primary outcomes were knowledge about stroke and stroke services, and impact on health, specifically mood. MAIN RESULTS We identified 152 abstracts, of which 36 studies were potentially relevant to this review. The current analysis includes nine completed trials, a further eight studies are ongoing. Of the nine trials, three evaluated a programme of lectures and the remaining trials evaluated the provision of information. There is some evidence that information combined with educational sessions improved knowledge and was more effective than providing information only. Information provision only had no effect on mood, perceived health status or quality of life for patients or carers. Two trials used an objective measure of satisfaction and no significant differences were found between groups. One trial reported that information and education sessions for carers improved 'family functioning'. REVIEWER'S CONCLUSIONS The results of the review are limited by the variable quality of the trials and the wide range of outcome measures used. The general effectiveness of information provision has not been conclusively demonstrated. Future work should address the expressed needs of patients and carers and seek to identify appropriate teaching strategies which can be successfully implemented within clinical practice.
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Affiliation(s)
- A Forster
- Department of Health Care for the Elderly, St Luke's Hospital, Bradford, West Yorkshire, UK, BD5 ONA.
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Morrison V, Johnston M, Walter RM. Predictors of distress following an acute stroke: Disability, control cognitions, and satisfaction with care. Psychol Health 2000. [DOI: 10.1080/08870440008402001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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MacWalter RS, Coid DR, Fraser HW, Ersoy Y. The Dundee Stroke Register: experience of the first ten years. Scott Med J 1999; 44:103-5. [PMID: 10533207 DOI: 10.1177/003693309904400403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective to establish a register of all patients admitted to Dundee hospitals with acute stroke has been achieved. To do this a computerised database system has been established and a prospective survey has been conducted of clinical data of patients at time of admission, with follow-up at one and three years. All patients with a WHO diagnosis of acute stroke (excluding patients with subarachnoid haemorrhage), from January 1988 have been recorded. By the end of 1998, 3222 patients had been registered. The Dundee Stroke register database is the largest in Scotland and one of the largest in the world. The establishment of the register and database has required substantial investment of resources and the collaboration of the NHS, universities and the private sector. The operation of the register has heightened interest in stroke. It also provides present and future opportunities for clinical research and audit studies and the monitoring of outcomes.
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Affiliation(s)
- R S MacWalter
- Department of Medicine, Ninewells Hospital & Medical School, Dundee.
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