Caring for continence in stroke care settings: a qualitative study of patients' and staff perspectives on the implementation of a new continence care intervention.

OBJECTIVES: Investigate the perspectives of patients and nursing staff on the implementation of an augmented continence care intervention after stroke. DESIGN: Qualitative data were elicited during semi-structured interviews with patients (n = 15) and staff (14 nurses; nine nursing assistants) and analysed using thematic analysis. SETTING: Mixed acute and rehabilitation stroke ward. PARTICIPANTS: Stroke patients and nursing staff that experienced an enhanced continence care intervention. RESULTS: Four themes emerged from patients' interviews describing: (a) challenges communicating about continence (initiating conversations and information exchange); (b) mixed perceptions of continence care; (c) ambiguity of focus between mobility and continence issues; and (d) inconsistent involvement in continence care decision making. Patients' perceptions reflected the severity of their urinary incontinence. Staff described changes in: (i) knowledge as a consequence of specialist training; (ii) continence interventions (including the development of nurse-led initiatives to reduce the incidence of unnecessary catheterisation among patients admitted to their ward); (iii) changes in attitude towards continence from containment approaches to continence rehabilitation; and (iv) the challenges of providing continence care within a stroke care context including limitations in access to continence care equipment or products, and institutional attitudes towards continence. CONCLUSION: Patients (particularly those with severe urinary incontinence) described challenges communicating about and involvement in continence care decisions. In contrast, nurses described improved continence knowledge, attitudes and confidence alongside a shift from containment to rehabilitative approaches. Contextual components including care from point of hospital admission, equipment accessibility and interdisciplinary approaches were perceived as important factors to enhancing continence care.

Cochrane Stroke Group: twenty years of evidence-based stroke medicine.

The Cochrane Stroke Group was one of the first specialist review groups set up within The Cochrane Collaboration and has been in existence for 20 years. Its key outputs include a number of high profile reviews in the area of the management of stroke, which have become one of the most important sources of information for clinical practice guidelines. The work of the group is only possible through a collaborative network of staff, editors, and authors.

Is informal caregiving independently associated with poor health? A population-based study.

BACKGROUND: Providing informal care has been linked with poor health but has not previously been studied across a whole population. We aimed to study the association between informal care provision and self-reported poor health. METHOD: We used data from the UK 2001 Census. The relationship between informal caregiving and poor health was modelled using logistic regression, adjusting for age, sex, marital status, ethnicity, economic activity and educational attainment. RESULTS: We included 44,465,833 individuals free from permanent sickness or disability. 5,451,902 (12.3%) participants reported providing informal care to another person. There was an association between provision of informal caregiving and self-reported poor health; OR 1.100, 95% CI 1.096 to 1.103. This association remained after adjustment for age, sex, ethnic group, marital status, economic activity and educational attainment. The association also increased with the amount of care provided (hours per week). CONCLUSIONS: Around one in eight of the UK population reports that he or she is an informal caregiver. This activity is associated with poor health, particularly in those providing over 20 h care per week.

Developing and validating a predictive model for stroke progression.

BACKGROUND: Progression is believed to be a common and important complication in acute stroke, and has been associated with increased mortality and morbidity. Reliable identification of predictors of early neurological deterioration could potentially benefit routine clinical care. The aim of this study was to identify predictors of early stroke progression using two independent patient cohorts. METHODS: Two patient cohorts were used for this study - the first cohort formed the training data set, which included consecutive patients admitted to an urban teaching hospital between 2000 and 2002, and the second cohort formed the test data set, which included patients admitted to the same hospital between 2003 and 2004. A standard definition of stroke progression was used. The first cohort (n = 863) was used to develop the model. Variables that were statistically significant (p < 0.1) on univariate analysis were included in the multivariate model. Logistic regression was the technique employed using backward stepwise regression to drop the least significant variables (p > 0.1) in turn. The second cohort (n = 216) was used to test the performance of the model. The performance of the predictive model was assessed in terms of both calibration and discrimination. Multiple imputation methods were used for dealing with the missing values. RESULTS: Variables shown to be significant predictors of stroke progression were conscious level, history of coronary heart disease, presence of hyperosmolarity, CT lesion, living alone on admission, Oxfordshire Community Stroke Project classification, presence of pyrexia and smoking status. The model appears to have reasonable discriminative properties [the median receiver-operating characteristic curve value was 0.72 (range 0.72-0.73)] and to fit well with the observed data, which is indicated by the high goodness-of-fit p value [the median p value from the Hosmer-Lemeshow test was 0.90 (range 0.50-0.92)]. CONCLUSION: The predictive model developed in this study contains variables that can be easily collected in practice therefore increasing its usability in clinical practice. Using this analysis approach, the discrimination and calibration of the predictive model appear sufficiently high to provide accurate predictions. This study also offers some discussion around the validation of predictive models for wider use in clinical practice.

