Read the latest CLAHRC Community e-newsletter: Stroke and Rehabilitation ​

Author Andrew Njenga
Posted 2019.03.06

CLAHRC Community e-newsletter
Issue 80

Stroke and Rehabilitation 

East of England: New BITEs from our Enduring Disability and/or Disadvantage theme, including vulnerability in autism, and developing an app and wearable device for aggressive behaviours; Greater Manchester: “Our Work Our Impact” is now available! Read about how we've turned evidence into practice through applied research; Oxford: Low calorie meal replacements are a cost-effective routine treatment for obesity in the NHS; Peninsula: PenCHORD mentored Health Service Modelling Analyst instrumental in securing 8m funding for new adult mental health ward at Torbay Hospital; details here. South London: Registration open for our 2nd implementation science research conference: advancing the science of scaling up (18 July 2019) - submit your abstract by 15 April!  


CLAHRC East Midlands

Research to Implement Evidence Based In-Hospital Stroke Rehabilitation (REVIHR)
Four stroke units in the East Midlands region participated in the REVIHR study, which looked at stroke rehabilitation services are delivered under the pressures facing the NHS today. 
Findings shed light on the challenges faced by clinicians as well as the key ingredients for successful delivery of evidence based stroke rehabilitation. One of the issues identified was that stroke survivors do not get adequate opportunities to practice day-to-day activities, which would help them regain their skills and prepare them to return home. Strained inter-professional relationships led to a lack of shared rehabilitation ethos across the multidisciplinary team and hindered effective goal setting and patient hand over.
Strategies were identified to overcome these challenges within existing resources. Findings stressed the importance of good team work and collaboration between stroke professionals.

Creation of a co-designed interdisciplinary team development programme (Concord project)
Our new project is designing a team development programme for staff working in the stroke rehabilitation unit at Northampton General Hospital. The programme will be co-produced during a series of workshops with staff, patients, researchers and Bridges Self-Management Social Enterprise. The staff and patients will shape the content of the workshops as well as the final development programme.
The lessons learned and benefits of working in this way to develop the programme will also be captured through observations of the workshops and interviews with the staff attending. The final programme will be suitable for use in other stroke units to increase spread and impact. 
The team development programme has great potential to improve the efficiency and effectiveness of ward activities specifically related to stroke rehabilitation, and to increase staff morale.


CLAHRC Greater Manchester

Have you seen the all new GM-SAT2?
It is recommended, stroke survivors should be offered a structured review at six and twelve months post stroke, and annually thereafter. Unfortunately approximately a third of stroke survivors are offered a review and this may be even lower for stroke survivors living in care homes.
CLAHRC-GM identified that the original Greater Manchester Stroke Assessment Tool (GMSAT) needed further development for those living in care homes. In response, the toolkit was modified through collaboration with a group of professionals experienced in carrying out reviews. A mixed-methods evaluation study then explored the value, acceptability and feasibility of delivery of the modified GM-SAT in a care home setting. The toolkit has been further refined and the (GM-SAT2) developed. This version was created to support reviews for all stroke survivors, regardless of where they reside.
The GM-SAT2 was launched on the 4th December 2018 at the 13th UK Stroke Forum Conference in Telford.

Findings of the OSCARSS (Organising support for carers of stroke survivors) study coming soon!
Stroke is the leading cause of disability in the UK and family members often provide post-stroke support at great personal cost. OSCARSS is a large-scale national cluster randomised controlled trial, exploring the implementation and effectiveness of a new approach to supporting these informal caregivers of stroke.
The study includes 35 ‘clusters’ formed of Stroke Association services across the UK. Over an 18 month recruitment period, 414 carers agreed to take part in the OSCARSS trial. OSCARSS also includes an embedded mixed-methods process evaluation to answer questions about implementation and experiences in the trial. This has involved interviews and surveys, with 21 carers and 103 Stroke Association staff taking part. All data have been collected and analysis is underway.
Audrey Bowen and Emma Patchwood, co-chief investigators of OSCARSS will be at the European Stroke Organisation Conference in Milan in May 2019 to present the findings of this important trial.

