The Unmet Needs of Stroke Survivors and Stroke Caregivers: A Systematic Narrative Review.

INTRODUCTION: Facilitating stroke survivors and their caregivers to lead a fulfilling life after stroke requires service providers to think about their different needs. Poor post stroke care may lead to unmet needs in stroke survivors and stroke caregivers. This may compromise them in leading their lives optimally after stroke. OBJECTIVES & METHODOLOGY: This systematic narrative review examines articles published from 1990 to 2017, generated from Ovid, MEDLINE, CINAHL, and PubMed. The search was also supplemented by an examination of reference lists for related articles via Scopus. We included 105 articles. FINDINGS: We found that the type of unmet needs in stroke survivors and the contributing factors were substantially different from their caregivers. The unmet needs in stroke survivors ranged from health-related needs to re-integration into the community; while the unmet needs in stroke caregivers ranged from information needs to support in caring for the stroke survivors and caring for themselves. Additionally, the unmet needs in both groups were associated with different factors. CONCLUSION: More research is required to understand the unmet needs of stroke survivors and stroke caregivers to improve the overall post-stroke care services.

Modeling non-syndromic autism and the impact of TRPC6 disruption in human neurons.

An increasing number of genetic variants have been implicated in autism spectrum disorders (ASDs), and the functional study of such variants will be critical for the elucidation of autism pathophysiology. Here, we report a de novo balanced translocation disruption of TRPC6, a cation channel, in a non-syndromic autistic individual. Using multiple models, such as dental pulp cells, induced pluripotent stem cell (iPSC)-derived neuronal cells and mouse models, we demonstrate that TRPC6 reduction or haploinsufficiency leads to altered neuronal development, morphology and function. The observed neuronal phenotypes could then be rescued by TRPC6 complementation and by treatment with insulin-like growth factor-1 or hyperforin, a TRPC6-specific agonist, suggesting that ASD individuals with alterations in this pathway may benefit from these drugs. We also demonstrate that methyl CpG binding protein-2 (MeCP2) levels affect TRPC6 expression. Mutations in MeCP2 cause Rett syndrome, revealing common pathways among ASDs. Genetic sequencing of TRPC6 in 1041 ASD individuals and 2872 controls revealed significantly more nonsynonymous mutations in the ASD population, and identified loss-of-function mutations with incomplete penetrance in two patients. Taken together, these findings suggest that TRPC6 is a novel predisposing gene for ASD that may act in a multiple-hit model. This is the first study to use iPSC-derived human neurons to model non-syndromic ASD and illustrate the potential of modeling genetically complex sporadic diseases using such cells.

Therapy-based rehabilitation services for patients living at home more than one year after stroke.

BACKGROUND: Current practice of rehabilitation intervention mainly concentrates on the first six months of stroke. At present, there is no agreed consensus about the benefits of such a service more than one year after stroke. OBJECTIVES: To ascertain whether therapy-based rehabilitation services can influence outcome one year or more after stroke. SEARCH STRATEGY: We searched the trials registers of the following Cochrane Review Groups: Stroke Group (last searched September 2007), Effective Practice and Organisation of Care Group (last searched October 2006) and Dementia and Cognitive Improvement Group (last searched October 2006). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2006), MEDLINE (1966 to October 2006), EMBASE (1980 to October 2006), CINAHL (1982 to October 2006), AMED (1985 to October 2006), PEDro (1952 to October 2006), British Nursing Index (1993 to October 2006), DARE (1994 to October 2006), HMIC (1979 to October 2006) and NHS EED (1991 to October 2006). We also searched dissertation databases and ongoing trials and research registers, scanned reference lists and contacted researchers and experts in the field. SELECTION CRITERIA: All randomised controlled trials of community-based stroke patients, in which at least 75% were recruited one year after stroke and received a therapy-based rehabilitation intervention that was compared with conventional care. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials and extracted data on a number of pre-specified outcomes. The primary outcomes were the proportion of participants who had deteriorated or were dependent in personal activities of daily living at the end of scheduled follow up. MAIN RESULTS: We identified five trials of 487 participants that were eligible for the review. Overall, there was inconclusive evidence as to whether therapy-based rehabilitation intervention one year after stroke was able to influence any relevant patient or carer outcome. Trials varied in design, type of interventions provided, quality, and outcomes assessed. AUTHORS' CONCLUSIONS: This review highlights the dearth of evidence investigating long-term therapy-based rehabilitation interventions for patients with stroke.