Scottish Stroke Research Network: the first three years.

Research networks were introduced in the UK to facilitate and improve clinical research and stroke was seen as a priority topic for local research network development. The Scottish Stroke Research Network (SSRN) is one of 11 stroke research networks in the UK. In this article we review the progress of the Scottish Stroke Research Network in the three years since inception. Between 2006-2009 the number of active hospital research sites has increased from 10 to 22 expanding to involve 20 stroke research nurses. There was a corresponding 58% increase in recruitment of participants into stroke studies, from 376 in 2006/07 to 594 in 2008/09. The majority (17/20) of our current studies are interventional. Data from one of these, the CLOTs trial (Clots in Legs Or sTocking after Stroke), demonstrates that the annual recruitment in Scotland increased from a median of 94 (range 6-122) patients per year in the six years before the SSRN, to 140 (135-158) patients per year after SSRN involvement. We currently screen about 50% of Scottish stroke patients and approximately 5% of Scottish stroke patients are participating in research studies that we support. The SSRN has made good progress in the first three years. Increasing the recruitment of screened patients remains a challenge.

Rationale and design of INTERSTROKE: a global case-control study of risk factors for stroke.

UNLABELLED: Stroke is a major global health problem. It is the third leading cause of death and the leading cause of adult disability. INTERHEART, a global case-control study of acute myocardial infarction in 52 countries (29,972 participants), identified nine modifiable risk factors that accounted for >90% of population-attributable risk. However, traditional risk factors (e.g. hypertension, cholesterol) appear to exert contrasting risks for stroke compared with coronary heart disease, and the etiology of stroke is far more heterogeneous. In addition, our knowledge of risk factors for stroke in low-income countries is inadequate, where a very large burden of stroke occurs. Accordingly, a similar epidemiological study is required for stroke, to inform effective population-based strategies to reduce the risk of stroke. METHODS: INTERSTROKE is an international, multicenter case-control study. Cases are patients with a first stroke within 72 h of hospital presentation in whom CT or MRI is performed. Proxy respondents are used for cases unable to communicate. Etiological and topographical stroke subtype is documented for all cases. Controls are hospital- and community-based, matched for gender, ethnicity and age (+/-5 years). A questionnaire (cases and controls) is used to acquire information on known and proposed risk factors for stroke. Cardiovascular (e.g. blood pressure) and anthropometric (e.g. waist-to-hip ratio) measurements are obtained at the time of interview. Nonfasting blood samples and random urine samples are obtained from cases and controls. Study Significance: An effective global strategy to reduce the risk of stroke mandates systematic measurement of the contribution of the major vascular risk factors within defined ethnic groups and geographical locations.

Controlling ecological bias in evidence synthesis of trials reporting on collapsed and overlapping covariate categories.

Meta-analysis of randomized controlled trials based on aggregated data is vulnerable to ecological bias if trial results are pooled over covariates that influence the outcome variable, even when the covariate does not modify the treatment effect, or is not associated with the treatment. This paper shows how, when trial results are aggregated over different levels of covariates, the within-study covariate distribution, and the effects of both covariates and treatments can be simultaneously estimated, and ecological bias reduced. Bayesian Markov chain Monte Carlo methods are used. The method is applied to a mixed treatment comparison evidence synthesis of six alternative approaches to post-stroke inpatient care. Results are compared with a model using only the stratified covariate data available, where each stratum is treated as a separate trial, and a model using fully aggregated data, where no covariate data are used.

An observational study of acute stroke care in four countries: the European registers of stroke study.

