Enhanced physical therapy improves recovery of arm function after stroke. A randomised controlled trial.

Previous research on stroke rehabilitation has not established whether increase in physical therapy lead to better intrinsic recovery from hemiplegia. A detailed study was carried out of recovery of arm function after acute stroke, and compares orthodox physiotherapy with an enhanced therapy regime which increased the amount of treatment as well as using behavioural methods to encourage motor learning. In a single-blind randomised trial, 132 consecutive stroke patients were assigned to orthodox or enhanced therapy groups. At six months after stroke the enhanced therapy group showed a small but statistically significant advantage in recovery of strength, range and speed of movement. This effect seemed concentrated amongst those who had a milder initial impairment. More work is needed to discover the reasons for this improved recovery, and whether further development of this therapeutic approach might offer clinically significant gains for some patients.

Neurology in the United Kingdom. I: Historical development.

International comparisons suggest that British neurological services are underdeveloped. Historical factors which have contributed to the current state of neurological services in the United Kingdom are described. Key issues include the dominance of London and the concept of specialised hospitals in the early history of neurology; the subsequent recognition of the needs of other parts of the United Kingdom, of district general hospitals, and of patients with chronic neurological disabilities not necessarily included within the traditional bounds of neurology; and the relationship between neurology and general medicine. The paper concludes with some suggestions as to how neurology services might develop in the future.

Neurology in the United Kingdom. II: A study of current neurological services for adults.

Health care planning relies on accurate data, yet there are few published data on neurological services in the United Kingdom. This paper describes the number and distribution of consultant neurologists in the UK and is based on a questionnaire completed by Regional Health Authorities and their equivalents, by Special Health Authorities, and by regional representatives of the Association of British Neurologists. The data were published by the ABN in 1988 but have not previously been widely available. The study identified 190 consultant neurologists (152 whole time equivalents). Overall there was one whole time neurologist for 373,000 persons but the ratio varied by a factor of four in different regions. There was a wide variation in the distribution of consultant neurological sessions between Health Districts. One group of neurologists was based in centres. A second group spent most of their time within the Health District, but had an attachment to a Regional Centre.

Assessment of stroke.

Assessment involves firstly identification that a problem exists, and secondly quantification. It is needed for both routine purposes and research. The research purposes--assessment tool--should be valid, reliable, repeatable and sensitive. It is also important that the assessment should be comprehensive--not missing out essential elements. In clinical practice, the use of Check-list may be helpful. In research, formal assessment procedures are required. The precise assessment tools to be used will depend very much on the research question being asked.

Selection of aphasic stroke patients for intensive speech therapy.

Selection criteria for intensive speech therapy and the number of patients fulfilling these were investigated in 441 acute strokes coming from a Health District population during one year. Five patients from a total of 71 referred with speech and/or language difficulties were considered suitable for intensive speech therapy at 4 weeks after stroke. Although such therapy was not actually given, by 26 weeks three of the five had recovered and 14 further patients were considered suitable to receive intensive therapy. The most important selection criteria were Functional Communication Profile score of less than 85 and a clinical judgement that the patient was well enough to take part. It is recommended that decisions as to appropriateness of patients for intensive speech therapy be delayed beyond 4 weeks after stroke.

The natural history of visual neglect after stroke. Indications from two methods of assessment.

A simple copying task and a measure of position preference on a multiple-choice test were used to assess the incidence of visual neglect after stroke. The patients studied were drawn from a register of strokes occurring in a typical health district. These tests detected visual neglect in 8-11% of patients 3 weeks after stroke and it was more frequent after right-sided rather than left-sided brain damage. Significant neglect was rarely observed by 6 months after stroke but further recovery did occur between 6 months and 1 year. Neglect appeared to exert a slowing influence on rehabilitation and we propose that training procedures to combat neglect should be evaluated for routine use in rehabilitation centres.

Walking after stroke. Measurement and recovery over the first 3 months.

