1. Emerging Evidence -
Findings from the four stroke theme
projects.
Chair: Prof Marion Walker
A partnership between
Nottinghamshire Healthcare NHS Trust
and the University of Nottingham
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

2. Leading Change in
Early Supported Discharge
Dr Rebecca Fisher & Professor Marion Walker
A partnership between
Nottinghamshire Healthcare NHS Trust
and the University of Nottingham
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

3. • Overview of the Stroke Early Supported
Discharge research programme
• Are the benefits of ESD still evident in
practice? Results from a 3 year evaluation
– Christine Cobley, Research Associate
What to expect
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

4. Thanks to the Team
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
• Marion Walker
• Christine Cobley
• Fiona Nouri
• Nikki Chouliara
• Iskra Potgieter
• Amy Moody
• Brian Crosbie
• Meghan Thurston
• Catherine Gaynor
• Jo James
• Rebecca Larder

5. • UK Policy context: National Stroke Strategy 2007, Royal
College Physicians Clinical Guideline for Stroke
• Clinical trial data: demonstrated effectiveness of Early
Supported Discharge
• Large variation in quality of service provision across the UK
(Care quality commission 2011)
Why ESD?
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Rehab
Support
Hospital
Home
Acute
Rehab
Rehab
Support
ESD

6. • “In performing the research we aim to (a) gain
clarity around how an ESD service might be
organised (b) test methods to facilitate the
implementation of ESD services and report on
successes and challenges associated with
implementation (c) test methods to measure
the effectiveness of ESD services”
Our Remit
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

7. • Stroke Rehabilitation Implementation Research
• (A) What is the evidence?: Consensus on the core components of
evidence based Early Supported Discharge services
• (B) What is the context?: qualitative mapping used to describe
models of services operating in practice (how & why?)
• (C) Implementing change: facilitate evidence based practice
Educational programme: measuring effectiveness & team working
• (D) Evaluation: Are the benefits of ESD still evident in practice?
ESD research programme
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

8. A partnership between
Nottinghamshire Healthcare NHS Trust
and the University of Nottingham
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Are the benefits of stroke
Early Supported
Discharge still evident in
practice?

9. • Participants admitted to SU at NUH & SFH: Nov’10- Feb’12
• Eligibility criteria informed by international ESD Consensus
• Study differs to original trials: Evaluating ESD operating in real
world practice
• Both patients and carers eligible for ESD (whether or not they
were referred to service)
• Formation of Non-ESD cohort
• Baseline assessment within 14days stroke onset; participants
followed period of 12 months
Methods : Participants & Intervention
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

10. • Baseline & scheduled follow-up home visits (6, 26, 52 wk F/U)
• Choice determined by previous trials & meta-analyses investigating ESD
• Primary: BI
• Secondary:SF36; EQ5D;*NEADL;GHQ-28; Satisfaction Qu*
• Carer Outcomes: *GHQ-28; *SF-36; *Satisfaction Qu
*Assessments not completed at baseline, but 6w, 6m & 12m f/u stages
• Hospital data from Hospital Trust, Primary Care Trust & Local Authority
databases
– Admission & discharge to SU
– Place of residence on admission & discharge
– Service discharge to (if any)
– BI admission & discharge
– HRG code
– LOS on acute & rehab wards
– Readmissions at 28days & 1yr post baseline assessment
Methods : Data Collected
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

11. • LOS used to calculate associated hospital based costs patient
by patient basis
• Using HRG & Trim-points translated LOS into associated costs
• Used model of tariff unbundling that could be used to
generate savings from ESD related reduction LOS to fund ESD
services
• To compare with annual staffing of ESD services information
used:
– ESD Team Structure
– Banding & Whole Time Equivalent figures
Methods : Statistical Analysis
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

12. Flow of participants
through study

13. Baseline Characteristics of Participants
Collaboration for Leadership in Applied Health Research and Care for
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CLAHRC NDL
Variable ESD (n=135) Non ESD (n=158) Comparison P
Age, median (IQR) ††† 71(62-79) 76(65.75-82) 0.005*
N days between stroke onset & baseline
assessment, mean (SD) ††
7(7) 6(6) 0.503
Gender †
Women, N (%) 45(33.3%) 56 (35.4%) 0.705
Male, N (%) 90(66.6%) 102(64.6%)
Baseline BI, median (IQR) ††† 80 (65-95) 85 (70-95) 0.174
Ethnicity†
White, N(%) 127(94%) 155 (98.1%) 0.068
Other, N(%) 8 (6%) 3 (1.9%)
†Groups were compared using χ2 for Ethnicity & Gender. ††Groups were compared using t-test for N days between stroke onset and baseline
assessment. †††Groups were compared using Mann Whitney U Test for Age and Baseline Barthel score.
*Significant at P<0.05.

