Study protocol: ICONS: identifying continence options after stroke: a randomised trial

Systematic voiding programme in adults with urinary incontinence following acute stroke: the ICONS-II RCT

BACKGROUND

Urinary incontinence affects around half of stroke survivors in the acute phase, and it often presents as a new problem after stroke or, if pre-existing, worsens significantly, adding to the disability and helplessness caused by neurological deficits. New management programmes after stroke are needed to address urinary incontinence early and effectively.

OBJECTIVE

The Identifying Continence OptioNs after Stroke (ICONS)-II trial aimed to evaluate the clinical effectiveness and cost-effectiveness of a systematic voiding programme for urinary incontinence after stroke in hospital.

DESIGN

This was a pragmatic, multicentre, individual-patient-randomised (1 : 1), parallel-group trial with an internal pilot.

SETTING

Eighteen NHS stroke services with stroke units took part.

PARTICIPANTS

Participants were adult men and women with acute stroke and urinary incontinence, including those with cognitive impairment.

INTERVENTION

Participants were randomised to the intervention, a systematic voiding programme, or to usual care. The systematic voiding programme comprised assessment, behavioural interventions (bladder training or prompted voiding) and review. The assessment included evaluation of the need for and possible removal of an indwelling urinary catheter. The intervention began within 24 hours of recruitment and continued until discharge from the stroke unit.

MAIN OUTCOME MEASURES

The primary outcome measure was severity of urinary incontinence (measured using the International Consultation on Incontinence Questionnaire) at 3 months post randomisation. Secondary outcome measures were taken at 3 and 6 months after randomisation and on discharge from the stroke unit. They included severity of urinary incontinence (at discharge and at 6 months), urinary symptoms, number of urinary tract infections, number of days indwelling urinary catheter was in situ, functional independence, quality of life, falls, mortality rate and costs. The trial statistician remained blinded until clinical effectiveness analysis was complete.

RESULTS

The planned sample size was 1024 participants, with 512 allocated to each of the intervention and the usual-care groups. The internal pilot did not meet the target for recruitment and was extended to March 2020, with changes made to address low recruitment. The trial was paused in March 2020 because of COVID-19, and was later stopped, at which point 157 participants had been randomised (intervention, n = 79; usual care, n = 78). There were major issues with attrition, with 45% of the primary outcome data missing: 56% of the intervention group data and 35% of the usual-care group data. In terms of the primary outcome, patients allocated to the intervention group had a lower score for severity of urinary incontinence (higher scores indicate greater severity in urinary incontinence) than those allocated to the usual-care group, with means (standard deviations) of 8.1 (7.4) and 9.1 (7.8), respectively.

LIMITATIONS

The trial was unable to recruit sufficient participants and had very high attrition, which resulted in seriously underpowered results.

CONCLUSIONS

The internal pilot did not meet its target for recruitment and, despite recruitment subsequently being more promising, it was concluded that the trial was not feasible owing to the combined problems of poor recruitment, poor retention and COVID-19. The intervention group had a slightly lower score for severity of urinary incontinence at 3 months post randomisation, but this result should be interpreted with caution.

FUTURE WORK

Further studies to assess the effectiveness of an intervention starting in or continuing into the community are required.

TRIAL REGISTRATION

This trial is registered as ISRCTN14005026.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 31. See the NIHR Journals Library website for further project information.

Implementation interventions to promote the uptake of evidence-based practices in stroke rehabilitation

BACKGROUND

Rehabilitation based upon research evidence gives stroke survivors the best chance of recovery. There is substantial research to guide practice in stroke rehabilitation, yet uptake of evidence by healthcare professionals is typically slow and patients often do not receive evidence-based care. Implementation interventions are an important means to translate knowledge from research to practice and thus optimise the care and outcomes for stroke survivors. A synthesis of research evidence is required to guide the selection and use of implementation interventions in stroke rehabilitation.

OBJECTIVES

To assess the effects of implementation interventions to promote the uptake of evidence-based practices (including clinical assessments and treatments recommended in evidence-based guidelines) in stroke rehabilitation and to assess the effects of implementation interventions tailored to address identified barriers to change compared to non-tailored interventions in stroke rehabilitation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and eight other databases to 17 October 2019. We searched OpenGrey, performed citation tracking and reference checking for included studies and contacted authors of included studies to obtain further information and identify potentially relevant studies.