Why do patients with PSP fall? Evidence for abnormal otolith responses.

BACKGROUND: Patients with progressive supranuclear palsy (PSP) fall frequently, beginning early in the course of their disease. Abnormal vestibulospinal reflexes are suspected, but the angular vestibulo-ocular reflex, which is mediated by the labyrinthine semicircular canals, survives late into the course of the disease. OBJECTIVE: To test the hypothesis that otolithic-mediated reflexes are abnormal in PSP. METHODS: We tested otolith-ocular reflexes (the translational vestibulo-ocular reflex [tVOR]) during combined rotation-translation in nine patients with PSP and nine age-matched control subjects; subjects viewed far and near targets. We also tested click-induced otolith-spinal reflexes (vestibular-evoked myogenic potentials [VEMPs]) in 10 patients with PSP and 30 age-matched controls. RESULTS: All patients with PSP had small tVOR responses during near viewing that were, on average, only 12% of those of control subjects (p = 0.001). Patients with PSP also showed a reduction of the amplitude of VEMPs compared to control subjects (median [range]: 54.3 [16.8 to 214] vs 149 [11.6 to 466], p = 0.001). CONCLUSIONS: Taken together, these results indicate that abnormal otolith-mediated reflexes may be at least partly responsible for frequent falls in progressive supranuclear palsy, and deserve further study.

Changing occupational therapy and physiotherapy practice through guidelines and audit in the United Kingdom.

BACKGROUND: The National Clinical Guidelines for Stroke (NCGS) were produced and three rounds of the National Sentinel Audit of Stroke conducted to improve the quality of stroke care in the UK. OBJECTIVE: To compare the results of the occupational therapy and physiotherapy elements of the most recent national sentinel audit with the occupational therapy- and physiotherapy-specific recommendations of the NCGS. METHODS: Retrospective case-note audit. RESULTS: Over 95% of hospitals/sites who manage stroke in England, Wales and Northern Ireland took part in the most recent round of the sentinel audit. The clinical audit took place from 1 April to 30 June 2001 and incorporated 235 hospitals/sites. The organizational audit took place in January 2002 and incorporated 240 hospitals/sites. Data are presented from the 235 with both clinical and organizational data, under the headings of: approaches to rehabilitation; carers/families; rehabilitation interventions; and transfer to the community. Low rates of compliance with national standards were observed for all domains. CONCLUSION: Our findings suggest that occupational therapists and physiotherapists are not fully complying with the national standards for stroke care.

Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke.

OBJECTIVE: To evaluate an occupational therapy intervention to improve outdoor mobility after stroke. DESIGN: Randomised controlled trial. SETTING: General practice registers, social services departments, a primary care rehabilitation service, and a geriatric day hospital. PARTICIPANTS: 168 community dwelling people with a clinical diagnosis of stroke in previous 36 months: 86 were allocated to the intervention group and 82 to the control group. INTERVENTIONS: Leaflets describing local transport services for disabled people (control group) and leaflets with assessment and up to seven intervention sessions by an occupational therapist (intervention group). MAIN OUTCOME MEASURES: Responses to postal questionnaires at four and 10 months: primary outcome measure was response to whether participant got out of the house as much as he or she would like, and secondary outcome measures were response to how many journeys outdoors had been made in the past month and scores on the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire. RESULTS: Participants in the treatment group were more likely to get out of the house as often as they wanted at both four months (relative risk 1.72, 95% confidence interval 1.25 to 2.37) and 10 months (1.74, 1.24 to 2.44). The treatment group reported more journeys outdoors in the month before assessment at both four months (median 37 in intervention group, 14 in control group: P < 0.01) and 10 months (median 42 in intervention group, 14 in control group: P < 0.01). At four months the mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. No significant differences were observed in these measures at 10 months. CONCLUSION: A targeted occupational therapy intervention at home increases outdoor mobility in people after stroke.