14. Clinical Hospital Data
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Variable ESD (n=135) NESD (n=158) Comparison* P
BI adm, mean (SD) 11.4 (5.5) 10.7 (5.6) 0.326
BI disch, mean (SD) 18 (6) 18 (4.75) 0.749
Total LOS acute, median (IQR) 4(2-7) 3(2-5.75) 0.061
Total LOS rehab, median (IQR) 0(0-12) 6.5(0-15.75) 0.018*
Total LOS (rehab + acute stay), median
(IQR)
9(4-18.25) 11(5-21.0) 0.029*
Readmitted to SU within 28 days hospital
discharge N (%)
2(1.5%) 1(0.7%) 0.606
Readmitted to Gen ward within 28 days of
hospital discharge, N (%)
12(9.2%) 11(7.7%) 0.669
Readmitted to SU within 1 year baseline
assessment, N (%)
18(13.8%) 10 (7.0%) 0.073
Readmitted to Gen ward within 1 year
baseline assessment, N (%)
47 (36.0%) 62 (43.4%) 0.266
Case fatality, N (%) 11 (8.5%) 16 (11.2%) 0.544
†Groups were compared using χ2 for Readmissions and Case Fatality. †† t-test for BI †††Mann Whitney U Test for LOS. *Significant at P<0.05.

15. • ESD group significantly more knowledgeable
– Risk & practical help at 6 weeks (P<0.05)
– Community services & emotional support at 6weeks, 6 &
12months (P<0.05)
– Higher level overall satisfaction services received 6 weeks
& 6 months (P<0.01)
• No other differences on outcomes between groups at
individual time points
Comparison of patient outcomes:
Between Group Comparison
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

16. Comparison of patient outcomes:
Within Group Comparison
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
ESD (n=110) Non ESD (n=109)
Variable Baseline 6 Weeks 6 Months 12 Months P Baseline 6 Weeks 6 Months 12 Months P
BI 80(65-91) 95(84-100) 95(80-100) 90(75-100) 0.000* 85(70-95) 90(80-100) 95(80-100) 95(75-100) 0.000*
NEADL Q 35(24-49) 39(27-50) 31.5(18-46) 0.146 Q 35(24-52) 36(24.5-54) 36(20-50.5) 0.037
GHQ-28 25(18-35) 22(16-34) 19(12-30) 18.5(13-29) 0.000* 23(17-31) 22(16-29) 19.5(14-25) 20(13-26) 0.001*
PCS 32.9(24.3-
39.9)
32.4(25.4-
42.4)
33.9(22.9-
47.1)
31.7(21.3-
43.1)
0.010* 35.1(28.3-
43.3)
34.5(26.3-42.9) 33.3(24.8-
43.9)
35.3(24.1-
45.8)
0.413
MCS 50.3(38.8-
58.7)
47.1(35.7-
55.3)
52.4(43.9-
58.1)
53.3(44.2-
60.2)
0.000* 51.3(43.6-
58.0)
47.9(34.4-57.1) 54.1(45.8-
58.5)
53.5(48.1-
59.1)
0.006*
EuroQol
Index
0.74(0.65-
0.84)
0.78(0.7-0.88) 0.77(0.68-
1.00)
0.77(0.65-
0.88)
0.001* 0.75(0.68-
0.88)
0.77(0.69-0.88) 0.77(0.68-
0.88)
0.77(0.69-
0.88)
0.711
EuroQol
Imaginable
Health
55(45-70) 60(50-80) 65(50-80) 70(50-80) 0.000* 60(50-80) 65(50-80) 70(50-80) 75(50-85) 0.002*
†Median (interquartile range in parentheses). Groups were compared using Friedman Test. *Significant at P<0.05.

17. Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Parameter β Std. Error P value
Model A: Main Effects
Gender 0.206 0.2015 0.306
Ethnicity 0.170 0.4322 0.695
Age -0.661 0.1974 0.001*
ESD -0.065 0.1910 0.734
Time6Weeks 1.103 0.1492 0.000*
Time26Weeks 1.202 0.1575 0.000*
Time52Weeks 0.918 0.1556 0.000*
Model B: Interaction Effects
ESD*Gender -0.035 0.2730 0.898
ESD*Ethnicity -0.590 0.3127 0.059
ESD*Age -0.587 0.3030 0.053
ESD*Time6Weeks 1.569 0.2270 0.000*
ESD*Time26Weeks 1.500 0.2262 0.000*
ESD*Time52Weeks 1.057 0.2183 0.000*
*Significant at P<0.05
Generalised Estimating Equations analysis of
Barthel Index scores at 6, 26, and 52 weeks

18. • Interaction Model: explore between group differences whilst adjusting for
possible covariates
– Descriptive analyses age significantly different, model age insignificant in
relation to BI performance over time
– No differences between groups ethnic & sex variables
– Findings favoured ESD group: at 6weeks: 4.7 times likely BI ≥ 90
– Findings favoured ESD group: at 6months: 4.5 times likely BI ≥ 90
– Findings favoured ESD group: at 12 months: 2.9 times likely BI ≥ 90
• Sensitivity Analyses: Robustness of model explored adjusting BI threshold
values (85, 93, and 95) Findings remained consistent
Results:
GEE Modelling findings
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

19. Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Results: Carer Outcomes
• No Between Group differences
– Physical, mental & psychological well-being
– Satisfaction & knowledge stroke related services
• Within Group differences
– Significant improvement in mental health of carers
receiving ESD (χ2(2)=13.000, p = 0.002)
– Post-hoc analysis showed difference between 6weeks & 6
months (Z=-3.646, p=0.000)

20. Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Results: Unbundling National Stroke
Tariff
• Using Payment by Results scheme & stroke tariffs for each patient,
associated hospital based care costs calculated
• Used proposed model of unbundling National Stroke Tariff to calculate
potential savings could be associated with ESD
• Unbundling model involved splitting total LOS into discrete segments
attributing appropriate amounts of tariff to each
HRG
Code
Best
Practice
tariff (£)
Trim-
point
(days)
Day 0 to
3
Day 4 to
9
Day 10
to Trim-
point
Daily
cost
exceedi
ng trim-
point
LOS Hospital Receives Commissioner
saving
AA22z £4,570 57 £1,500 £1064 £2,006 £179 17 £4,570 £0.00
3 £1,500 £3,070
8 £2,564 £2,006
73 £4,570 + £2,864 -£2,864
AA23z £4,633 51 £1,500 £1088 £2,045 £181 17 £4,633 £0.00
3 £1,500 £3,133
8 £2,588 £2,045
73 £4,570 + £3,982 -£3,982

21. Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Results: Unbundling National Stroke
Tariff
• Of Study Sample, 237 assigned HRG AA22z or
AA23z
• Total saving of £245,217 calculated based on
total LOS
• Average Annual cost of ESD service involved in
study based on team composition: £350,000

22. Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Summary of Findings & Concluding
Remarks
• Study has measured effectiveness ESD in practice, for 1st time
• When adopting evidence based model, ESD services can
– Significantly reduce LOS
– Result in equivalent or better outcomes for patients & their
carers
• Presented quantitative methodology: evaluating effectiveness
of ESD services, using BI as measure of patient recovery
• Distinction to trials important
– Participants not randomised, groups compared formed
naturally
– ESD intervention investigated are services operating outside
strict, protocol driven trial environment

23. Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Summary of Findings & Concluding
Remarks
• Present model of tariff unbundling for use within English
Payment by Results Scheme, would ensure ESD related cost
savings associated with reduction in LOS were realised
• Findings in addition to policy & national guideline
recommendations, difficult to believe why ESD services are not
accessible to all eligible

24. Thank you for listening
rebecca.fisher@nottingham.ac.uk
www.clahrc-ndl.nihr.ac.uk
Twitter: @CLAHRC_NDL
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

29. Concern that it would be
unethical to withdraw such
an established and accepted
treatment.

30. Concern that it would be
unethical to withdraw such
an established and accepted
treatment.
A pilot study of home visits
in Australia recruited only
ten participants in 3m
despite admission records
suggesting more people
should have been
available.