BACKGROUND: The European Registers Of Stroke (EROS) project aimed to assess outcomes of stroke care across Europe, relating these to both case mix information from disease-specific population registers and the quality of stroke care provided at each centre. This included comparing information on quality of care with direct observation of the stroke care process in 4 centres. METHODS: Direct non-participant observational methods were used on a purposive sample of first-stroke patients admitted within the past 14 days to an acute-stroke unit or ward that admits stroke patients in 4 urban hospital sites in London, UK, Dijon, France, Kaunas, Lithuania, and St. Petersburg, Russia. We recorded patient characteristics with levels of contact with multi-disciplinary team (MDT) members and contact with families and mobilization to build a collection of 'snapshots' of stroke care throughout the patients' day. One independent observer undertook all observations over 1 day. RESULTS: We observed differences between centres in the proportion of observations where patients were alone (lowest proportion in London, highest proportion in St. Petersburg) (p > 0.001), where patients had contact with MDT members (p > 0.001) and family, and where patients were out of bed/mobile (p > 0.001) (both with highest proportion in London, lowest proportion in St. Petersburg). CONCLUSIONS: Higher levels of contact with the MDT, family contact and mobilization were observed in the Western European centres than the Eastern European and Russian centres. Differences in case mix may explain some, but not all, of these differences. Direct observation has some limitations; however, it could be developed in future studies to help identify other key aspects of effective stroke care.

Deep frontal and periventricular age related white matter changes but not basal ganglia and infratentorial hyperintensities are associated with falls: cross sectional results from the LADIS study.

BACKGROUND: Global age related white matter changes (ARWMC) are associated with progressive gait disturbances and falls, hypothesised to result from interruptions of cortico-subcortical circuits controlling balance, posture and locomotion. METHODS: The location of ARWMC in a large cohort of elderly non-disabled individuals with reported falls was analysed, using the cross sectional data of the Leukoaraiosis and Disability (LADIS) study. Detailed anatomical distributions of ARWMC assessed by MRI studies were analysed with respect to falls and balance performance. RESULTS: The severity of global ARWMC was significantly associated with a history of falls in the year prior to study inclusion (22.2% in the mild, 31.6% in the moderate and 37.3% in the severe ARWMC group according to the Fazekas scale; p = 0.002). Analysing the anatomical distribution of ARWMC, using the semiquantitative Scheltens scale, in multivariate analysis, periventricular (p = 0.006) and frontal deep (p = 0.033) ARWMC were independently associated with falls. Furthermore, logistic regression identified frontal deep (p = 0.003) ARWMC, but not basal ganglia and infratentorial hyperintensities, as significantly associated with balance disturbances. CONCLUSION: The association of frontal and periventricular ARWMC with falls supports the hypothesis that interruption of frontal subcortical motor circuits lead to balance disturbances and hence to an increased risk for falls in ARWMC.

Urinary tract infection after stroke.

BACKGROUND: Urinary tract infection (UTI) is a recognized complication of stroke. We aimed to determine the incidence of UTI after acute stroke, the risk factors associated with this complication, and its association with outcome. METHODS: Prospective study of consecutive acute stroke patients admitted to an urban teaching hospital. Routine clinical assessment included the modified National Institutes of Health Stroke Scale (mNIHSS) and modified Rankin scale (mRS). Patients were followed up for 3 months, including recording of clinician diagnosis of UTI. RESULTS: We studied 412 patients; 65 (15.8%) were diagnosed with UTI, at a median of 14 days (IQR = 4-39) post-stroke. In a binomial multivariate regression analysis, UTI was associated with urinary catheterization (OR = 3.03, 95% CI 1.41-6.52), higher mRS (OR = 1.85, 1.29-2.64) and increasing age (OR = 1.51, 1.13-2.00 for each decade). UTI was associated with death or disability at 3 months, however, this link was attenuated and became non-significant when measures of stroke severity and pre-stroke morbidity were included in a multivariate analysis. CONCLUSION: UTI is common after acute stroke. It is associated with urinary catheterization, post-stroke disability and increasing age. Avoidance of catheterization might reduce the incidence of this common complication.

A systematic review of repetitive functional task practice with modelling of resource use, costs and effectiveness.