Sixty surviving patients had their walking ability and speed assessed regularly over the first 3 months after an acute stroke. Sixty-four matched controls were studied to allow categorisation of speed as 'slow' or 'normal'. Fourteen patients never had any significant loss of walking speed; fifteen patients never recovered the ability to walk and one patient remained dependent upon verbal support. Of the 30 showing significant recovery, only 10 regained normal speed, and 8 remained dependent upon a physical aid at 3 months. Plotting individual recovery curves of walking speed over time showed the wide range of change which may be expected. It is argued that timing of gait over 10 metres is a valid reliable measure that is currently underused.

Stroke: associations with age, sex, and side of weakness.

This study on patients who had strokes investigates the relevance of a patient's age, sex, and the side of any symptoms in association with prestroke status, initial signs, initial disability, and recovery during the first six months. Disability was assessed using the Barthel activities of daily living (ADL) index; non-ADL (social) activities were measured using the Frenchay activities index. Data were collected from 976 patients registered in a community study, and were analyzed statistically using Chi square test, correlation coefficients (for age), analysis of covariance, and two-way analysis of variance. The 469 patients aged 75 years or older included more women (308; p less than 0.001), more who lived alone (147; p less than 0.001), and fewer patients with no prestroke disability (247; p less than 0.001). In this group, the 265 patients who were seen within one week of stroke had a more severe initial disability (p less than 0.001), but not a more severe paralysis. More patients from this age group died (268; p less than 0.001) and more survivors required long-term care. Further analysis showed that older patients made a less good recovery, even after allowing for the correlation between early and six-month Barthel scores (r = +0.41; p less than 0.01). Age had an inverse correlation with level of non-ADL activities at six months (r = -0.365; p less than 0.001). Young women had more severe initial disability (p less than 0.001), but other associations with sex reflected the preponderance of women in the the older age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Services for stroke patients one year after stroke.

The use of community services by stroke patients was investigated one year after their stroke. Survivors from a register of all patients from a defined community were followed up one year after their stroke. Four hundred and thirty six of the 492 survivors were seen: 301 lived at home with someone, 82 lived at home alone, and 53 were in long-stay care. One hundred and forty seven (38%) of those at home were visited by one or more community services, the major ones being district nurse (73), home help (73), day centres (42), and meals on wheels (30). Analysis suggests that these services reach the patients who need most help. However, some 57 (19%) disabled patients are being looked after at home without any outside help.

Memory disturbance after stroke: frequency and associated losses.

138 patients who survived an acute stroke had their memory assessed at 3 months. As a group these patients had no impairment of digit span when compared with published age-matched normal data. Immediate logical memory (of a story) was poor in 29 per cent, and 14 per cent could not draw a picture immediately after seeing it. Poor memory function was not associated with more severe strokes, but was associated with poor functional ability on everyday tasks. Poor visual recall was associated with lower abilities at ADL, independent of any effect of age. Statistically significant recovery was detected in immediate logical memory and visual recall between 3 and 6 months.

Loss of arm function after stroke: measurement, frequency, and recovery.

This study aims to establish the frequency of paralysis and other arm problems after stroke; the recovery of lost function; and to compare various tests of the affected arm. Thirteen per cent of the sample had no arm paralysis when first seen within 14 days. At 3 months 24 per cent of survivors had moderate or severe paralysis; 57 per cent could place nine pegs into holes within 50 seconds; 19 per cent had significant sensory disturbance; 5 per cent had shoulder pain; 8 per cent had restricted passive shoulder movement; and 17 per cent had some paralysis of the dominant arm. Between 3 and 6 months, improvement of motor power was seen in 40 per cent of patients, and 13 per cent of patients improved their function. Severity of initial paralysis was an important prognostic factor.

Hospital admission for acute stroke: who, for how long, and to what effect?

Data from 976 patients registered in a community survey as suffering an acute stroke have been analysed to discover what factors are associated with admission to hospital, how long patients spend in hospital, and whether there are any specific benefits attributable to hospital admission. Six hundred and twenty-five patients were admitted on account of their index stroke. These patients were compared with the 249 who remained at home throughout the first six months after the stroke--the remaining patients were admitted for other reasons or had their stroke in hospital. Two major factors related to an increased chance of admission: having a more severe disability and not having a carer. The same factors were associated with a longer length of stay for those who returned home within six months. Nevertheless 26% of patients managed at home were severely disabled when first seen within seven days. Patients admitted had a median stay of seven days if they died, 19 days if they returned home, and 149 days if they needed alternative long-term accommodation. Patients from the study population of 215 000 people occupied an average of 11.4 beds/100 000 over the first six months after their stroke. After making allowance for the increased severity of disability seen in those admitted to hospital, no differences in functional, social or emotional outcome were found for either place of care.