31. 1. National survey
 184 questionnaire posted
2. Opinions and perceptions
 42 interviews;
 17 with patients/staff involved in trial
 20 senior OT interviews;
 6 expert interviews
3. Feasibility RCT
 126 trial patients recruited

32. 1. National survey of practice
What is routine occupational therapy
practice when conducting pre-discharge
home visits for patients with a stroke?

33. How many visits?
 Pre discharge assessment visit
April and May 2011 mean 7 (sd 6.93) 0- 27
 Access visit
April and May 2011 mean 7 (sd 8.39) 0- 38
74% knew number of visits; 26% did not
87% policy to have 2 members of staff attending

34. Reason for home visit
Reason Frequency Percentage
Assess/practice activities of daily living
in home environment
79 96%
Identify/address safety issues 78 95%
Assess/practice mobility/transfers in
home environment
75 92%
As part of discharge planning 66 81%
Carer concerns 63 77%
Assess access to and within property 63 76%
Increase patient’s confidence and mood 59 72%

35. Time on visits
 Time at home on visits. Range 10-135 mins
Mean 63 mins (SD 20) i.e. just over an hour
 Time on travel. Range 15-180 mins
Mean 49 mins (SD 25.41)

36. Time on…
 Time to organise visits.
Range 10-240 mins
Mean 50 mins (SD 34.58)
 Time writing up report.
Range 2-210 mins
Mean 61 mins (SD 33.13)

37. Overall time
Mean time 223 minutes
i.e. almost 3 ¾ hours
to undertake the „average‟ home visit

38. What is in your visiting bag?

39. Summary
 National picture of home visits
 Reasons for visits
 Time/workload involved
 National links for interviews/further research

40. 2. Opinions and perceptions;
experts, OTs, patients.

41. 2. Opinions and perceptions;
experts, OTs, patients.
 Differing purposes of visits
 Effective use of resources
 „Entrenched practice‟
 Perceptions of patients
 Implementation aspects

42. 2. Opinions and perceptions;
experts, OTs, patients.
 Differing purposes of visits
 Effective use of resources
 „Entrenched practice‟
 Perceptions of patients
 Implementation aspects

43. Should it be an OT?
YES
„Unique still to OT … should be protected … and
not become generic‟ (042).

44. Should it be an OT?
YES
„Unique still to OT … should be protected … and
not become generic‟ (042).
NO
„It is always assumed to be an OT role … there
may be some instances when it could be more
appropriate for another profession to lead the
visit‟ (039).

45. Visiting
 There are often requests for visits which I feel
are inappropriate(127).

46. Visiting
 There are often requests for visits which I feel
are inappropriate(127).
 I don‟t think they [home visits] need to be
carried out as a routine task (106).

47. Visiting
 There are often requests for visits which I feel
are inappropriate(127).
 I don‟t think they [home visits] need to be
carried out as a routine task (106).
 I believe it should be made a policy that all
patients that have had a stroke have a pre-
discharge OT home visit (132).

48. Resource issues
 They are popular with patient and staff however
they lack some understanding of how much time
and effort they take (088).

49. Resource issues
 They are popular with patient and staff however
they lack some understanding of how much time
and effort they take (088).
 They‟re extraordinarily expensive in terms of
time and resource ….‟(Expert 1)

50. “…..they do not cost a lot, compared to a lot of
other interventions… if they then are reducing the
hospital stay by even one or two nights... OT time
isn't that expensive compared to a lot of things, to
a lot of other interventions…that go on in
hospital” (Expert 4)

51. Realistic?
„They get observed in a very artificial situation for
an hour and then the occupational therapist makes
a judgment on the basis of that as to whether
somebody‟s going to be able to manage, you
know, safely or not. And I think that that is
unrealistic‟ (Expert 1)

52. Realistic?
„They get observed in a very artificial situation for
an hour and then the occupational therapist makes
a judgment on the basis of that as to whether
somebody‟s going to be able to manage, you
know, safely or not. And I think that that is
unrealistic‟ (Expert 1)
„Home visits are an essential part of practice as
patients can present very differently in their own
environment‟ (039).