OBJECTIVES: To determine whether repetitive functional task practice (RFTP) after stroke improves limb-specific or global function or activities of daily living and whether treatment effects are dependent on the amount of practice, or the type or timing of the intervention. Also to provide estimates of the cost-effectiveness of RFTP. DATA SOURCES: The main electronic databases were searched from inception to week 4, September 2006. Searches were also carried out on non-English-language databases and for unpublished trials up to May 2006. REVIEW METHODS: Standard quantitative methods were used to conduct the systematic review. The measures of efficacy of RFTP from the data synthesis were used to inform an economic model. The model used a pre-existing data set and tested the potential impact of RFTP on cost. An incremental cost per quality-adjusted life-year (QALY) gained for RFTP was estimated from the model. Sensitivity analyses around the assumptions made for the model were used to test the robustness of the estimates. RESULTS: Thirty-one trials with 34 intervention-control pairs and 1078 participants were included. Overall, it was found that some forms of RFTP resulted in improvement in global function, and in both arm and lower limb function. Overall standardised mean difference in data suitable for pooling was 0.38 [95% confidence interval (CI) 0.09 to 0.68] for global motor function, 0.24 (95% CI 0.06 to 0.42) for arm function and 0.28 (95% CI 0.05 to 0.51) for functional ambulation. Results suggest that training may be sufficient to have an impact on activities of daily living. Retention effects of training persist for up to 6 months, but whether they persist beyond this is unclear. There was little or no evidence that treatment effects overall were modified by time since stroke or dosage of task practice, but results for upper limb function were modified by type of intervention. The economic modelling suggested that RFTP was cost-effective. Given a threshold for cost-effectiveness of 20,000 pounds per QALY gained, RFTP is cost-effective so long as the net cost per patient is less than 1963 pounds. This result showed some sensitivity to the assumptions made for the model. The cost-effectiveness of RFTP tends to stem from the relatively modest cost associated with this intervention. CONCLUSIONS: The evidence suggests that some form of RFTP can be effective in improving lower limb function at any time after stroke, but that the duration of intervention effect is unclear. There is as yet insufficient good-quality evidence to make any firm recommendations for upper limb interventions. If task-specific training is used, adverse effects should be monitored. While the effectiveness of RFTP is relatively modest, this sort of intervention appears to be cost-effective. Owing to the large number of ongoing trials, this review should be updated within 2 years and any future review should include a comparison against alternative treatments. Further research should evaluate RFTP upper limb interventions and in particular constraint-induced movement therapy, address practical ways of delivering RFTP interventions, be directed towards the evaluation of suitable methods to maintain functional gain, and be powered to detect whether RFTP interventions are cost-effective.

Association of gait and balance disorders with age-related white matter changes: the LADIS study.

OBJECTIVE: In the Leukoaraiosis and Disability (LADIS) Study, 11 European centers are evaluating the role of age-related white matter changes (ARWMC) as an independent determinant of the transition to disability in the elderly (65 to 84 years). We aimed at determining the influence of ARWMC on different objective measures of gait and balance. METHODS: Six hundred thirty-nine nondisabled individuals were prospectively enrolled and are being followed-up for 3 years. Subjects are graded in three standardized categories of ARWMC (mild, moderate, and severe) according to central MRI reading. Quantitative tests of gait and balance include the Short Physical Performance Battery (SPPB; range: 0 [poor] to 12 [normal]), a timed 8-m walk, and a timed single leg stance test. RESULTS: In cross-sectional analysis, deficiencies in gait and balance performance were correlated with the severity of ARWMC (SPPB: 10.2 +/- 2.1 in the mild, 9.9 +/- 2.0 in the moderate, 8.9 +/- 2.6 in the severe group; p < 0.001). Walking speed correlated with the severity of ARWMC (1.24 +/- 0.28 m/second in the mild, 1.18 +/- 0.32 m/second in the moderate, and 1.09 +/- 0.31 m/second in the severe group; p < 0.001). Balance was best in individuals with mild ARWMC (single leg stance time: 18.9 +/- 10.8 seconds) compared with moderate and severe ARWMC (16.4 +/- 10.8 and 13.6 +/- 11.2 seconds) (p < 0.001). Physically inactive individuals had a higher risk of a pathologic SPPB score (moderate vs mild ARWMC: odds ratio 1.60, 95% CI 1.02 to 2.52; severe vs mild ARWMC: odds ratio 1.75, 95% CI 1.09 to 2.80). CONCLUSIONS: Our findings support a strong association between the severity of age-related white matter changes and the severity of gait and motor compromise. Physical activity might have the potential to reduce the risk of limitations in mobility.

Repetitive task training for improving functional ability after stroke.