SELECTION CRITERIA

We included individual and cluster randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies comparing an implementation intervention to no intervention or to another implementation approach in stroke rehabilitation. Participants were qualified healthcare professionals working in stroke rehabilitation and the patients they cared for. Studies were considered for inclusion regardless of date, language or publication status. Main outcomes were healthcare professional adherence to recommended treatment, patient adherence to recommended treatment, patient health status and well-being, healthcare professional intention and satisfaction, resource use outcomes and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any implementation intervention compared to no intervention.

MAIN RESULTS

Nine cluster randomised trials (12,428 patient participants) and three ongoing trials met our selection criteria. Five trials (8865 participants) compared an implementation intervention to no intervention, three trials (3150 participants) compared one implementation intervention to another implementation intervention, and one three-arm trial (413 participants) compared two different implementation interventions to no intervention. Eight trials investigated multifaceted interventions; educational meetings and educational materials were the most common components. Six trials described tailoring the intervention content to identified barriers to change. Two trials focused on evidence-based stroke rehabilitation in the acute setting, four focused on the subacute inpatient setting and three trials focused on stroke rehabilitation in the community setting. We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence was very low (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.53 to 2.64; 2 trials, 39 clusters, 1455 patient participants; I2 = 0%). Low-certainty evidence indicates implementation interventions in stroke rehabilitation may lead to little or no difference in patient adherence to recommended treatment (number of recommended performed outdoor journeys adjusted mean difference (MD) 0.5, 95% CI -1.8 to 2.8; 1 trial, 21 clusters, 100 participants) and patient psychological well-being (standardised mean difference (SMD) -0.02, 95% CI -0.54 to 0.50; 2 trials, 65 clusters, 1273 participants; I2 = 0%) compared with no intervention. Moderate-certainty evidence indicates implementation interventions in stroke rehabilitation probably lead to little or no difference in patient health-related quality of life (MD 0.01, 95% CI -0.02 to 0.05; 2 trials, 65 clusters, 1242 participants; I2 = 0%) and activities of daily living (MD 0.29, 95% CI -0.16 to 0.73; 2 trials, 65 clusters, 1272 participants; I2 = 0%) compared with no intervention. No studies reported the effects of implementation interventions in stroke rehabilitation on healthcare professional intention to change behaviour or satisfaction. Five studies reported economic outcomes, with one study reporting cost-effectiveness of the implementation intervention. However, this was assessed at high risk of bias. The other four studies did not demonstrate the cost-effectiveness of interventions. Tailoring interventions to identified barriers did not alter results. We are uncertain of the effect of one implementation intervention versus another given the limited very low-certainty evidence.

AUTHORS' CONCLUSIONS

We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence is very low.

Interventions for treating urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40% to 60% of people admitted to hospital after a stroke, with 25% still having problems when discharged from hospital and 15% remaining incontinent after one year.This is an update of a review published in 2005 and updated in 2008.

OBJECTIVES

To assess the effects of interventions for treating urinary incontinence after stroke in adults at least one-month post-stroke.

SEARCH METHODS

We searched the Cochrane Incontinence and Cochrane Stroke Specialised Registers (searched 30 October 2017 and 1 November 2017 respectively), which contain trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearched journals and conference proceedings.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction, risk of bias assessment and implemented GRADE.