53. Patients
“I was quite happy in as much as I know that the
fact I‟d got a home visit they were considering me,
releasing me from hospital so I was quite happy to
conform with anything that would encourage them
to say, you can go home” (Patient 1)

54. “Without a doubt, it was things that I haven‟t even
thought about, the height of the bed the amount
of steps from the stairs…would I be able to use
the stair lift…if there hadn‟t been a home visit
things could have gone disastrously wrong”
(Patient 5)

55. 3. Feasibility RCT
 Worked with clinical
colleagues to agree the
methodology
 Clinicians had power as
gate keepers in process

56. 3. Feasibility RCT
 Worked with clinical
colleagues to agree the
methodology
 Clinicians had power as
gate keepers in process
 „New‟ methodology in
rehab research;
 RCT arm (clinical
uncertainty)
 Cohort arm („Sure‟)- but
asked to define

57. 3. Feasibility RCT
 RCT- 93 patients
randomly allocated;
 47 to intervention arm
(home visit) and
 46 to control (interview)
arm.
 Cohort -33

58. Feasibility RCT
 RCT -93 patients
randomly allocated;
 47 to intervention arm
46 to control
 Parallel -33

59. Recruitment

60. Systematic collection of data
 Mean cost of home visit £208 (SD £107).
 Mean cost of a hospital interview £75 (SD£40).

61. Trial Issues for future
 Measures
 Protocol adherence
 Safety- more falls in in home visit arm- more
confident? Chance?
 Control group- too much intervention?

62. Relevant?
 Data shows interesting differences /RCT
feasible
 Main paper was 10th most read article in Clinical
Rehabilitation
 Pump Priming award from NUH for virtual
reality project based on interviews→
 The Senior Stroke Association Fellowship.

63. HOVIS 2?

64. Thanks to…
TEAM HOVIS
Phillip Whitehead
Karen Fellows
Nikki Sprigg
Claire Edwards
STEERING GROUP
Prof Nadina Lincoln
Chris Sampson
Cecily Palmer
Oswald Newold
Dr Nicola Brain
Dr Guo Boliang
Dr Daniel Simpkins
Dr Lyn Legg
Prof Marion Walker
Dr Kate Radford
Dr Annie McCluskey
Prof Marilyn James
Dr Amanda Crompton
Prof Cath Sackley
Dr Ruth Parry
Dr Karen Stainer
Dr Tracy Sach
and of course the Ward Staff
and Patients

66. Wii STAR: Wii Stroke Therapy for
Arm Rehabilitation
PJ Standen, Kate Threapleton, Louise Connell,
Andy Richardson, David Brown, Steven Battersby,
Fran Platts
A partnership between
Nottinghamshire Healthcare NHS Trust
and the University of Nottingham
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

67. Background
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
• Need new approach to provide the necessary rehabilitation of
upper limb following stroke.
• Patients have decreasing access to appropriate therapy and even if
sent home with exercises, adherence to treatment is poor.
• Exercise plans can appear rigid and inflexible. Their effectiveness is
irrelevant if they exhaust patients’ capabilities and motivation (Clay
and Hopps, 2003).
• Adherence could be improved if treatments are designed that are
amenable or adaptable to more appropriately fit into the lifestyles
and limitations of patients and their families.

68. Background
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
• Virtual reality and interactive video gaming have emerged as new
treatment approaches in stroke rehabilitation (Laver et al, 2011).
• Commercial gaming consoles already used in clinical settings (eg
Saposnik et al 2010): advantages of being widely acceptable,
providing easily perceived feedback and their low cost facilitates
unrestricted home use.
• But games not designed for therapeutic use and current systems do
not capture movement of fingers.

69. Development of equipment
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
• In conjunction with users we developed
a low cost intervention for home use
that was flexible and motivating in
order to improve adherence.
• After several iterations we produced the
virtual glove which allows capture of
position of thumb and three fingers and
translates into game play.
• Designed to facilitate practice of
movements that underlie everyday tasks
such as grasp and release.

70. Development of games
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
• Four games each with different levels
of challenge to keep the participants
motivated to continue to use the
system, but to ensure that they can
achieve some success.
• Scores displayed on the screen at the
end of a game.
• A log of when the system is in use is
collected by the computer as well as
what games are being played and
what scores the user obtains.

71. Feasibility trial
Collaboration for Leadership in Applied Health Research and Care for
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CLAHRC NDL
We approached patients who
• were aged 18 or over who
• were recovering from a stroke
• were no longer receiving any other intensive rehabilitation
• still experiencing problems with their upper limb
• Recruited from stroke wards City Hospital, ESD and Community
Support Team and Stroke Outreach Service.
• Randomly allocated to either the intervention (virtual glove) group
or the control group (usual care).
• Intervention group had the virtual glove, games and a PC in their
homes for a period of 8 weeks.
• They were advised to use the system for 20 mins 3x day
(max 56 hours).

