1. Rehabilitation research: the impact on your life after stroke Helen Rodgers Professor of Stroke Care Newcastle University

2. Acknowledgements Stroke Unit Trialists Collaboration Early Supported Discharge Trialists Professor Anne Forster Professor Peter Langhorne Professor Tony Rudd Professor Marion Walker

3. “to get over a strong attack of apoplexy is impossible, over a weak one is not easy”

4. ‘A stroke of God’s hand’ Oxford English Dictionary 1599

5. Treatment Put to bed with head well raised Bleed freely (1-2 pints) Apply warm mustard poultices Open bowels quickly and freely Throw up a turpentine clyster Cut off the hair Apply rags of vinegar (or gin) and water 8-10 leeches on temple opposite paralysed side

6. King’s Fund Forum Consensus and controversy in stroke The treatment of stroke June 27, 28 and 29, 1988 Regent’s College, Inner Circle Regent Park, London NW1

7. Problems in rehabilitation shortage of therapy long unoccupied periods failure to recognise and respond to mood disturbance delegation of care to inadequately trained medical staff confusion by too many people involved

8. Problems in rehabilitation misunderstandings and rivalries between professionals breakdown in communication between professionals, patients and carers insufficient appreciation of the impact of stroke on the family ill prepared discharge

10. Cornerstones of stroke care TIA clinic stroke unit early supported discharge long term support

11. Planning stroke services incidence outcome prevalence

12. Oxford Community Stroke Register OXVASC Study South London Stroke Register

13. Stroke is an emergency

15. Features of stroke unit care Consultant doctor specialising in stroke care Links with patient and carer organisations Weekly meeting of all professionals Good information for patients about stroke Staff provided with up-to-date training

18. Early Supported Discharge

19. The case against hospital rehabilitation artificial environment promotion of dependence boring risk of infection poor nutrition emphasis on physical recovery isolation

20. The case for community rehabilitation Home is the most appropriate environment Involvement and empowerment of patients and carers More emphasis on psychological and social issues Less isolation Cheaper

21. The case against community rehabilitation carer stress may not be co-ordinated or timely intrusive travelling primary care work load

22. Absolute outcomes (additional events per 100 patients treated) Alive (6-12 months)1 (2-4) Not significant Living at home5 (1-9) P = 0.02 Independent6 (1 – 10) P = 0.02

23. Early supported discharge improved satisfaction with services no impact on mood no adverse effect on carer mood or health

24. Economics of ESD services Length of stay reduced by 8 (5-11) days ESD is slightly cheaper

26. How should community stroke care be organised and provided?

28. Outpatient Service Trialists T o assess the effects of therapy based rehabilitation services targeted towards stroke patients resident in the community within one year of stroke onset. 14 trials heterogeneous interventions including 1617 patients Lancet 2004

29. Outpatient Service Trialists “Patients receiving rehabilitation at home within one year of stroke onset are more likely to have a better outcome, in terms of independence and achievement of maximum level of function in all aspects of daily life.”

31. Developing services Evidence Professional knowledge, Judgement, values and expertise Patient, carer and public knowledge, values and input

32. NICE: stroke quality standard 45 minutes of each therapy minimum 5 days per week level to meet rehabilitation goals as long as continuing to benefit

33. Nutrition

34. Swallowing

35. FOOD Trial food supplements early tube feeding PEG feeding

36. A Very Early Rehabilitation Trial (AVERT) - Phase III clinical trial Design Randomised controlled trial of very early rehabilitation versus standard care. Features blinded assessment intention to treat analysis multi-centre large (n = 2104)* largest stroke rehab study multi-disciplinary rehabilitation focused intervention

37. Physiotherapy after stroke ‘Approaches’ Focused training Muscle strengthening Treadmill Repetitive movements Constraint induced movement Van Peppen, Clin Rehab 2004

38. Task orientated rehabilitation is best

39. Rehabilitation goals

40. Aerobic exercise

41. Mental Practice

42. Video Games

43. Outdoor Mobility Programme 42% of patients don’t get out of the house as much as they would like after stroke lack of information physical limitations fear of falling

44. Mobility Interventions Walking (23%) Bus(17%) Dial–A–Ride(13%) Driving(10%) Shop mobility (8%) Scooter(8%) Voluntary car(6%) Wheelchair use(9%) Passenger car(4%) Taxi (4%) Mean 6 sessions

45. Results – comparison of groups Four monthsControl n = 82 Intervention n = 86 Comparison Yes I get out as much as I want to 30 (37%)56 (65%)RR = 1.78 (95% CI 1.29 to 2.46) Journeys Median (mean) 15 (22)38 (43)Mann-Whitney p<0.001 EADL mobility section Median 69Mann-Whitney p<0.05 University of Nottingham

46. Depression Anxiety Emotionalism Memory Concentration

47. Fatigue

48. Stroke family support workers improve outcome for patients with mild/moderate disability improve satisfaction with some aspects of service provision

49. Evaluating effect of a training programme for caregivers TRAINING PROGRAMME Stroke unit setting Structured, competency based, with assessment of carer skills V ‘USUAL CARE’ Stroke unit setting Information and advice available from MDT

53. High quality research leads to service improvement............. and some surprises

54. Advances in stroke care there have been significant improvements in stroke care important and unacceptable gaps remain in service provision