MAIN RESULTS

We included 20 trials (reporting 21 comparisons) with 1338 participants. Data for prespecified outcomes were not available except where reported below.Intervention versus no intervention/usual careBehavioural interventions: Low-quality evidence suggests behavioural interventions may reduce the mean number of incontinent episodes in 24 hours (mean difference (MD) -1.00, 95% confidence interval (CI) -2.74 to 0.74; 1 trial; 18 participants; P = 0.26). Further, low-quality evidence from two trials suggests that behavioural interventions may make little or no difference to quality of life (SMD -0.99, 95% CI -2.83 to 0.86; 55 participants).Specialised professional input interventions: One trial of moderate-quality suggested structured assessment and management by continence nurse practitioners probably made little or no difference to the number of people continent three months after treatment (risk ratio (RR) 1.28, 95% CI 0.81 to 2.02; 121 participants; equivalent to an increase from 354 to 453 per 1000, 95% CI 287 to 715).Complementary therapy: Five trials assessed complementary therapy using traditional acupuncture, electroacupuncture and ginger-salt-partitioned moxibustion plus routine acupuncture. Low-quality evidence from five trials suggested that complementary therapy may increase the number of participants continent after treatment; participants in the treatment group were three times more likely to be continent (RR 2.82, 95% CI 1.57 to 5.07; 524 participants; equivalent to an increase from 193 to 544 per 1000, 95% CI 303 to 978). Adverse events were reported narratively in one study of electroacupuncture, reporting on bruising and postacupuncture abdominal pain in the intervention group.Physical therapy: Two trials reporting three comparisons suggest that physical therapy using transcutaneous electrical nerve stimulation (TENS) may reduce the mean number of incontinent episodes in 24 hours (MD -4.76, 95% CI -8.10 to -1.41; 142 participants; low-quality evidence). One trial of TENS reporting two comparisons found that the intervention probably improves overall functional ability (MD 8.97, 95% CI 1.27 to 16.68; 81 participants; moderate-quality evidence).Intervention versus placeboPhysical therapy: One trial of physical therapy suggests TPTNS may make little or no difference to the number of participants continent after treatment (RR 0.75, 95% CI 0.19 to 3.04; 54 participants) or number of incontinent episodes (MD -1.10, 95% CI -3.99 to 1.79; 39 participants). One trial suggested improvement in the TPTNS group at 26-weeks (OR 0.04, 95% CI 0.004 to 0.41) but there was no evidence of a difference in perceived bladder condition at six weeks (OR 2.33, 95% CI 0.63 to 8.65) or 12 weeks (OR 1.22, 95% CI 0.29 to 5.17). Data from one trial provided no evidence that TPTNS made a difference to quality of life measured with the ICIQLUTSqol (MD 3.90, 95% CI -4.25 to 12.05; 30 participants). Minor adverse events, such as minor skin irritation and ankle cramping, were reported in one study.Pharmacotherapy interventions: There was no evidence from one study that oestrogen therapy made a difference to the mean number of incontinent episodes per week in mild incontinence (paired samples, MD -1.71, 95% CI -3.51 to 0.09) or severe incontinence (paired samples, MD -6.40, 95% CI -9.47 to -3.33). One study reported no adverse events.Specific intervention versus another interventionBehavioural interventions: One trial comparing a behavioural intervention (timed voiding) with a pharmacotherapy intervention (oxybutynin) contained no useable data.Complementary therapy: One trial comparing different acupuncture needles and depth of needle insertion to assess the effect on incontinence reported that, after four courses of treatment, 78.1% participants in the elongated needle group had no incontinent episodes versus 40% in the filiform needle group (57 participants). This trial was assessed as unclear or high for all types of bias apart from incomplete outcome data.Combined intervention versus single interventionOne trial compared a combined intervention (sensory motor biofeedback plus timed prompted voiding) against a single intervention (timed voiding). The combined intervention may make little or no difference to the number of participants continent after treatment (RR 0.55, 95% CI 0.06 to 5.21; 23 participants; equivalent to a decrease from 167 to 92 per 1000, 95% CI 10 to 868) or to the number of incontinent episodes (MD 2.20, 95% CI 0.12 to 4.28; 23 participants).Specific intervention versus attention controlPhysical therapy interventions: One study found TPTNS may make little or no difference to the number of participants continent after treatment compared to an attention control group undertaking stretching exercises (RR 1.33, 95% CI 0.38 to 4.72; 24 participants; equivalent to an increase from 250 to 333 per 1000, 95% CI 95 to 1000).

AUTHORS' CONCLUSIONS

There is insufficient evidence to guide continence care of adults in the rehabilitative phase after stroke. As few trials tested the same intervention, conclusions are drawn from few, usually small, trials. CIs were wide, making it difficult to ascertain if there were clinically important differences. Only four trials had adequate allocation concealment and many were limited by poor reporting, making it impossible to judge the extent to which they were prone to bias. More appropriately powered, multicentre trials of interventions are required to provide robust evidence for interventions to improve urinary incontinence after stroke.

