Background and Purpose-To present a systematic review of studies that addresses the effects of intensity of augmented exercise therapy time (AETT) on activities of daily living (ADL), walking, and dexterity in patients with stroke. Summary of Review-A database of articles published from 1966 to November 2003 was compiled from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE, and PiCarta using combinations of the following key words: stroke, cerebrovascular disorders, physical therapy, physiotherapy, occupational therapy, exercise therapy, rehabilitation, intensity, dose-response relationship, effectiveness, and randomized controlled trial. References presented in relevant publications were examined as well as abstracts in proceedings. Studies that satisfied the following selection criteria were included: (1) patients had a diagnosis of stroke; (2) effects of intensity of exercise training were investigated; and (3) design of the study was a randomized controlled trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for ADL, walking speed, and dexterity using fixed and random effect models. Correlation coefficients were calculated between observed individual effect sizes on ADL of each study, additional time spent on exercise training, and methodological quality. Cumulative meta-analyses (random effects model) adjusted for the difference in treatment intensity in each study was used for the trials evaluating the effects of AETT provided. Twenty of the 31 candidate studies, involving 2686 stroke patients, were included in the synthesis. The methodological quality ranged from 2 to 10 out of the maximum score of 14 points. The meta-analysis resulted in a small but statistically significant SES with regard to ADL measured at the end of the intervention phase. Further analysis showed a significant homogeneous SES for 17 studies that investigated effects of increased exercise intensity within the first 6 months after stroke. No significant SES was observed for the 3 studies conducted in the chronic phase. Cumulative meta-analysis strongly suggests that at least a 16-hour difference in treatment time between experimental and control groups provided in the first 6 months after stroke is needed to obtain significant differences in ADL. A significant SES supporting a higher intensity was also observed for instrumental ADL and walking speed, whereas no significant SES was found for dexterity. Conclusion-The results of the present research synthesis support the hypothesis that augmented exercise therapy has a small but favorable effect on ADL, particularly if therapy input is augmented at least 16 hours within the first 6 months after stroke. This meta-analysis also suggests that clinically relevant treatment effects may be achieved on instrumental ADL and gait speed.

Complications after acute stroke are common, confirming that stroke rehabilitation requires active and knowledgeable medical input. Knowing the nature and timing of complications, together with the identification of high-risk patients, may be useful to those planning stroke services. The differences in our results and those previously reported, most notably for skin breaks, are probably due to the different methods used, in particular patient selection and diagnostic criteria for complications. Although complications may be useful as a measure of outcome in comparative studies (eg, therapeutic trials and audit), the methodological difficulties in accurately and reliably measuring them must be addressed.

ObjectiveTo describe and explain stroke survivors and informal caregivers’ experiences of primary care and community healthcare services. To offer potential solutions for how negative experiences could be addressed by healthcare services.DesignSystematic review and meta-ethnography.Data sourcesMedline, CINAHL, Embase and PsycINFO databases (literature searched until May 2015, published studies ranged from 1996 to 2015).Eligibility criteriaPrimary qualitative studies focused on adult community-dwelling stroke survivors’ and/or informal caregivers’ experiences of primary care and/or community healthcare services.Data synthesisA set of common second order constructs (original authors’ interpretations of participants’ experiences) were identified across the studies and used to develop a novel integrative account of the data (third order constructs). Study quality was assessed using the Critical Appraisal Skills Programme checklist. Relevance was assessed using Dixon-Woods’ criteria.Results51 studies (including 168 stroke survivors and 328 caregivers) were synthesised. We developed three inter-dependent third order constructs: (1) marginalisation of stroke survivors and caregivers by healthcare services, (2) passivity versus proactivity in the relationship between health services and the patient/caregiver dyad, and (3) fluidity of stroke related needs for both patient and caregiver. Issues of continuity of care, limitations in access to services and inadequate information provision drove perceptions of marginalisation and passivity of services for both patients and caregivers. Fluidity was apparent through changing information needs and psychological adaptation to living with long-term consequences of stroke.LimitationsPotential limitations of qualitative research such as limited generalisability and inability to provide firm answers are offset by the consistency of the findings across a range of countries and healthcare systems.ConclusionsStroke survivors and caregivers feel abandoned because they have become marginalised by services and they do not have the knowledge or skills to re-engage. This can be addressed by: (1) increasing stroke specific health literacy by targeted and timely information provision, and (2) improving continuity of care between specialist and generalist services.Systematic review registration numberPROSPERO 2015:CRD42015026602

As part of a survey to collect data which would be useful in planning a district stroke service we set out to discover what the service users' (patients' and carers') perceptions and knowledge of their illness were. We prospectively identified 164 consecutive patients with acute stroke admitted to hospital. Of the 110 (67%) survivors 65 (59%) patients and 80 (73%) carers completed a semi-structured interview. Most (46, 71%) patients and (68, 85%) carers thought they understood what a stroke was but 14 (22%) patients and 12 (15%) carers did not differentiate between a 'stroke' and a 'heart attack'. Carers were significantly more likely than patients to want know all the details about the patients' condition and treatment, to discuss the risk of recurrence, to receive written information and to join information groups. They were more likely than patients to feel that they had to ask for information, yet they were better able to identify general risk factors for stroke. Many patients and carers want more information and discussion about their illness and treatment during their hospital stay, however, some do not. Therefore information giving must be considered on an individual basis. Information could be delivered by: increasing available literature, voluntary group meetings, Stroke Family Care Officers and audio-visual information packages. The most efficient way of achieving an increased understanding amongst patients and carers needs to be found.