Individual patient data meta-analysis of randomized controlled trials of community occupational therapy for stroke patients.

BACKGROUND AND PURPOSE: Trials of occupational therapy for stroke patients living in the community have varied in their findings. It is unclear why these discrepancies have occurred. METHODS: Trials were identified from searches of the Cochrane Library and other sources. The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) score at the end of intervention. Secondary outcome measures included the Barthel Index or the Rivermead ADL (Personal ADL), General Health Questionnaire (GHQ), Nottingham Leisure Questionnaire (NLQ), and death. Data were analyzed using linear or logistic regression with a random effect for trial and adjustment for age, gender, baseline dependency, and method of follow-up. Subgroup analyses compared any occupational therapy intervention with control. RESULTS: We included 8 single-blind randomized controlled trials incorporating 1143 patients. Occupational therapy was associated with higher NEADL scores at the end of intervention (weighted mean difference [WMD], 1.30 points, 95% confidence intervals [CI], 0.47 to 2.13) and higher leisure scores at the end of intervention (WMD, 1.51 points; 95% CI, 0.24 to 2.79). Occupational therapy emphasizing activities of daily living (ADL) was associated with improved end of intervention NEADL (WMD, 1.61 points; 95% CI, 0.72 to 2.49) and personal activities of daily living (odds ratio [OR], 0.65; 95% CI, 0.46 to 0.91), but not NLQ. Leisure-based occupational therapy improved end of intervention NLQ (WMD, 1.96 points; 95% CI, 0.27 to 3.66) but not NEADL or PADL. CONCLUSIONS: Community occupational therapy significantly improved personal and extended activities of daily living and leisure activity in patients with stroke. Better outcomes were found with targeted interventions.

Evaluation of a multiprofessional community stroke team: a randomized controlled trial.

OBJECTIVES: There is inconclusive evidence of the effectiveness of stroke rehabilitation by a community stroke team. The aim was to evaluate a specialist multiprofessional team in a community setting. DESIGN: Randomized controlled trial. SETTING: Community. PARTICIPANTS: Stroke patients and their informal carers who were referred to receive rehabilitation from a community stroke team. OUTCOME MEASURES: Barthel Index, Extended Activities of Daily Living Scale (EADL), General Health Questionnaire (GHQ-12) by patient and carer, Carer Strain Index (CSI), Euroquol, knowledge of stroke and satisfaction with services six months after recruitment. RESULTS: There were no significant differences between patients who received rehabilitation from community stroke team (n = 189) and those who received routine care (n = 232) in their independence in activities of daily living, mood, quality of life or knowledge of stroke. The patients in the community stroke team group were significantly more satisfied with the emotional support they had received (p < 0.01). There were no significant differences between the groups in satisfaction with practical help or overall satisfaction. Carers of patients in the community stroke team were under significantly less strain than carers in the routine care group (p < 0.04). Carers of patients in the community stroke team group were significantly more satisfied with their knowledge of stroke (p < 0.01) and were more satisfied overall (p < 0.01). CONCLUSIONS: The patients treated by the community stroke team were more satisfied with the emotional support they received and had equivalent outcomes in terms of independence in activities of daily living and mood. Their carers were under less strain and were more satisfied with their knowledge of stroke recovery, the emotional support they received and overall satisfaction with services. The results support the provision of rehabilitation by a community-based specialist multiprofessional team.

The impact of cognitive impairment on upper body dressing difficulties after stroke: a video analysis of patterns of recovery.

OBJECTIVE: to study the underlying cognitive deficits influencing a stroke patient's ability to relearn to dress. The aim was to investigate how recovery had occurred and whether the nature of cognitive impairment was the reason for persistent dressing problems. METHODS: the dressing performance of 30 stroke patients was compared at the sub-acute stage and three months later. Standardised cognitive and physical tests were carried out, together with a video analysis of patients putting on a polo shirt. RESULTS: thirteen patients with preserved power in the upper limb used both arms to put on the shirt. Despite visuospatial impairment or apraxia in some cases, all were successful given sufficient time. Out of 17 patients with arm paresis, 12 were dependent putting on the shirt. Amongst the five who were independent, significantly fewer cases of cognitive impairment were seen on tests for apraxia (p<0.05) and visuospatial perception (p<0.05). Video analysis confirmed the importance of cognitive problems such as neglect or apraxia. Three patients who failed shirt dressing showed neglect or apraxia at follow up and had persistent arm paresis. Test failures also occurred amongst those who were independent. DISCUSSION: cognitive impairment affected patients attempting to relearn to dress with one hand, but did not affect patients who used both hands. The three patients who remained impaired on cognitive tests at follow up were unable to adapt or learn any compensatory strategies. The influence of cognition on a person's ability to learn compensatory strategies has implications for the design of rehabilitation therapies.