Reliability and validity of the Turkish version of the Danish Prostatic Symptom Score to assess lower urinary tract symptoms in stroke patients

BACKGROUND

Lower urinary tract dysfunction (LUTD) is one of the most frequently encountered problems in stroke.OBJECTİVE:To assess the validity and reliability of the Turkish Danish Prostatic Symptom Score (DAN-PSS) in stroke patients with LUTD.

METHODS

A total of 50 patients were included in the study. The reliability was assessed using Cronbach α and intraclass correlation coefficient (ICC) methods, and the validity using the correlations between the subgroup and overall scores of DAN-PSS and the scores of the Barthel Index (BI), International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), and Short Form 36 (SF-36).

RESULTS

The Cronbach α values were found >0.97 and ICC 0.953-0.990 for all subgroup scores. We found a significant negative correlation between all the sub-scores of DAN-PSS and the BI, and a significant positive correlation between all the sub-scores of DAN-PSS and ICIQ-SF (p < 0.05). The symptom score of DAN-PSS had a significant negative correlation with the physical functioning, physical and emotional role subdomains of the SF-36 survey (p < 0.05).

CONCLUSIONS

We have shown the reliability and validity of the Turkish DAN-PSS, and we think that it will be useful to utilize it in the monitoring of patients with stroke and in clinical studies.

Technology-assisted toilets: Improving independence and hygiene in stroke rehabilitation

BACKGROUND AND PURPOSE

Dependence on assistance for toileting is a widespread problem for persons receiving healthcare. Technology-assisted toilets, which hygienically wash and dry the perineal region, are devices that could improve toileting independence in a variety of patients. The objective was to investigate whether technology-assisted toilets improve toileting independence, quality of life, and whether technology-assisted toilets can provide sufficient toileting hygiene in stroke rehabilitation.

METHODS

This pilot study was carried out in a stroke rehabilitation unit. Thirty participants were recruited. Participants had a bowel movement and cleaned themselves using the technology-assisted toilet on one to three occasions. Participants rated their toileting before using the technology-assisted toilet and after each technology-assisted toilet use with the Psychosocial Impact of Assistive Devices Scale (PIADS). After each session, participants were rated for cleanliness.

RESULTS

PIADS scores were analyzed from eight individual participants, five of whom completed the full protocol. PIADS scores were significantly higher with the technology-assisted toilet than with the participants' regular toileting routine (p < 0.05). Technology-assisted toilets cleaned effectively in 73% of cases (16/22, p < 0.05).

CONCLUSION

Technology-assisted toilets improved stroke patients' psychosocial outcomes compared to standard toileting and completely cleaned participants in the majority of cases. A larger study should confirm technology-assisted toilet's benefit in stroke rehabilitation through improved independence and hygiene.

Implementing a Systematic Voiding Program for Patients With Urinary Incontinence After Stroke

We explored health professionals' views of implementing a systematic voiding program (SVP) in a multi-site qualitative process evaluation in stroke services recruited to the intervention arms of a cluster randomized controlled feasibility trial during 2011-2013. We conducted semi-structured group or individual interviews with 38 purposively selected nursing, managerial, and care staff involved in delivering the SVP. Content analysis of transcripts used normalization process theory (NPT) as a pre-specified organization-level exploratory framework. Barriers to implementing the SVP included perceived lack of suitability for some patient groups, patient fear of extending hospital stay, and difficulties with SVP enactment, scheduling, timing, recording, and monitoring. Enablers included the guidance provided by the SVP, patient and relative involvement, extra staff, improved nursing skill and confidence, and experience of success. Three potential mechanisms of consistency, visibility, and individualization linked the SVP process with improvements in outcome, and should be emphasized in SVP implementation.

Effects of Transcutaneous Electrical Nerve Stimulation at Two Frequencies on Urinary Incontinence in Poststroke Patients: A Randomized Controlled Trial

OBJECTIVE

The objective of this study was to compare the effects of two frequencies of transcutaneous electrical nerve stimulation (TENS) on urinary incontinence caused by stroke.

