Therapists\u27 use of the graded repetitive arm supplementary program (GRASP) intervention: A practice implementation survey study

The aims of this study were: (1) to explore the extent of practice implementation of GRASP in the United Kingdom; (2) using an implementation framework, to explore UK therapists\u27 opinions of implementing GRASP; and (3) if GRASP is found to be used in the United Kingdom, to investigate differences in opinions between therapists who are using GRASP in practice and those who are not

Determining the sample size for a cluster-randomised trial: Bayesian hierarchical modelling of the ICC estimate

In common with many cluster-randomised trials, it was difficult to determine the appropriate sample size for the planned trial of the effectiveness of a systematic voiding programme for post-stroke incontinence due to the lack of a robust estimate of the intra-cluster correlation coefficient (ICC). One approach to overcome this problem is a method of combining ICC values in the Bayesian framework (Turner et al. 2005). We adopted this approach and used Bayesian hierarchical modelling to estimate the ICC

Prescribing upper limb exercises after stroke: A survey of current UK therapy practice.

Objective: To investigate the current practice of physiotherapists and occupational therapists in prescribing upper limb exercises to people after stroke and to explore differences between professions and work settings. Design: A cross-sectional survey design. Participants: Occupational therapists and physiotherapists working in UK stroke rehabilitation. Results: The survey's response rate was 21.0% (n = 322); with 295 valid responses. Almost two thirds of therapists (64.7%, n = 191) agreed that they always prescribe upper limb exercises to a person with stroke if they can actively elevate their scapula and have grade 1 finger/wrist extension. Most therapists (98.6%, n = 278) prescribed exercises to be completed outside of therapy time, with exercises verbally communicated to family. Standardised upper limb specific outcome measures were used to evaluate the prescribed exercises by 21.9% (n = 62) of therapists. Differences were found between professions and across work settings. Conclusion: The majority of prescribed upper limb exercises were of low intensity (range of motion or stretching exercises) rather than repetitive practice or strengthening exercises. The use of standardised outcome measures was low. Progression of exercises and the provision of written instructions on discharge occur less frequently in inpatient settings than outpatient and community settings

Evaluation of a rehabilitation support service after acute stroke: Feasibility and patient/carer benefit

Background: Stroke survivors returning home after discharge from hospital and their carers require support to meet their rehabilitation needs (independence in Activities of Daily Living, exercise, psychosocial support). Voluntary or charitable care providers may be able to address some of these needs. Objective: To explore the feasibility of delivering and evaluating enhanced support to stroke survivors and their carers, with a Rehabilitation Support Worker (RSW). Methods: 16 consecutive stroke survivors and their carers were included. All participants received usual hospital care. Seven of these patients and their carers were also allocated an RSW from a charitable care provider. The RSW accompanied therapy training sessions with the patient, carer and therapist in hospital. On discharge, the RSW visited the patient and carer at home over the initial 6 week post-discharge period to support them in practising rehabilitation skills. Patient function (Barthel Index) and patient/carer confidence were independently assessed at discharge (Week 0). The above assessments and patient/carer mood (GHQ-12) and Carer Giver Strain were also assessed at Weeks 1, 6 and 12. RSWs were interviewed for their views about the service. Results: Participants’ functional ability at Week 1 post-discharge was significantly higher in the RSW group. At 6 and 12 weeks post-discharge, functional ability was not significantly different between groups. Carers in the intervention group were less confident at all time points, however, this was not significant. There was no significant effect on carer strain or well-being. Interviews with RSWs highlighted areas of their training that could be enhanced and the need for greater clarity as to their role. Conclusions: The results showed that a definitive trial of rehabilitation support is feasible. A number of obstacles however would need to be overcome including: difficulty in identifying suitable patients, clarity of the RSW role, and appropriate training content

Clinical academic research internships for nurses, midwives and allied health professionals: a qualitative evaluation

Background: Nurses, midwives and allied health professionals are integral to research, yet rarely engage simultaneously in research and clinical practice. Clinical academic internships offer a route to access academic research training. This study aimed to elucidate facilitators and barriers to participation and engagement, and suggest improvements for future programmes. Method: The experiences of 10 health professional research interns were explored, using a method based on a synthesis between grounded theory and content analysis. Findings: Four categories emerged: 1) integrating clinical and research aspirations; 2) Support – or lack of it; 3) The hidden curriculum; 4) The legacy effect. Within these categories, respondents identified a variety of facilitators and barriers to engagement, including unforeseen challenges. Conclusion: Formal support is necessary but not sufficient to foster engagement and maximise benefits. Participation must be supported by colleagues and enabled by institutional structures. The potential impact of internships on engagement with research is considerable but requires collaboration between all stakeholders. Implications for Practice: Deeper institutional engagement is needed so that internship opportunities are fully supported by all colleagues and practically enabled by institutional structures. Future schemes should attempt to promote opportunities to collaborate via group projects to reduce researcher isolation

Medication adherence early after stroke: using the Perceptions and Practicalities framework to explore stroke survivors’, informal carers’ and nurses’ experiences of barriers and solutions

Background: Secondary prevention medication after stroke reduces risk of recurrence, but adherence is often poor. Stroke survivors’, carers’ and nurses’ perspectives of early post-stroke medication adherence are unexplored. Aim: to explore stroke survivors’, carers’ and nurses’ views and experiences about adhering to medication early after post-stroke hospital discharge. Methods: Qualitative individual and group interviews, utilizing the Perceptions and Practicalities framework. Nine people <2 months post-stroke, three carers, and fifteen nurses from one UK stroke unit participated. Interviews were digitally recorded, transcribed and thematically analysed. Results: There were four main themes with two subthemes. 1) Perceptions of medication taking after stroke. Factors affecting adherence included depression, imperceptible benefits, and concerns about adverse effects. 2) Perceptions about those at higher risk of poor medication adherence. Nurses suggested that poor adherence might be more likely in those living alone or with previous nonadherence. 3) Practicalities of taking medication early after stroke; these included post-stroke disabilities, cognition, polypharmacy, and lack of information. 4a) Practicalities of addressing poor medication adherence during the hospital stay. Solutions included multidisciplinary co-ordination, but nurses and stroke survivors described suboptimal use of opportunities to promote adherence. 4b) Practicalities of addressing poor medication adherence post-discharge. Solutions included modifications and support from carers, but stroke survivors reported difficulties in evolving systems for taking medications. Conclusions: Stroke survivors and informal carers lack knowledge and support needed to manage medication early after discharge. Nurses’ opportunities to promote medication adherence are under-exploited. Medication adherence strategies to support stroke survivors early after discharge are needed

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 care Behavioural 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 placebo Physical 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 intervention Behavioural 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 intervention One 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 control Physical 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

Does repetitive task training improve functional activity after stroke? A Cochrane systematic review and meta-analysis.

Repetitive task training resulted in modest improvement across a range of lower limb outcome measures, but not upper limb outcome measures. Training may be sufficient to have a small impact on activities of daily living. Interventions involving elements of repetition and task training are diverse and difficult to classify: the results presented are specific to trials where both elements are clearly present in the intervention, without major confounding by other potential mechanisms of action