Eye-position dependence of torsional velocity during interaural translation, horizontal pursuit, and yaw-axis rotation in humans.

The translational vestibulo-ocular reflex (tVOR) stabilizes an image on the fovea during linear movements of the head. It has been suggested that the tVOR may share pathways with the pursuit system. We asked whether the tVOR and pursuit would be similar in their behavior relative to Listing's Law. We compared torsional eye velocity as a function of vertical orbital position during interaural translation, pursuit, and yaw-axis rotation. We found that the eye-position-dependence of torsion was similar during translation and pursuit, which differed from that during yaw-axis rotation. These findings further support a close relationship between the mechanisms that generate pursuit and the tVOR.

Bedside vestibular examination.

A careful neuro-otologic examination is important in the diagnosis of vestibular disorders. This article reviews the bedside examination, beginning with the underlying physiologic principles. Techniques for testing static and dynamic vestibulo-ocular and vestibulospinal function are summarized. Finally, the use of specific provocative maneuvers is described.

Rotation of Listing's plane with convergence: independence from eye position.

PURPOSE: To determine whether asymmetrical vergence results in a rotation of Listing's plane independent of vergence-associated changes of eye position in the orbit. METHODS: Six normal subjects were required to fixate on a 3x3 array (40 degrees on a side) of light-emitting diodes arranged on a flat screen 124 cm from the subject. Disparity-induced vergence was elicited with a horizontal Fresnel prism (30 cm/m, approximately 17 degrees) placed in front of one eye. In four subjects accommodative vergence (10 degrees to 15 degrees) was produced by placing a minus spherical lens in front of one eye while the other eye was covered. Eye position was measured binocularly using three-axis search coils. Control data were collected without prisms during monocular and binocular viewing. For all data a planar regression was used to fit torsional eye position as a function of horizontal and vertical position to calculate the horizontal and vertical primary positions that define the orientation of Listing's plane. RESULTS: In the prism experiment, the horizontal primary position of the eye not wearing the prism rotated temporally by 3.9 degrees +/-1.7 degrees compared with the both eyes viewing control condition. The rotation of the prism eye was in a similar range (3.4 degrees +/-2.0 degrees). With accommodation, the horizontal primary position of the viewing eye rotated temporally by 4.4 degrees +/-1.4 degrees compared with the monocular viewing control. In both the accommodation and the prism paradigms there was usually a rotation of vertical primary position downward. CONCLUSIONS: Vergence-induced changes in Listing's plane can be independent of changes in orbital position associated with vergence. This finding supports a role for changes in central innervation in the elaboration of Listing's law.

The effect of hyperventilation on downbeat nystagmus in cerebellar disorders.

Hyperventilation can affect nystagmus in patients with vestibular disorders. However, the effects on nystagmus in patients with cerebellar disease have not been systematically studied. Using the magnetic field search coil technique, we studied the effects of hyperventilation on nystagmus in a series of cerebellar patients. In four of eight patients, hyperventilation produced an increase in the slow-phase velocity of downbeat nystagmus. We speculate that this effect may be mediated through metabolic effects on cerebellar calcium channels.

Occupational therapy for stroke patients not admitted to hospital: a randomised controlled trial.