METHODS

Eighty-one patients with poststroke urinary incontinence were recruited and randomized into the following three groups with a 1:1 ratio: a 20-Hz TENS group, a 75-Hz TENS group, and a no-treatment control group (n = 27 per group). TENS currents were biphasic square waves with pulse durations of 150 μsecs and pulse frequencies of 20 Hz or 75 Hz and were applied for 30 mins once per day for 90 days. The positive electrodes were placed in the region of the second sacral level on opposite sides of the vertebral column; the negative electrodes were placed on the inside of the middle and lower third of the junction between the posterior superior iliac spine and the ischial node. Overactive Bladder Symptom Scores, Barthel Index, urodynamic values, and voiding diary parameters were assessed before and after 90 days.

RESULTS

The patients treated with 20 Hz had superior Overactive Bladder Symptom Scores, Barthel Index totals, urodynamic values, and voiding diary parameters (P < 0.05). In the 75-Hz group, values were statistically improved compared with the no-treatment group (P < 0.05), but the results were significantly inferior to those of the 20-Hz group (P < 0.05).

CONCLUSIONS

Twenty-hertz TENS improved incontinence symptoms and promoted activities of daily living better than 75-Hz TENS. These results will aid future research regarding TENS parameters.

Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial

Background

Urinary incontinence (UI) affects half of patients hospitalised after stroke and is often poorly managed. Cochrane systematic reviews have shown some positive impact of conservative interventions (such as bladder training) in reducing UI, but their effectiveness has not been demonstrated with stroke patients.

Methods

We conducted a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP) for the management of UI after stroke. Stroke services were randomised to receive SVP (n = 4), SVP plus supported implementation (SVP+, n = 4), or usual care (UC, n = 4).

Feasibility outcomes were participant recruitment and retention. The main effectiveness outcome was presence or absence of UI at six and 12 weeks post-stroke. Additional effectiveness outcomes included were the effect of the intervention on different types of UI, continence status at discharge, UI severity, functional ability, quality of life, and death.

Results

It was possible to recruit patients (413; 164 SVP, 125 SVP+, and 124 UC) and participant retention was acceptable (85% and 88% at six and 12 weeks, respectively). There was no suggestion of a beneficial effect on the main outcome at six (SVP versus UC: odds ratio (OR) 0.94, 95% CI: 0.46 to 1.94; SVP+ versus UC: OR: 0.62, 95% CI: 0.28 to 1.37) or 12 weeks (SVP versus UC: OR: 1.02, 95% CI: 0.54 to 1.93; SVP+ versus UC: OR: 1.06, 95% CI: 0.54 to 2.09).

No secondary outcomes showed a strong suggestion of clinically meaningful improvement in SVP and/or SVP+ arms relative to UC at six or 12 weeks. However, at 12 weeks both intervention arms had higher estimated odds of continence than UC for patients with urge incontinence.

Conclusions

The trial has met feasibility outcomes of participant recruitment and retention. It was not powered to demonstrate effectiveness, but there is some evidence of a potential reduction in the odds of specific types of incontinence. A full trial should now be considered.

Trial registration

ISRCTN Registry, ISRCTN08609907, date of registration: 7 July 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-15-509) contains supplementary material, which is available to authorized users.

Post-stroke urinary incontinence

AIM

To provide a comprehensive review of the current evidence on post-stroke urinary incontinence.

METHOD

An electronic database search was performed to identify relevant studies and review articles related to Urinary Incontinence (UI) in the stroke population between the years 1966 and 2012.

FINDINGS

Urinary incontinence following stroke is a common problem affecting more than one-third of acute stroke patients and persisting in up to a quarter at 1 year. It is well established that this condition is a strong marker of stroke severity and is associated with poorer functional outcomes and increased institutionalisation and mortality rates compared with those who remain continent. Despite evidence linking better outcomes to those patients who regain continence, the results of national audits have demonstrated that the management of UI following stroke is suboptimal, with less than two-thirds of stroke units having a documented plan to promote continence.

CONCLUSION

Current evidence supports a thorough assessment to categorise the type and severity of post-stroke urinary incontinence. An individually tailored, structured management strategy to promote continence should be employed. This has been associated with better stroke outcomes and should be the aim of all stroke health professionals.