Driving after a stroke.

Four hundred and thirty-eight stroke patients from a community register covering a period of 28 months were interviewed at one year post-stroke. Of 144 (34%) living at home who had been driving prior to their stroke, 82 (58%) did not resume post-stroke. Assessments of arm function, walking, functional ability and IQ showed ex-drivers to be significantly more disabled than drivers. Stopping driving was associated with a loss of social activities and with a higher frequency of depression amongst ex-drivers when compared with drivers. This was despite 79% of ex-drivers having easy access to alternative car transport. Extending mobility allowance to the 49 (60%) ex-drivers over 65 years old at the time of their stroke might ease their situation. More appropriate assessments would be needed to establish whether ex-drivers would benefit from retraining or car adaptations to enable them to return to driving.

Multiple sclerosis--management and rehabilitation.

After reviewing the size of the problem of multiple sclerosis, and the likely case-load for doctors in different settings, this paper than proceeds to consider the major challenges in management and rehabilitation for this disease. The latter resolve themselves into what to discuss with the patient; relapses and their prevention, including general advice on such matters as stress, pregnancy, and infection; major problems including bladder and bowel dysfunction, sexual difficulties, spasticity, ataxia and incoordination, vision, and intellectual and psychological manifestations, and other problems, such as menstruation, obesity, and pressure sores. The paper concludes with a discussion of the role of specialist physicians.

Study of fatal cases of Friedreich's ataxia.

A study of 82 fatal cases of Friedreich's ataxia showed that over half the patients died of heart failure while nearly three-quarters had evidence of cardiac dysfunction during life. A high incidence of diabetes mellitus (23%) was another finding, and four patients developed diabetic ketosis terminally.

Outlook after an acute stroke: urinary incontinence and loss of consciousness compared in 532 patients.

Data from a sample of 532 patients seen within seven days of an acute stroke has been analysed to compare the prognostic importance of urinary incontinence with that of a history of any depression of consciousness. Urinary incontinence was more specific and had a higher predictive value. Considering conscious patients with moderate or severe initial disability, after six months 53 per cent of incontinent patients had died and 57 per cent of the survivors were still moderately or severely disabled whereas only 19 per cent of continent patients had died and 80 per cent of survivors made a good recovery. We conclude that early urinary incontinence is an important indicator of poor prognosis, identifying patients who may need extra attention.

Development of a stroke and neurological rehabilitation unit in a district general hospital.

We describe the experience of setting up a 16-bed unit for the rehabilitation of non-progressive and progressive neurological disorders. Its aim was the active involvement of patients and their families in the rehabilitation process. Various innovations were instigated by the multidisciplinary teams, including early visits home and a leisure service. Over the first two years, 318 patients were admitted to the unit, 51% attributable to stroke.

The prevention and management of stroke.

The Government's Health of the nation strategy demands a reduction in the level of ill-health and death caused by stroke. This review describes the present state of knowledge on the prevention and management of stroke. Effective intervention in stroke has a number of major implications, including: health education for the public; education of health professionals (general practitioners, consultants and others); availability of guidelines and protocols; access to specialist advice, investigations and their interpretation, and rapid treatment, including surgery; availability of specially trained nurses for screening and monitoring; and availability of specialist multidisciplinary teams in hospitals and the community.

Why admit stroke patients to hospital?

Stroke patients consume nearly one-twentieth of all National Health Service resources, and much of this is attributable to the admission of patients with acute strokes to hospital. However, patients rarely need to be admitted for diagnostic or therapeutic reasons, and rehabilitation given in hospital is sometimes inappropriate. The major reason for admission relates to nursing during the acute illness, yet this could be done at home in more cases than at present. It is suggested that rehabilitation services should be more readily available to patients at home, so that fewer need to be admitted and so that those admitted can return home sooner. This might lead to a more appropriate rehabilitation, less anxiety and depression in the patient and his family, and a more efficient use of limited resources.

The heart disease of Friedreich's ataxia: a clinical and electrocardiographic study of 115 patients, with an analysis of serial electrocardiographic changes in 30 cases.

One hundred and fifteen patients with carefully defined Friedreich's ataxia were assessed clinically and electrocardiographically for evidence of heart disease. Cardiac symptoms, of which dyspnoea and palpitations were the most frequent, occurred in less than 30 per cent. Abnormalities on clinical examination were present in a similar proportion; harsh systolic murmurs, ventricular hypertrophy and added heart sounds were the commonest of these. Cardiac failure and persistent arrhythmias were rare and occurred late in the evolution of the neurological disease. Two patients presented with heart disease before developing neurological symptoms. Cardiac signs and symptoms were uncommon in patients without electrocardiographic abnormalities. About two-thirds of the cases had definitely abnormal ECG recordings. The characteristic finding was of widespread T-wave inversion with ventricular hypertrophy. Serial ECGs, recorded over periods of up to 32 years, were available in 30 cases and showed that abnormalities may develop in patients with Friedreich's ataxia at any time up until 20 years after the onset of neurological symptoms. In four patients initial ECG abnormalities had either improved or disappeared subsequently.

Motor loss and swallowing difficulty after stroke: frequency, recovery, and prognosis.

Data relating to motor loss and swallowing difficulties in a community sample of 976 patients who suffered an acute stroke have been analysed. About 17% of patients seen within one week had no paralysis; at 6 months 48% of survivors had no paralysis and 9% had severe paralysis. The Motricity Index used to study motor loss related to functional loss and walking ability; it seems to be a simple valid measure of motor loss. Severe paralysis was associated with a high fatality rate, and only 6%-10% of survivors of an initially severe paralysis made a full recovery by 6 months. If severe persisted at 3 weeks, full recovery was not observed. Loss of sitting balance was associated with a poor outcome. Of conscious patients seen within one week, 14% choked on attempting to swallow and a further 28% had abnormal swallowing: this 42% of patients had a high fatality rate.

Epidemiology of some neurological diseases with special reference to work load on the NHS.

This paper reviews evidence relating to the incidence, prevalence, and likely workload upon the NHS in relation to neurological diseases, particularly those causing long-term disability. Three studies suggest that a population of 250,000 people will contain about 5000 people with disabling neurological disease, of whom 1500 will be sufficiently disabled to require daily assistance. The review highlights the scarcity of reliable information concerning the epidemiology of neurological diseases and their disabilities, and emphasizes the need to plan neurological services at the level of the district general hospital serving a population of 250,000 people.

Functional abilities after stroke: measurement, natural history and prognosis.

Actual functional performance of 976 acute stroke patients was assessed using the Barthel index: the data were analysed to determine the frequency of disability after stroke, the validity of the Barthel index, and the recovery seen. At 6 months, over 45% of survivors were functionally independent. Validity of the Barthel index was confirmed: it related as expected with motor loss and factor analysis showed a single major factor. The items of the Barthel index form an hierarchical scale. There was some recovery between 3 weeks and 6 months in almost all patients: the major prognostic factors were urinary incontinence, functional ability, sitting balance and age.

Hand contractures in Parkinson's disease.

Three cases of hand contractures due to Parkinson's disease and possible mechanisms that may be involved in their pathogenesis are described.

The Bristol Stroke Unit.

The Bristol Stroke Unit was set up in 1975 in order to provide a service for stroke patients and to undertake both service and biomedical research. During the first 5 years, 472 stroke patients were seen and 388 were treated. Detailed information was kept on most patients and this has been used for studies on prediction and outcome. General principles of management evolved and these are itemized. Important developments include the expansion of the Unit remit to include the management of other disabling disorders such as multiple sclerosis, a greater emphasis on service research, and the development of a voluntary service.