Recent Submissions

  • Randomized controlled feasibility trial of swallow strength and skill training with surface electromyographic biofeedback in acute stroke patients with dysphagia

    Benfield, Jacqueline; England, Timothy J.; Everton, Lisa F.
    Background & Objectives: Swallow strength and skill training with surface electromyography (sEMG) biofeedback may improve dysphagia but little is known about the feasibility and efficacy of this intervention in acute stroke. Methods: We conducted a randomized controlled feasibility study in acute stroke patients with dysphagia. Participants were randomized to either usual care or usual care plus swallow strength and skill training with sEMG biofeedback. Primary outcomes were feasibility and acceptability. Secondary measures included swallowing and clinical outcomes, safety and swallow physiology. Results: Twenty-seven patients (13 biofeedback, 14 control) with average age of 73.3 (SD 11.0) and National Institute of Health Stroke Scale (NIHSS) of 10.7 (5.1) were recruited 22.4 (9.5) days post stroke. About 84.6% of participants completed >80% of sessions; failed sessions were mainly due to participant availability, drowsiness or refusal. Sessions lasted for an average of 36.2 (7.4) min. Although 91.7% found the intervention comfortable with satisfactory administration time, frequency and time post stroke, 41.7% found it challenging. There were no treatment-related serious adverse events. The biofeedback group had a lower Dysphagia Severity Rating Scale (DSRS) score at 2 weeks compared to control (3.2 vs. 4.3), but the difference did not reach statistical significance. Conclusions: Swallow strength and skill training with sEMG biofeedback appears feasible and acceptable to acute stroke patients with dysphagia. Preliminary data suggests it is safe and further research refining the intervention and investigating treatment dose and efficacy is warranted.
  • Evaluating the Use of Oral Trials for Inpatient Dysphagia Management: An Initial Cross-Sectional Database Study.

    Julier, Rebecca; Benfield, Jacqueline
    Purpose Oral trials, otherwise known as swallow trials or tasters, are widely used in dysphagia management. However, to date, no studies have investigated the effectiveness of oral trials or outlined how the approach is utilized in everyday practice. This article aims to start a dialogue regarding this much-used but little-evidenced dysphagia intervention by exploring three main aspects to (a) identify the patient demographics and environments in which oral trials are used in hospital, (b) explore clinical decision making around the approach, and (c) consider clinical implications around current findings and future areas for research. Method A cross-sectional examination of 118 patients on the dysphagia caseload of a United Kingdom-based inpatient speech and language therapy team was conducted. Statistical analysis explored demographic differences between oral trials groups and the rest of the dysphagia caseload. Results Twenty-three of 118 (19.5%) individuals on the caseload were or had been on oral trials during admission. Individuals in the oral trials group were significantly more likely to have a neurological diagnosis than the full oral intake group (78.3% vs. 30.5%, p < .001). There was a lack of uniformity in oral trials recommendations, and the rationale behind quantity and types of diet or fluids offered was unclear. Conclusions This study begins to evidence the use of a dysphagia therapy not previously explored within existing literature. It highlights the wide use of oral trials within the hospital trust observed. Based on current evidence, it would be difficult for clinicians to know how to implement oral trials as an intervention. Further research is required both to explore the effectiveness of this approach and also to develop a consensus within practice around how, why, and when oral trials are offered. This would ensure an equitable and effective service is offered and would ensure a high standard of evidence-based practice within dysphagia management.
  • Self-managed, computerised speech and language therapy for patients with chronic aphasia post-stroke compared with usual care or attention control (Big CACTUS): a multicentre, single-blinded, randomised controlled trial.