Pain in motor neuron disease.

Twenty-seven of 42 patients with motor neuron disease had significant pain. The nature and duration of the pain are described along with an illustrative case-report. The aetiology and most effective treatment of this common complication of motor neuron disease remain unclear.

Controlled trial of a home-care service for acute stroke patients.

In a controlled trial of a home-care service available for the first 6 months after acute stroke, 440 patients received the new service and 417 patients were in the control group. The trial group used more hospital bed days, had a slightly higher admission rate, and did not show better emotional adjustment to stroke than the control group. There was no difference between the 2 groups in stress on relatives. Functional recovery was equal in the 2 groups. A quarter of patients managed at home in each group were severely disabled. Providing a new service does not necessarily alter clinical decisions in the short term, and care should be taken before expanding domiciliary services to reduce hospital use.

Social activities after stroke: measurement and natural history using the Frenchay Activities Index.

A method of assessing general (i.e. other than personal care) activities of stroke patients is described: the Frenchay Activities Index (FAI), a scale comprising 15 individual activities summed to give an overall score from 0 (low) to 45 (high). Data from 976 patients with acute stroke were analysed to establish the validity and reliability of the index, and to give information on the level of activities seen before stroke, at 6 months and 1 year post-stroke. Factors related to a lower overall score included loss of functional (ADL) ability, more depression, a lower IQ and, at 1 year, being female.

Stroke: the influence of age upon outcome.

This study is based upon 162 consecutive patients seen at a rehabilitation unit, and investigates the effect age has upon the manifestations and antecedents of stroke, and its outcome at six months. In this group of patients, age had little influence upon the severity of stroke, the deficits seen initially or the functional ability at six months. However, age had an influence upon the pattern of care given to these patients, in that older patients were likely to stay in hospital longer. There was an increasing proportion of women in the older age groups.

Motor neurone disease: can we do better? A study of 42 patients.

A feeling that patients with motor neurone disease were not always well managed prompted a study of the symptoms, functional levels, and use of aids in a group of 42 patients. Pain, falls, constipation, and swelling of the legs emerged as the major symptomatic problems. At the time of assessment two thirds of the patients appeared to be in need of aids which had not been provided. Disturbance of sleep secondary to positional nocturnal discomfort caused much distress to both the patient and spouse; and this might be eased by the use of an electric turning bed. Over half the patients said that they disliked attending neurology outpatient clinics. Criticism centred on poor transport arrangements, lack of information about the control of symptoms, and unsatisfactory help from junior staff. A key worker should be identified as part of a new strategy for managing these patients.

Long-term survival after stroke.

A total of 162 patients referred for rehabilitation were followed-up for two years. Using the t test and the chi-square test, 15 variables distinguishing the 107 survivors from the 55 who died were identified. Multiple regression analysis identified three factors that gave a predictive equation which correctly identified 92% of the two-year survivors and 48% of those dying in that time. These factors were the severity of the stroke (represented by the patient's walking ability), the presence of pre-existing cardiovascular disease (indicated by a history of myocardial infarction), and the patient's age. Pre-stroke motivation or fitness may also influence long-term survival. The technique of using multiple regression analysis allows a clearer separation of the important prognostic factors than the more usual comparative statistical methods.

The hemiplegic arm after stroke: measurement and recovery.

Seven clinical tests have been used to study the recovery of arm function in 92 patients over 2 years following their stroke. These tests are simple and quick, and can be used by any interested observer. They form a hierarchical scale that measures recovery. Statistically significant improvement is only seen in the first 3 months. Fifty-six patients initially had non-functional arms; eight made a "complete recovery" and 14 a partial recovery. The tests described are inadequate on their own because they are not sufficiently sensitive at the upper range of ability. While recovery of lost function does relate to the degree of initial neurological loss in the arm, it seems to be largely independent of the overall severity of the stroke.