72. Feasibility trial
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
Measures of upper limb function were taken at baseline, 4
weeks and 8 weeks
• Wolf Motor Functions Test - a measure of upper limb functioning
• 9 Hole Peg Test - a test of fine motor co-ordination
• Nottingham Extended Activities of Daily Living
• Motor Activity Log - how well and how much they use their more
impaired arm to accomplish each of a range of ADL
• For intervention group only: frequency and type of requests for
help; duration and type of support provided; frequency of using the
equipment

74. Feasibility trial
Collaboration for Leadership in Applied Health Research and Care for
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CLAHRC NDL
Three sets of results
• Adherence: did participants use the equipment as frequently as we
had recommended?
• Did the outcome measures show any difference between the
groups?
• How much time did the research team spend supporting home use
of the intervention?

75. Adherence Data
Collaboration for Leadership in Applied Health Research and Care for
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CLAHRC NDL
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 8 9 13 17 22 23 24 26
%
Participant ID
Percentage of Recommended Use
Recommended
time used %
Recommended
days used %

76. Barriers to use
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL
• Equipment outages.
• Needing someone to help them set up equipment or put on the glove.
• If the participant is computer literate the games are likely to become boring:
“I would say the first few weeks was brilliant. But as I say, then as it got
going longer on, it was sort of, well, some days I couldn't be bothered and
then some days, if you've got something else to do, it was just sort of
missing it out. But at first, yes, it was really good.” (P8).
• Other health problems and fatigue
• Competing commitments: “And what time the family came, if the family
came just when I had started it – I had to then leave it” (P4) , and more
passive pastimes: “I admit it depended what was on the telly” (P4).
• Getting back to pre stroke life especially once mobile

77. Facilitators
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• Flexibility: “Whereas with a computer, you could say four o'clock/five
o'clock, if you felt all right, you could do it sort of any time you wanted to.
You're not set to a time all the time, which was quite good.” (P8)
• Immersion in games: “You just forget what – you sort of look at the time
and, say it was ten o'clock, you're playing and then the next time you look
up you think, crikey, it's half-past eleven, sort of thing.” (P8)
• Belief in its therapeutic nature: “Oh yeah, of course, because it helps –
well, it helps you a lot in your movement. First and fore, with the
position, you know, then you enjoy the games.” (P9)
• Support and encouragement from relatives

78. Outcome measures
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• 22 participants completed outcome measures at 4 weeks and 18 at
8 weeks.
• The only significant (p<0.05) difference was a higher reported use in
the intervention group of the affected limb on the MAL at 8 weeks
when compared to the control group .
• The lack of differences between the two groups was probably due
to the considerable variation in how much the equipment was used.
– Looking at the intervention group only, there was a significantly
(p<0.05) higher change from baseline on WOLF grip strength in those
with a higher use of the equipment, when compared to those with a
lower use.

79. Therapist Time - Participant Visits
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• Intervention group only
– Total number of visits = 118 (mean = 9.83; SD = 3.97)
– Includes visits to complete baselines, outcome measures and all visits related to
delivering the intervention
0
2
4
6
8
10
12
14
16
18
1 2 3 4 8 9 13 17 22 23 24 26
Visits
Participant ID
Total Number of Visits

80. Therapist Time – Duration of Visits
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• 146 hours was spent delivering the intervention in total
19
22
14
52
21
15
3
0
5
10
15
20
25
30
35
40
45
50
55
Baseline Midpoint OM Final OM Int Training Technical Other Comms Other Research
Hours
Research Activity
Total Hours Delivering Intervention

81. Therapist time - conclusions
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• Mean number of visits (9.83) over approximately 8 weeks, duration
is not extraordinary.
• The complexities of delivering a novel intervention in a community
setting probably account for above average amount of visits.
• Some participants with complex stroke pathology (cognitive
issues, profound sensory disturbance) demanded more ‘one to one’
therapy time.
• After an initial OT/PT assessment, there may be an argument for
trained support staff to deliver this intervention which could have
cost-benefits to a service.