    Witts, Helen (2019-09)
    Abstract: BACKGROUND: Post-stroke aphasia might improve over many years with speech and language therapy; however speech and language therapy is often less readily available beyond a few months after stroke. We assessed self-managed computerised speech and language therapy (CSLT) as a means of providing more therapy than patients can access through usual care alone. METHODS: In this pragmatic, superiority, three-arm, individually randomised, single-blind, parallel group trial, patients were recruited from 21 speech and language therapy departments in the UK. Participants were aged 18 years or older and had been diagnosed with aphasia post-stroke at least 4 months before randomisation; they were excluded if they had another premorbid speech and language disorder caused by a neurological deficit other than stroke, required treatment in a language other than English, or if they were currently using computer-based word-finding speech therapy. Participants were randomly assigned (1:1:1) to either 6 months of usual care (usual care group), daily self-managed CSLT plus usual care (CSLT group), or attention control plus usual care (attention control group) with the use of computer-generated stratified blocked randomisation (randomly ordered blocks of sizes three and six, stratified by site and severity of word finding at baseline based on CAT Naming Objects test scores). Only the outcome assessors and trial statistician were masked to the treatment allocation. The speech and language therapists who were doing the outcome assessments were different from those informing participants about which group they were assigned to and from those delivering all interventions. The statistician responsible for generating the randomisation schedule was separate from those doing the analysis. Co-primary outcomes were the change in ability to retrieve personally relevant words in a picture naming test (with 10% mean difference in change considered a priori as clinically meaningful) and the change in functional communication ability measured by masked ratings of video-recorded conversations, with the use of Therapy Outcome Measures (TOMs), between baseline and 6 months after randomisation (with a standardised mean difference in change of 0·45 considered a priori as clinically meaningful). Primary analysis was based on the modified intention-to-treat (mITT) population, which included randomly assigned patients who gave informed consent and excluded those without 6-month outcome measures. Safety analysis included all participants. This trial has been completed and was registered with the ISRCTN, number ISRCTN68798818. FINDINGS: From Oct 20, 2014, to Aug 18, 2016, 818 patients were assessed for eligibility, of which 278 (34%) participants were randomly assigned (101 [36%] to the usual care group; 97 [35%] to the CSLT group; 80 [29%] to the attention control group). 86 patients in the usual care group, 83 in the CSLT group, and 71 in the attention control group contributed to the mITT. Mean word finding improvements were 1·1% (SD 11·2) in the usual care group, 16·4% (15·3) in the CSLT group, and 2·4% (8·8) in the attention control group. Word finding improvement was 16·2% (95% CI 12·7 to 19·6; p<0·0001) higher in the CSLT group than in the usual care group and was 14·4% (10·8 to 18·1) higher than in the attention control group. Mean changes in TOMs were 0·05 (SD 0·59) in the usual care group (n=84), 0·04 (0·58) in the CSLT group (n=81), and 0·10 (0·61) in the attention control group (n=68); the mean difference in change between the CSLT and usual care groups was -0·03 (-0·21 to 0·14; p=0·709) and between the CSLT and attention control groups was -0·01 (-0·20 to 0·18). The incidence of serious adverse events per year were rare with 0·23 events in the usual care group, 0·11 in the CSLT group, and 0·16 in the attention control group. 40 (89%) of 45 serious adverse events were unrelated to trial activity and the remaining five (11%) of 45 serious adverse events were classified as unlikely to be related to trial activity. INTERPRETATION: CSLT plus usual care resulted in a clinically significant improvement in personally relevant word finding but did not result in an improvement in conversation. Future studies should explore ways to generalise new vocabulary to conversation for patients with chronic aphasia post-stroke. FUNDING: National Institute for Health Research, Tavistock Trust for Aphasia.
  • Development of a Pathway for Returning To Driving After A Stroke in Derby

    Bates, Laura; Bartram, Anna; Richardson, Andy; Bullock, Suzie; Clements, Karen; Whiteman, Elizabeth; Fletcher, Kim (2019)
  • The intrauterine device and the intrauterine system

    Searle, Stephen (2014-08)
    Intrauterine contraception is used by about 100 million women worldwide, making it the most popular form of fertility regulation. In UK community contraception clinics, however, long-acting reversible contraception has increased to 28% of users, and intrauterine contraception accounts for only 8% of methods used by women accessing these services. Potential exists to increase uptake of these more effective methods. In this chapter, we review the clinical advantages, disadvantages and cost-effectiveness of intrauterine contraception. We discuss the management of complications along with advice for trainers, and briefly consider issues in developing countries.
  • A low cost virtual reality system for home based rehabilitation of the arm following stroke: a randomised controlled feasibility trial.