BACKGROUND: The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation. OBJECTIVES: To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice. SEARCH STRATEGY: We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors. SELECTION CRITERIA: Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified. DATA COLLECTION AND ANALYSIS: Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information. MAIN RESULTS: Fourteen trials with 17 intervention-control pairs and 659 participants were included. PRIMARY OUTCOMES: results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach. SECONDARY OUTCOMES: results were statistically significant for activities of daily living (SMD 0.29, 95% CI 0.07 to 0.51), but not for quality of life or impairment measures. There was no evidence of adverse effects. Follow-up measures were not significant for any outcome at six or twelve months. Treatment effects were not modified by intervention amount or timing, but were modified by intervention type for lower limbs. AUTHORS' CONCLUSIONS: Repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. The review potentially investigates task specificity rather more than repetition. Further research should focus on the type and amount of training, and how to maintain functional gain.

Epidemiological aspects of referral to TIA clinics in Glasgow.

A retrospective cohort study was carried out of new referrals to transient ischaemic attack (TIA) clinics in Glasgow. The aims of the study were to describe the profile of referrals and to assess the odds ratios for TIA, minor stroke or amaurosis fugax of both cardiovascular risk factors and clinical features. In total, data were collected for 813 new referrals in a period of six months. Thirteen point eight percent of referrals were from other Health Boards. The overall referral rate among residents of Greater Glasgow NHS Board was 165.6 per 100,000 per year. About 20% of referrals were made by clinicians in secondary care. The specialties from which referrals were most commonly made were accident and emergency, general medicine, ophthalmology and geriatric assessment. The most common risk factors in patients referred were hypertension (52.9%), smoking (31.7%), ischaemic heart disease (22.7%) and former smokers (22.4%). The most common clinical features were hemiparesis (13.3%), weakness of an upper limb (8.7%), vertigo (7.9%) and dysphasia (7.3%). In 48.7% of cases, a non-cerebrovascular diagnosis was made. Separate multivariate models were established for risk factors and clinical features. In the model for risk factors, five factors were significant for risk of TIA, stroke or amaurosis fugax. These were hyperlipidaemia, age over 64 years, hypertension, smoking and ex-smoking. In the model for clinical features, five factors were also significant. These were visual field defect, speech defact, facial weakness and hemiparesis.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke.

BACKGROUND: There are a number of different approaches to physiotherapy treatment following stroke that, broadly speaking, are based on neurophysiological, motor learning and orthopaedic principles. Some physiotherapists base their treatment on a single approach, while others use a mixture of components from a number of different approaches. OBJECTIVES: To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched May 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005) and CINAHL (1982 to May 2005). We contacted experts and researchers with an interest in stroke rehabilitation. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials of physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function in adult participants with a clinical diagnosis of stroke. Outcomes included measures of disability, motor impairment or participation. DATA COLLECTION AND ANALYSIS: Two review authors independently categorised the identified trials according to the inclusion and exclusion criteria, documented their methodological quality, and extracted the data. MAIN RESULTS: Twenty-one trials were included in the review, five of which were included in two comparisons. Eight trials compared a neurophysiological approach with another approach; eight compared a motor learning approach with another approach; and eight compared a mixed approach with another approach. A mixed approach was significantly more effective than no treatment or placebo control for improving functional independence (standardised mean difference (SMD) 0.94, 95% confidence intervals (CI) 0.08 to 1.80). There was no significant evidence that any single approach had a better outcome than any other single approach or no treatment control. AUTHORS' CONCLUSIONS: There is evidence that physiotherapy intervention, using a mix of components from different approaches, is significantly more effective than no treatment or placebo control in the recovery of functional independence following stroke. There is insufficient evidence to conclude that any one physiotherapy approach is more effective in promoting recovery of lower limb function or postural control following stroke than any other approach. We recommend that future research should concentrate on investigating the effectiveness of clearly described individual techniques and task-specific treatments, regardless of their historical or philsophical origin.

Occupational therapy for patients with problems in activities of daily living after stroke.