82. What we have learnt
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• Identifying potential participants difficult and time consuming.
• Once identified, recruitment reasonable (62% of 47 consented).
• Huge variation in adherence and outcomes but inclusion criteria
deliberately wide.
• Adherence low but it’s low for other unsupervised rehabilitation.
• Eight weeks is a long time to ask people to use kit especially if they are
trying to return to their pre stroke life.
• No reason to drop any of the outcome measures if going for definitive
trial, although baseline measures sometimes required two visits.
• We provided a high level of support perhaps because it was a novel
intervention in a community setting.

83. Thank you for listening
p.standen@nottingham.ac.uk
kate.threaplrton@nottingham.ac.uk
www.clahrc-ndl.nihr.ac.uk
Twitter: @CLAHRC_NDL
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84. Return to Work after Stroke:
A Feasibility Randomised Controlled Trial
Mary Grant
On behalf of:
KA Radford, EJ Sinclair, J Terry, MF Walker, NB Lincoln,
A Drummond, J Phillips, C Coole, L Watkins, E Rowley, B Guo,
N Brain, K Muhiddin, M Jarvis, M Jenkinson,
C Sampson, C Edwards
A partnership between
Nottinghamshire Healthcare NHS Trust
and the University of Nottingham
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85. Collaboration for Leadership in Applied Health Research and
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• 110,000 strokes annually a quarter of which occur in
working age adults, less than half of stroke survivors
resume work (Daniel et al., 2009)
• Health risks - greater than heart disease (Waddell and
Aylwood, 2005)
• Reduced quality of life
• Dramatic societal costs of £8.9 billion a year (Saka et
al., 2009)
Background

86. • Vocational Rehabilitation: a process whereby those
disadvantaged by illness or disability can access, maintain
or return to employment (Tyerman and Meehan, 2004)
• Work is a recognised health outcome (NHS Outcomes
Framework, 2010)
• Rehabilitation frequently fails to address work needs
(Playford et al., 2011)
• Lack of evidence for stroke-specific vocational rehabilitation
(SSVR)
Background continued
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87. Collaboration for Leadership in Applied Health Research and
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1. Interview and mapping study of current provision
2. Intervention development phase (case study
design)
3. Feasibility trial with economic and intervention
analysis
4. Qualitative study with stroke survivors and
employers to explore usefulness and acceptability
of the intervention
Four stage project