    Richardson, Andy (2017-03)
    OBJECTIVE: To assess the feasibility of conducting a randomised controlled trial of a home-based virtual reality system for rehabilitation of the arm following stroke. DESIGN: Two group feasibility randomised controlled trial of intervention versus usual care. SETTING: Patients' homes. PARTICIPANTS: Patients aged 18 or over, with residual arm dysfunction following stroke and no longer receiving any other intensive rehabilitation. INTERVENTIONS: Eight weeks' use of a low cost home-based virtual reality system employing infra-red capture to translate the position of the hand into game play or usual care. MAIN MEASURES: The primary objective was to collect information on the feasibility of a trial, including recruitment, collection of outcome measures and staff support required. Patients were assessed at three time points using the Wolf Motor Function Test, Nine-Hole Peg Test, Motor Activity Log and Nottingham Extended Activities of Daily Living. RESULTS: Over 15 months only 47 people were referred to the team. Twenty seven were randomised and 18 (67%) of those completed final outcome measures. Sample size calculation based on data from the Wolf Motor Function Test indicated a requirement for 38 per group. There was a significantly greater change from baseline in the intervention group on midpoint Wolf Grip strength and two subscales of the final Motor Activity Log. Training in the use of the equipment took a median of 230 minutes per patient. CONCLUSIONS: To achieve the required sample size, a definitive home-based trial would require additional strategies to boost recruitment rates and adequate resources for patient support.
  • What speech and language therapy do community dwelling stroke survivors with aphasia receive in the UK?

    Witts, Helen (2018-07)
    BACKGROUND: Speech and language therapy provision for aphasia (a language disorder) post stroke has been studied over time through surveys completed by speech and language therapists. This paper revisits provision based on what was received by 278 patients in 21 UK speech and language therapy departments in 2014-2016. AIMS: To explore the speech and language therapy received by community dwelling people with post stroke aphasia in the UK. METHODS AND PROCEDURES: A quantitative content analysis was conducted by two speech and language therapist researchers. Therapy goals recorded were coded into categories and subcategories. Descriptive statistics were used to identify the frequency with which goal categories were targeted, average therapy time received, length and frequency of therapy sessions, personnel involved and mode of delivery. OUTCOMES AND RESULTS: Forty-five percent of participants were in receipt of therapy in the three month window observed. Six goal categories were identified. Rehabilitation was the most frequent (60%) followed by enabling (17.2%), review (4.3%), assessment (3.6%), supportive (3.5%) and activity to support therapy (2.8%). The median amount of therapy received in three months was 6.3 hours at an average of one 60-minute session every two weeks. Seventy-seven percent of therapy sessions were delivered by qualified speech and language therapists and 23% by assistants. Ninety percent of sessions were one to one, face to face sessions whilst 9.5% were group sessions. DISCUSSION: In line with previous reports, speech and language therapy for community dwelling stroke survivors with aphasia is restricted. Rehabilitation is a large focus of therapy but the intensity and dose with which it is provided is substantially lower than that required for an effective outcome. Despite this, one to one face to face therapy is favoured. More efficient methods to support more therapeutic doses of therapy are not commonly used in routine clinical services.
  • Dorsiflexory Phalangeal Osteotomy for Grade II Hallux Rigidus: Patient-Focused Outcomes at Eleven-Year Follow-Up.

    Coutts, A; Kilmartin, TE (2019-01)
    Dorsiflexory phalangeal osteotomy has been shown to be an effective treatment for mild to moderate hallux rigidus in short- to medium-term follow-up studies. It is speculated that the procedure alters the mechanical function of the joint and reduces the demand for hallux dorsiflexion by elevating the proximal phalanx into a more dorsiflexed position. However, it has been demonstrated that the first metatarsophalangeal (MTP) joint space and joint range of motion are reduced by the procedure, calling into question the long-term effectiveness of the operation. This study reviewed 27 dorsiflexory phalangeal osteotomy cases at an average of 11 years postoperatively. Twenty-one (77%) patients reported that they were completely satisfied with the results of their surgery; 4 (15%) patients reported that they were satisfied with reservations; and 2 (7%) patients reported that they were dissatisfied. The patients who were satisfied with reservations complained of interphalangeal (IP) joint pain or stiffness. One patient developed second MTP joint metatarsalgia after surgery, and in 1 patient first MTP joint pain returned at 24 months after surgery. One dissatisfied patient complained of second MTP joint metatarsalgia, and a second patient required revision excisional arthroplasty for continued joint pain. Ten patients (38%) reported stiffness of the first MTP joint, but only 2 patients reported any restriction of activity. Footwear restrictions were reported by 15 (58%) patients preoperatively and by 9 (35%) patients at final follow-up. Dorsiflexory phalangeal osteotomy maybe a reliable long-term treatment for grade II or moderate hallux rigidus and is a safe and effective alternative to first MTP joint fusion in joints where movement is still present and joint cartilage is viable.