BACKGROUND: Patients who have a stroke are not always admitted to hospital, and 22-60% remain in the community, frequently without coordinated rehabilitation. We aimed to assess the efficacy of an occupational therapy intervention for patients with stroke who were not admitted to hospital. METHODS: In this single-blind randomised controlled trial, consecutive stroke patients on a UK community register in Nottingham and Derbyshire were allocated randomly to up to 5 months of occupational therapy at home or to no intervention (control group) 1 month after their stroke. The aim of the occupational therapy was to encourage independence in personal and instrumental activities of daily living. Patients were assessed on outcome measures at baseline (before randomisation) and at 6 months. The primary outcome measure was the score on the extended activities of daily living (EADL) scale at 6 months. Other outcome measures included the Barthel index, the general health questionnaire 28, the carer strain index, and the London handicap scale. All assessments were done by an independent assessor who was unaware of treatment allocation. The analysis included only data from completed questionnaires. FINDINGS: 185 patients were included: 94 in the occupational therapy group and 91 in the control group. 22 patients were not assessed at 6 months. At follow-up, patients who had occupational therapy had significantly higher median scores than the controls on: the EADL scale (16 vs 12, p<0.01, estimated difference 3 [95% CI 1 to 4]); the Barthel index (20 vs 18, p<0.01, difference 1, [0-1]); the carer strain index (1 vs 3, p<0.05, difference 1 [0 to 2]); and the London handicap scale (76 vs 65, p<0.05, difference 7, [0.3 to 13.5]). There were no significant differences on the general health questionnaire between the patient or carer. INTERPRETATION: Occupational therapy significantly reduced disability and handicap in patients with stroke who were not admitted to hospital.

Directional abnormalities of vestibular and optokinetic responses in cerebellar disease.

Directional abnormalities of vestibular and optokinetic responses in patients with cerebellar degeneration are reported. Three-axis magnetic search-coil recordings of the eye and head were performed in eight cerebellar patients. Among these patients, examples of directional cross-coupling were found during (1) high-frequency, high-acceleration head thrusts; (2) constant-velocity chair rotations with the head fixed; (3) constant-velocity optokinetic stimulation; and (4) following repetitive head shaking. Cross-coupling during horizontal head thrusts consisted of an inappropriate upward eye-velocity component. In some patients, sustained constant-velocity yaw-axis chair rotations produced a mixed horizontal-torsional nystagmus and/or an increase in the baseline vertical slow-phase velocity. Following horizontal head shaking, some patients showed an increase in the slow-phase velocity of their downbeat nystagmus. These various forms of cross-coupling did not necessarily occur to the same degree in a given patient; this suggests that different mechanisms may be responsible. It is suggested that cross-coupling during head thrusts may reflect a loss of calibration of brainstem connections involved in the direct vestibular pathways, perhaps due to dysfunction of the flocculus. Cross-coupling during constant-velocity rotations and following head shaking may result from a misorientation of the angular eye-velocity vector in the velocity-storage system. Finally, responses to horizontal optokinetic stimulation included an inappropriate torsional component in some patients. This suggests that the underlying organization of horizontal optokinetic tracking is in labyrinthine coordinates. The findings are also consistent with prior animal-lesion studies that have shown a role for the vestibulocerebellum in the control of the direction of the VOR.

Eye-movement recordings in the evaluation of ophthalmologic and neurologic disorders.

This review focuses on the use of quantitative eye-movement recordings in the diagnosis of ophthalmologic and neurologic disorders and in the investigation of the pathophysiologic mechanisms of and possible treatments for these disorders. Recently developed methods for measuring eye movements about all three axes of rotation (horizontal, vertical, and torsion) are emphasized. These techniques are providing important insights into the basic physiology of eye-movement control and into the mechanisms of ocular motor disturbances in which torsion plays a significant role.

Practical guidelines for independent assessment in randomized controlled trials (RCTs) of rehabilitation.

OBJECTIVE: To provide guidelines for conducting independent assessments in randomized controlled trials (RCTs) of rehabilitation. The article aims to assist those who plan to put independent assessment into practice and to be an introduction for those who are new to independent assessment. ISSUES: Possible causes of unblinding to group allocation are discussed, such as unblinding by other people, the environment, patients and assessors themselves. Other issues discussed in this paper are bias during assessment and monitoring levels of unblinding. CONCLUSION: The importance of monitoring levels of unblinding is stressed. Although it may not be possible to always keep an assessor blind in RCTs of rehabilitation, we should strive for perfection. It is therefore advocated that levels of unblinding should be reported.