BACKGROUND: Occupational therapy aims to help people reach their maximum level of function and independence in all aspects of daily life. OBJECTIVES: To determine whether occupational therapy focused specifically on personal activities of daily living improves recovery for patients following stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched January 2006). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006), CINAHL (1983 to March 2006), PsycLIT (1974 to March 2006), AMED (1985 to March 2006), Wilson Social Sciences Abstracts (1984 to March 2006) and the following Web of Science databases: Science Citation Index (1945 to March 2006), Social Science Citation Index (1956 to March 2006) and Arts and Humanities Citation Index (1975 to March 2006). In an effort to identify further published, unpublished and ongoing trials we searched The Occupational Therapy Research Index and Dissertation Abstracts register, scanned reference lists of relevant articles, contacted authors and researchers and handsearched relevant journals. SELECTION CRITERIA: We identified randomised controlled trials of an occupational therapy intervention (compared to usual care or no care) where stroke patients practiced personal activities of daily living, or performance in activities of daily living was the focus of the occupational therapy intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials and extracted data for pre-specified outcomes. The primary outcomes were the proportion of patients who had deteriorated or were dependent in personal activities of daily living and performance in personal activities of daily living at the end of follow up. MAIN RESULTS: We identified 64 potentially eligible trials and included 10 studies (1348 participants). Occupational therapy interventions reduced the odds of a poor outcome (Peto odds ratio 0.67 (95% confidence interval (CI) 0.51 to 0.87; P = 0.003). and increased personal activity of daily living scores (standardised mean difference 0.18 (95% CI 0.04 to 0.32; P = 0.01). For every 11 (95% CI 7 to 30) patients receiving an occupational therapy intervention to facilitate personal activities of daily living, one patient was spared a poor outcome. AUTHORS' CONCLUSIONS: Patients who receive occupational therapy interventions are less likely to deteriorate and are more likely to be independent in their ability to perform personal activities of daily living. However, the exact nature of the occupational therapy intervention to achieve maximum benefit needs to be defined.

Screening for thrombophilia in high-risk situations: systematic review and cost-effectiveness analysis. The Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) study.

OBJECTIVES: To assess the risk of clinical complications associated with thrombophilia in three high-risk patient groups: women using oral oestrogen preparations, women during pregnancy and patients undergoing major orthopaedic surgery. To assess the effectiveness of prophylactic treatments in preventing venous thromboembolism (VTE) and adverse pregnancy outcomes in women with thrombophilia during pregnancy and VTE in patients with thrombophilia, undergoing major orthopaedic surgery. To evaluate the relative cost-effectiveness of universal and selective VTE history-based screening for thrombophilia compared with no screening in the three high-risk patient groups. DATA SOURCES: Electronic databases including MEDLINE, EMBASE, and four other major databases were searched up to June 2003. REVIEW METHODS: In order to assess the risk of clinical complications associated with thrombophilia, a systematic review of the literature on VTE and thrombophilia in women using oral oestrogen preparations and patients undergoing major orthopaedic surgery; and studies of VTE and adverse obstetric complications in women with thrombophilia during pregnancy was carried out. Meta-analysis was used to calculate pooled odds ratios (ORs) associated with individual clinical outcomes, stratified by thrombophilia type and were calculated for each patient group. To assess the effectiveness of prophylaxis, a systematic review was carried out on the use of prophylaxis in the prevention of VTE and pregnancy loss in pregnant women with thrombophilic defects and the use of thromboprophylaxis in the prevention of VTE in patients with thrombophilia undergoing major elective orthopaedic surgery. Relevant data were summarised according to the patient groups and stratified according to the types of prophylaxis. A narrative summary was provided; where appropriate, meta-analysis was conducted. An incremental cost-effectiveness analysis was then carried out, from the perspective of the NHS in the UK. A decision analytical model was developed to simulate the clinical consequences of four thrombophilia screening scenarios. Results from the meta-analyses, information from the literature and results of two Delphi studies of clinical management of VTE and adverse pregnancy complications were incorporated into the model. Only direct health service costs were measured and unit costs for all healthcare resources used were obtained from routinely collected data and the literature. Cost-effectiveness was expressed as incremental cost-effectiveness ratios (ICERs); an estimate of the cost per adverse clinical complication prevented, comparing screening with no screening, were calculated for each patient group. RESULTS: In the review of risk of clinical complications, 81 studies were included, nine for oral oestrogen preparations, 72 for pregnancy and eight for orthopaedic surgery. For oral contraceptive use, significant associations of the risk of VTE were found in women with factor V Leiden (FVL); deficiencies of antithrombin, protein C, or protein S, elevated levels of factor VIIIc; and FVL and prothrombin G20210A. For hormone replacement therapy (HRT), a significant association was found in women with FVL. The highest risk in pregnancy was found for FVL and VTE, in particular, homozygous carriers of this mutation are 34 times more likely to develop VTE in pregnancy than non-carriers. Significant risks for individual thrombophilic defects were also established for early, recurrent and late pregnancy loss; preeclampsia; placental abruption; and intrauterine growth restriction. Significant associations were found between FVL and high factor VIIIc and postoperative VTE following elective hip or knee replacement surgery. Prothrombin G20210A was significantly associated with postoperative pulmonary embolism. However, antithrombin deficiency, MTHFR and hyperhomocysteinaemia were not associated with increased risk of postoperative VTE. In the review of the effectiveness of prophylaxis, based on available data from eight studies, low-dose aspirin and heparin was found to be the most effective in preventing pregnancy loss in thrombophilic women during pregnancy, while aspirin alone was the most effective in preventing minor bleeding. All the studies on thrombophilia and major elective orthopaedic surgery included in the review of risk complications were also used in the review of the effectiveness of thromboprophylaxis. However, there were insufficient data to determine the relative effectiveness of different thromboprophylaxis in preventing VTE in this patient group. For the cost-effectiveness analysis, of all the patient groups evaluated, universal screening of women prior to prescribing HRT was the most cost-effective (ICER pound6824). In contrast, universal screening of women prior to prescribing combined oral contraceptives was the least cost-effective strategy (ICER pound202,402). Selective thrombophilia screening based on previous personal and/or family history of VTE was more cost-effective than universal screening in all the patient groups evaluated. CONCLUSIONS: Thrombophilia is associated with increased risks of VTE in women taking oral oestrogen preparations and patients undergoing major elective orthopaedic surgery, and of VTE and adverse pregnancy outcomes in women with thrombophilia during pregnancy. There is considerable difference in the magnitude of the risks among different patient groups with different thrombophilic defects. In women who are on combined oral contraceptives, the OR of VTE among those who are carriers of the FVL mutation was 15.62 (95% confidence interval 8.66 to 28.15). However, in view of the prevalence of thrombophilia and the low prevalence of VTE in non-users of combined oral contraceptives, the absolute risk remains low. Significant risks for VTE and adverse pregnancy outcomes have been established with individual thrombophilic defects. Thrombophilic defects including FVL, high plasma factor VIIIc levels and prothrombin G20210A are associated with the occurrence of postoperative VTE in elective hip or knee replacement therapy. These associations are observed in patients who were given preoperative thromboprophylaxis and are, therefore, of clinical significance. Universal thrombophilia screening in women prior to prescribing oral oestrogen preparations, in women during pregnancy and in patients undergoing major orthopaedic surgery is not supported by current evidence. The findings from this study show that selective screening based on prior VTE history is more cost-effective than universal screening. Large prospective studies should be undertaken to refine the risks and establish the associations of thrombophilias with VTE among hormone users and in patients undergoing orthopaedic surgery. The relative value of a thrombophilia screening programme to other healthcare programmes needs to be established.