88. Aim of study
To test the feasibility of designing and delivering
occupational therapy-led stroke-specific
vocational rehabilitation (SSVR) and measuring
it’s effectiveness in a pilot randomised controlled
trial (RCT)
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89. Method
Stroke survivors recruited from
acute and stroke rehab stroke wards
OT-led stroke-specific
vocational rehabilitation
(SSVR)
Usual Care
(UC)
Postal follow-up: 3, 6 and 12 months
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90. Intervention
• Best practice guidelines (Tyerman and Meehan, 2004)
• Mapping work (Sinclair et al., 2013)
• Assessment, information, education, work preparation
and phased return to work (Grant et al., 2012)
• Case co-ordination model (Fadyl and McPherson, 2009)
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91. Inclusion Criteria
• Confirmed stroke diagnosis
• Aged 16+
• In paid/voluntary work, education, >1 hour per week
Exclusion Criteria
• Not intending to RTW
• Unable to give informed consent
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92. Participants
Gender: n (%)
Male
Female
17 (73.9%)
6 (26.1%)
19 (82.6%)
4 (17.4%)
Age
Mean (SD)
Range
58.3 (12.7)
24-78
53.8 (12.6)
18-77
Length of Hospital Stay
Mean days (SD) 19.6 (21.6) 27.1 (26.9)
Occupation: n (%)
Non-Professional
Professional
4 (17.4%)
19 (82.6%)
12 (52.2%)
11 (47.8)
Characteristic SSVR (n=23) Control (n=23)
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93. 0
5
10
15
20
25
30
35
Minor
Moderate
Moderate/Seve
re
Severe
Missing
NIHSS; Stroke Severity (%) SSVR
Control
0
5
10
15
20
25
30
35
LACS PACS TACS POCS Missing
Bamford Classification (%) SSVR
Control
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94. Participants
0
1
2
3
4
5
6 Visual Impairments (n)
SSVR
Control
0
5
10
15
20
25
30
35
40
45
Not affected Aphasia Dysarthria Dysarthria and
aphasia
Speech and Language
Impairments (%)
SSVR
Control
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95. Primary Outcome
• Returned to work: yes/no
Secondary Outcomes
• Mood: Hospital Anxiety and Depression Scale (HADS)
• Work Productivity: Work Productivity and Activity Impairment
Instrument (WPAI) and Work Limitations Questionnaire (WLQ)
• Social Participation: Sydney Psychosocial Reintegration Scale
(SPRS)
• Activities of Daily Living: Nottingham Extended Activities of Daily
Living (NEADL)
• Health Status: EQ-5D
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96. Results: Participants
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97. Feasibility
0
20
40
60
80
100
3m 6m 12m
Questionnaire Response Rates (%)
SSVR
Control
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98. Primary Outcome
0
20
40
60
80
100
3m 6m 12m
Participants in Work (%) SSVR
Control
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99. 0
2
4
6
8
10
12
14
16
18
20
22
3m 6m 12m
Nottingham Extended Activities of Daily
Living: Median Score SSVR
Control
0
2
4
6
8
3m 6m 12m 3m 6m 12m
Anxiety Depression
Hospital Anxiety and Depression Scale:
Median Scores SSVR
Control
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100. Secondary Outcomes
-2
3
8
3m 6m 12m
WLQ: % Productivity Loss SSVR
Control
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101. Secondary Outcomes
0
15
30
45
60
3m 6m 12m
Sydney Psychosocial Reintegration
Scale: Median Score SSVR
Control
.00
.20
.40
.60
.80
1.00
3m 6m 12m
EQ5D: Average of Scaled Scores
SSVR
Control
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102. Discussion
• Primary outcome: More intervention group participants
were in work at 12 months
• Secondary outcomes: Relatively little variation between
the two groups.
• Feasibility: Feasible to recruit, deliver and measure early
SSVR - overall response rate of 73.9% - only one person
withdrew from intervention
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103. Limitations
• More information known about the intervention
group
• Fixed time period
• Descriptive comparisons
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104. Conclusions
• Early OT-led SSVR can be effectively delivered and
measured using standardised and bespoke
questionnaires
• SSVR can potentially influence return to work rates
• Knowledge from this feasibility study useful in planning
future research: larger scale studies needed to
demonstrate effect
• Impact of research: dissemination of new knowledge and
new SSVR OT post commissioned in Nottingham
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105. References
• Daniel K, Wolfe CDA, Busch MA, McKevitt C (2009) What are the social
consequences of stroke in working aged adults? A systematic review.
Stroke, 40, 431-440
• Fadyl JK, McPherson KM (2009) Approaches to vocational rehabilitation after
traumatic brain injury: a review of the evidence. Journal of Head Trauma
Rehabilitation, 24(3), 195-212.
• Grant M, Sinclair E, Walker MF, Radford KA. Vocational rehabilitation
following stroke: describing intervention. International Journal of Stroke.
2012; 7 (Suppl 2):29.
• Department of Health (2010) The NHS Outcomes Framework
2011/12, London: Department of Health.
• Playford ED, Radford K, Burton C, Gibson A, Jellie B, Sweetland J, Watkins
C. (2011) Mapping Vocational Rehabilitation Services for people with Long
term neurological conditions: Summary report. Department of Health.
Available at: http://www.ltnc.org.uk/ Accessed 10.12.12.
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106. References
• Saka O, McGuire A, Wolfe C (2009) Cost of stroke in the United Kingdom.
Age and Ageing, 38(1), 27–32
• Sinclair E, Radford K, Grant M, Terry J (2013) Developing stroke specific
vocational rehabilitation: a soft systems analysis of current service provision.
Disability and Rehabilitation. Published online, May 2013.
DOI:10.3109/09638288.2013.793410
• Tyerman A, Meehan M J (eds) (2004) Vocational assessment and
rehabilitation after acquired brain injury: Interagency guidelines. London:
British Society of Rehabilitation Medicine/ Job Centre Plus/ Royal College of
Physicians
• Wadell G, Aylward AK (2005) The scientific and conceptual basis of
incapacity benefits. London: HMSO
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107. Thank you for listening
Collaboration for Leadership in Applied Health Research and Care for
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kate.radford@nottingham.ac.uk
Mary Grant – mcxmig@nottingham.ac.uk
www.clahrc-ndl.nihr.ac.uk