CLAHRC North Thames

Mechanical thrombectomy is cost-effective up to 24 hours from stroke
Ischaemic stroke is the most common type of stroke, occurring when a blood clot blocks an artery cutting blood flow to part of the brain. Stroke can lead to coma, severe disability and eventually death if not treated promptly.  Mechanical clot retrieval (thrombectomy) is an intervention to remove clots when the current medical treatment (thrombolysis) is not sufficient to dissolve them. Current guidance only supports this intervention within 6 hours from stroke onset. CLAHRC North Thames researchers compared the cost-utility of mechanical thrombectomy in addition to medical treatment versus medical treatment alone performed beyond 6 hours from stroke onset in the NHS. Our work demonstrates mechanical thrombectomy is cost-effective up to 24 hours from acute ischemic stroke symptom onset – we propose the NHS implements this intervention on the basis of improvement in quality of life as well as economic grounds.
Contact: Elena Pizzo 

Centralised stroke services offer sustainable improvements in care and outcomes
A recent paper published in the BMJ provides further evidence of the benefits of centralising acute stroke services in urban areas where all stroke patients are treated in a specialist unit. It reports that in London, where such a model was implemented in 2010, improvements in care and reductions in mortality and length of stay (demonstrated in a previous paper by this team) were sustained over time. In Greater Manchester, where a similar model was adopted in 2015, similar improvements in care and outcomes were observed. This research was funded by the NIHR Health Services and Delivery Programme (reference 10/1009/09). Steve Morris and Naomi Fulop were in part-supported by NIHR CLAHRC North Thames; Ruth Boaden and Catherine Perry by NIHR CLAHRC Greater Manchester; and Charles Wolfe and Christopher McKevitt by NIHR CLAHRC South London. Further information on the study:

CLAHRC North West Coast

Exploring the barriers and enablers to using e-bikes by stroke survivors 
Stroke survivors’ face a number of barriers to physical activity such as environmental barriers e.g. access to transport or physiological barriers as a result of a disability e.g. post stroke fatigue.  These barriers can contribute to stroke survivors leading a sedentary lifestyle.  Electrically assisted bikes (e-bikes) are similar to conventional cycles except they are fitted with a battery and a motor and provide assistance when the person is pedalling. E-bikes have grown in popularity over the last decade and been shown to be an alternative form of physical activity for sedentary individuals or those with physical limitations.

Improving psychological support for stroke survivors
Stroke can have huge emotional impacts on stroke survivors and their carers. However, psychological services and support for these difficulties have been shown to be insufficient. Evidence and guidance to enable service providers to provide appropriate support is lacking.
The Accelerating the Delivery of Psychological Therapies after Stroke study (ADOPTS), was committed to improving psychological support, by exploring the feasibility of implementing and researching a collaborative psychological care pathway.  We have developed an evidence-based pathway to enhance access to psychological support.  Our research project aimed to see if we could use services that already exist for general psychological support (e.g. Increasing Access to Psychological Therapies (IAPT) services) and adapt them to be useful for stroke survivors.


Managing low back pain
Low back pain is the leading cause of disability worldwide – affecting nearly one in ten people. It can be debilitating and life-changing, reducing people's ability to work, function normally and enjoy life. Back Skills Training (BeST), a novel cognitive behavioural intervention, has been shown to significantly reduce disability and pain compared to conventional treatments, with benefits lasting up to 36 months post-treatment and significantly improved patient quality of life and satisfaction.
CLAHRC Oxford’s iBesT project aims to improve the management of patients with low back pain in the NHS by increasing clinician access to training in BeST, via an online model. Following the success of a comprehensive evaluation of an in-house developed online training format for iBeST, it is now being rolled out more broadly as a Massive Open Online Course (MOOC), via the Future Learn website, further expanding it’s impact and reach across the NHS.
Read more here

Self-directed and supervised exercise treatments for rheumatoid arthritis of the hand 
Rheumatoid arthritis (RA) is an autoimmune disease affecting about half a million people in the UK. While RA can affect any joint, it is most common in the small joints of the hand and can be very disabling, affecting almost every function of life, from self-care to the ability to work. 
'Strengthening and Stretching for Rheumatoid Arthritis of the Hand' (SARAH) programme is a proven and effective exercise-based therapy used alongside drugs to treat rheumatoid arthritis (RA) of the hand. The iSARAH project builds on the knowledge and experience gained from the iBeST programme, aiming to train more therapists, more quickly in how to deliver SARAH to patients via an online training model, both for clinicians/therapists and patients themselves.
Read more here. 