Electrostimulation for promoting recovery of movement or functional ability after stroke.

BACKGROUND: Electrostimulation might improve motor recovery after stroke by providing neuromuscular re-training. OBJECTIVES: To find if electrostimulation improved functional motor ability, and the ability to undertake activities of daily living. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), CINAHL (1982 to January 2004), AMED - Allied and Complementary Medicine Database (1985 to January 2004), Physiotherapy Evidence Database (PEDro), REHABDATA and the ISI Science Citation Index (1981 to 2003). We placed a request on the PHYSIO e-mail discussion list and contacted authors of relevant studies to elicit any unpublished or ongoing studies, searched the reference lists of included trials and contacted trialists. SELECTION CRITERIA: Randomised controlled trials of electrostimulation delivered to the peripheral neuromuscular system which was designed to improve voluntary movement control, functional motor ability and activities of daily living. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS: Of the 2077 references identified, 24 trials were included in this review. For electrostimulation compared with no treatment this review found that electrostimulation improved some aspects of functional motor ability and some aspects of motor impairment and normality of movement. In addition, there was a significant difference in favour of no treatment compared with electrostimulation for an aspect of functional motor ability. For electrostimulation compared with placebo this review found that electrostimulation improved an aspect of functional motor ability. For electrostimulation compared with conventional physical therapy this review found that electrostimulation improved an aspect of motor impairment. There were no statistically significant differences between electrostimulation and control treatment for all other outcomes. However, these results need to be interpreted with reference to the following: (1) the majority of analyses only contained one trial; (2) variation was found between included trials in time after stroke, level of functional deficit, and dose of electrostimulation; and (3) the possibility of selection and detection bias in the majority of included trials. AUTHORS' CONCLUSIONS: At present, there are insufficient robust data to inform clinical use of electrostimulation for neuromuscular re-training. Research is needed to address specific questions about the type of electrostimulation that might be most effective, in what dose and at what time after stroke.