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Investigating the association between inpatient stroke therapy and disability, destination on discharge, length of stay and mortality: a prospective cohort study using the Sentinel Stroke National Audit Programme

Por: Gittins · M. · Lugo-Palacios · D. G. · Vail · A. · Bowen · A. · Paley · L. · Bray · B. · Gannon · B. · Tyson · S.
Objective

‘More is better’ is a recognised mantra within stroke therapy, however, this has been developed in patients receiving long term rehabilitation. We investigated the relationship between amount of therapy received (from therapists and psychologists) and key patient outcomes during inpatient care.

Design

A secondary analysis of data from a prospective cohort study was performed. Multilevel mixed models adjusting for measured confounders (eg, severity), explored the relationship between therapy dose (average minutes per day of stay) and outcomes (disability, length of stay, home at discharge and mortality). Therapy was explored using simple linear terms and flexible natural cubic splines to allow for more complex relationships.

Setting

Data from the Sentinel Stroke National Audit Programme, covering England, Wales and Northern Ireland between July 2013 and July 2015 contained 94 905 adults with a stroke and still an inpatient after 72 hours. These patients received 92% (physiotherapy), 88% (occupational therapy), 57% (speech and language therapy) and 5% (clinical psychology), respectively.

Results

The average amount of therapy, for individual and ‘any’ therapy combined per day of stay was low. Overall, 41% were discharged with an ‘independent’ modified Rankin Scale (≤2), 14% died, 44% were discharged home, and the median length of stay was 16 days. We observed complex relationships between amount of therapy received and outcomes. An additional minute of ‘any’ therapy, occupational therapy, speech and language therapy and clinical psychology was associated with improved outcomes. Conversely, more physiotherapy was also associated with lower mortality and shorter length of stay, but also lower independence and discharge home.

Conclusions

Our findings suggest for stroke inpatients requiring therapy, ‘More is better’ may be overly simplistic. Strong limitations associated with analysis of routine data restrict further robust investigation of the therapy–response relationship. Robust prospective work is urgently needed to further investigate the relationships observed here.

Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systematic review and meta-analysis of 381 studies (the meta-TENS study)

Por: Johnson · M. I. · Paley · C. A. · Jones · G. · Mulvey · M. R. · Wittkopf · P. G.
Objective

To investigate the efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for relief of pain in adults.

Design

Systematic review and meta-analysis.

Data sources

Medline, Cochrane Central, Embase (and others) from inception to July 2019 and updated on 17 May 2020.

Eligibility criteria for study selection

Randomised controlled trials (RCTs) comparing strong non-painful TENS at or close to the site of pain versus placebo or other treatments in adults with pain, irrespective of diagnosis.

Data extraction and synthesis

Reviewers independently screened, extracted data and assessed risk of bias (RoB, Cochrane tool) and certainty of evidence (Grading and Recommendations, Assessment, Development and Evaluation). Mean pain intensity and proportions of participants achieving reductions of pain intensity (≥30% or >50%) during or immediately after TENS. Random effect models were used to calculate standardised mean differences (SMD) and risk ratios. Subgroup analyses were related to trial methodology and characteristics of pain.

Results

The review included 381 RCTs (24 532 participants). Pain intensity was lower during or immediately after TENS compared with placebo (91 RCTs, 92 samples, n=4841, SMD=–0·96 (95% CI –1·14 to –0·78), moderate-certainty evidence). Methodological (eg, RoB, sample size) and pain characteristics (eg, acute vs chronic, diagnosis) did not modify the effect. Pain intensity was lower during or immediately after TENS compared with pharmacological and non-pharmacological treatments used as part of standard of care (61 RCTs, 61 samples, n=3155, SMD = –0·72 (95% CI –0·95 to –0·50], low-certainty evidence). Levels of evidence were downgraded because of small-sized trials contributing to imprecision in magnitude estimates. Data were limited for other outcomes including adverse events which were poorly reported, generally mild and not different to comparators.

Conclusion

There was moderate-certainty evidence that pain intensity is lower during or immediately after TENS compared with placebo and without serious adverse events.

PROSPERO registration number

CRD42019125054.

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