Stroke patients to be admitted to hospitals with 24/7 specialist stroke care
As a direct result of operational research carried out by PenCLAHRC's PenCHORD team, the NHS Long Term Plan, published in January 2019, has proposed that stroke services be restructured over the next five years, with sustainability and transformation programmes and integrated care systems reconfiguring stroke services into specialist centres.
PenCLAHRC’s Health Services Modelling team has identified the optimal number and locations for stroke services such as thrombolysis and thrombectomy. The NHS plan suggests reconfiguration of services will increase life-changing thrombectomies from one per cent to 10 per cent of stroke patients by 2022. Under the restructure the current ‘post code lottery’ of access to the best care, will become a thing of the past. The NHS plan suggests these changes will assist with the provision of services “amongst the best in Europe for delivering thrombolysis” by 2025.
Read more here.

Home-based cardiac rehabilitation for heart patients improves quality of life
An NIHR-funded trial involving researchers from PenCLAHRC has found that home-based rehabilitation for people with heart failure improves quality of life and has been added as an NIHR Signal to the Discovery Portal.
216 people with heart failure, predominantly men with an average age of 70, were recruited for a home-based programme co-developed with patients, caregivers and clinicians and facilitated by a trained cardiac nurse or physiotherapist. Participants were supported via face-to-face and telephone sessions, home-based exercise programmes and a patient progress tracker. Support was also offered to caregivers to help them better understand heart failure and the importance of their own physical and mental well-being when providing care.
The study found that 90% of participants remained in the programme - more than double the average attendance rate for hospital-based rehabilitation and that the average cost, estimated at £418 per participant, fell well within the NHS tariff for cardiac rehabilitation in England.
Read more here.

CLAHRC South London

Rates of stroke in south London drop by over 40%
The number of people in south London having strokes has steadily decreased by 43% since 2000, according to a study by researchers at King’s College London. The research was funded by the NIHR Guy’s and St Thomas’ Biomedical Research Centre and supported by CLAHRC South London.
The research, published in PLOS Medicine, looked particularly at people in south London who had an ischaemic stroke – one caused by a blood clot, between 2000 and 2015.
The team behind the research attribute the reduced rate to a range of factors, including improved prevention measures, such as medication like statins. The reduction in the rates of smoking and drinking is also an important factor. Making these lifestyle changes can significantly lower people’s risk of having a stroke.
Read more here.

Helping patients with self-management after stroke
Reorganisation of acute stroke care in the last 10 years has transformed survival and clinical outcomes, but long-term care remains inadequate. People with stroke tend to be more socially isolated and have higher rates of depression and anxiety compared to the general population. Studies consistently demonstrate people with stroke (and carers) feel abandoned by services when discharged from hospital or community rehabilitation. This is unlikely to change as the pressure on community rehabilitation services increases, and more people are living with complex stroke into older age with multiple morbidities.
Bridges Self-Management programme is designed to help stroke survivors take a leading role in their own rehabilitation. Developed by researchers at CLAHRC South London in conjunction with stroke survivors, Bridges is tailored to the needs of every patient regardless of their level of disability and motivation.
Read more here.

CLAHRC Yorkshire and Humber

Promoting exercise after stroke                                                                  
The aim of this project from the TK2A Theme of the NIHR CLAHRC YH was to explore ways to promote exercise in stroke survivors using a series of 5 co-production workshops. Participants included stroke survivors, health care professionals, exercise prescribers, social services, commissioners, medics, the voluntary sector, and students from the product design course at Sheffield Hallam University.
Five briefs emerged from the research: a marketing campaign to burst myths and promote physical activity, a video raising awareness of the benefits of promoting exercise, a staff training package, a stroke survivor's passport to access relevant and customised information and to keep one's medical record in one place, a buddy box to increase wellbeing among survivors. The Full report is available here.

Technology use in stroke
The NIHR CLAHRC YH TaCT theme are continuing to bring together academics, local and international innovative industrial partners, engineers, designers, clinicians, stroke survivors and carers to co-design, develop and implement new technologies to facilitate self-managed post-stroke rehabilitation. Our projects include:

  • Emego: We have quantified and compared stroke upper-limb muscle activity and function with the Action Research Arm Test (ARAT) and the Medical Research Council’s Oxford Grading Scale.
  • Upper Limb (UL) Sensor: We have used an off the shelf sensor to measure UL real-world UL movement over 96 hours with 30 chronic stroke survivors and 30 aged matched controls.
  • Action Research Arm Test (ARAT) modification: We have added an item to the ARAT that involves using both hands to complete a task and redesigned the test kit which has resulted in a test kit that is a third of the size of the original and four times lighter (12kg to 3kg)