Dr Isobel Hubbard

Background/aim: In Australia, all stroke survivors should not drive for four weeks and transient ischaemic attack (TIA) survivors should not drive for two weeks. This study investigates the provision of return-to-driving education in the acute hospital setting and the use of this education by a cohort of Australian patients who have experienced a mild stroke or TIA and who are discharged directly home from their acute hospital admission. Methods: A medical record audit was conducted of stroke patients discharged home from a regional hospital in Australia. All audited patients were sent a post-discharge anonymous survey of their post-stroke driving behaviours. Results: A total of 78 medical records were audited (32 women, 46 men; 15 TIA, 63 strokes). Mean age was 67.4¿years (SD¿=¿13.7, range 20¿89¿years). Only 27 (34.6%) patients had documented evidence that return-to-driving was discussed with them by a health professional, with only 10 (12.8%) having a restriction period documented. A total of 31 surveys were analysed (10 females, 21 males) and 20 participants had returned to driving. From 31 survivors of mild stroke/TIA, 21 recalled receiving advice on return-to-driving and seven resumed driving during the non-driving period of one month. Conclusions: Inconsistencies exist in the documentation of return-to-driving management after acute stroke or TIA and it is unknown whether patients who lack documentation in their medical records were provided with education or not.

Gaps exist in the knowledge of return-to-driving guidelines, and education is needed for Australian health professionals working in the field of stroke. In this paper, authors evaluate the implementation of an e-learning module. A pre- and post-module knowledge test and survey were used to assess the e-module's success in achieving its learning objectives. Initially, 204 learners completed the module, with 68% of learners scoring 100% in the post-module knowledge test. Only 12 learners completed the survey. The authors recommend that health professionals other than occupational therapists access this e-module, and a review on e-module structure is required to improve results of knowledge tests.

Outline of problem: Allied health professionals working in rural settings have broad caseloads requiring advanced skills as general specialists. This can include children with specialised needs. Design: Educational secondments were coordinated for allied health professionals to achieve self-nominated learning objectives. Learning objectives were assessed using pre and post evaluations to determine the effect of the educational secondment on knowledge and confidence specific to the nominated learning outcomes. Setting: Educational secondments were undertaken by allied health professionals from New South Wales Health facilities in regional or rural locations outside of the Sydney metropolitan area. The educational secondments occurred in tertiary-level hospitals or specialist health facilities. Key measures for improvement: Using self-reported questionnaires, allied health secondees¿ outcomes were assessed prior to the secondment, immediately following and again at 6 months post-secondment, and their managers at 6 months post-secondment. The program aimed to improve the allied health professional's knowledge and confidence around self-selected learning objectives related to the specialised care of children with complex health needs in rural settings. Strategies for change: Allied health professionals reported increased knowledge and confidence immediately following the secondment which was sustained at 6 months. On the basis of this outcome, the secondment program will continue. Effects of change: The secondment program resulted in changes to the ongoing clinical practice of participating clinicians as well as other health professionals within the departments where they worked. Lessons learnt: Educational secondments can improve the knowledge and skills of allied health professionals working in rural and remote locations with a view to improving access to equitable health care for children living in rural settings.

Background and Purpose-As populations age, an increasing number of older women are living with stroke. This study looks at long-term outcomes for women with stroke, comparing mortality rates for women with poor physical function (PF) and those with higher levels of function. The purpose is to understand not only how long women might live after a stroke, but also how long they live with physical disability. Methods-The study uses 15 years of data on women from the Australian Longitudinal Study on Women's Health 1921 to 1926 cohort. The risk of stroke and the risk of stroke and poor PF were estimated using Cox proportional hazard model. Among women who reported a stroke during the study period, mortality risk was compared according to their physical functioning level after that stroke. Results-Almost half of the women who had a stroke and poor PF survived past 10 years. The 10-year mortality rate was 37% for women with stroke and adequate PF and 51% for women with stroke and poor PF at the time of the stroke (hazard rate ratio, 1.52; 95% CI, 1.18-1.95; P=0.0015 adjusting for demographic and health covariates). Conclusions-This study provides evidence of the long-term outcomes of stroke among older women, with women living for many years with poor PF. This outcome has important implications for the women's quality of life during their later years and in understanding the burden of disability associated with stroke.

Introduction: This systematic review aimed to determine whether stroke survivors routinely received return-to-driving education in the acute hospital setting prior to discharge home; and if education was provided, were the restrictions in driving guidelines adhered to. Method: A systematic search was conducted of PubMed, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Web of Science, Scopus, Pedro and OTseeker databases for original research reporting findings on the adherence to return-to-driving legislation and clinical guidelines after stroke, and return-to-driving behaviours in stroke survivors up to 1 month post stroke. Results: Three studies met the inclusion criteria and reported on a combined total of 252 stroke survivors living in the United Kingdom. Forty-eight per cent of stroke survivors received education on the 1 month driving restriction. A total of 61.4% of participants waited 1 month prior to returning to driving. Conclusion: This review found that there is limited literature available on the management of return to driving following acute stroke but there is evidence that education may not be routinely provided in the acute hospital setting and that many stroke survivors could be returning to driving within the 1 month restriction.

Stroke is the leading cause of adult disability, and as a consequence, most therapists will provide health care to patients with stroke during their professional careers. An increasing number of studies are investigating the association between upper limb recovery and changes in brain activation patterns following stroke. In this review, we explore the translational implications of this research for health professionals working in stroke recovery. We argue that in light of the most recent evidence, therapists should consider how best to take full advantage of the brain's natural ability to reorganize, when prescribing and applying interventions to those with a stroke-affected upper limb. The authors propose that stroke is a brain-based problem that needs a brain-based solution. This review addresses two topics, anticipating recovery and maximizing recovery. It proposes five practice-ready recommendations that are based on the evidence reviewed. The over-riding aim of this review and discussion is to challenge therapists to reconsider the health care they prescribe and apply to people with a stroke-affected upper limb.

Background Although many people survive an initial stroke, little is known about long-term impacts of stroke on survival. Methods Data from the Australian Longitudinal Study on Women's Health were used to compare 12-year survival rates in older women with prevalent stroke, incident stroke, and no stroke. Cox regression models were fitted to assess the effect of lifestyle and demographic characteristics on the relationship between stroke and all-cause mortality. The "no stroke" group was used as the reference category in all statistical models. Results At baseline, 4% of the women reported a previous stroke (prevalent stroke). At survey 2 in 1999, a further 3% reported having a stroke between 1996 and 1999 (incident stroke). Stroke was significantly associated with reduced long-term survival. Age-Adjusted hazards ratios (HRs) were: 1.64 (1.43-1.89) for the "prevalent stroke" group and 2.29 (1.97-2.66) for the "incident stroke" group. Adjusting for comorbidities reduced the HRs, but the risk of death was still significantly higher in the 2 stroke groups. Adjusting for demographic and lifestyle factors did not make any further difference to the relationship between stroke and survival. However, obesity and past smoking were also risk factors for mortality. Conclusions This study highlights the long-term impacts of stroke on life expectancy and the importance of comorbidities and other lifestyle factors in affecting poststroke survival.

Background. Upper-limb (UL) dysfunction is experienced by up to 75% of patients poststroke. The greatest potential for functional improvement is in the first month. Following reperfusion, evidence indicates that neuroplasticity is the mechanism that supports this recovery. Objective. This preliminary study hypothesized increased activation of putative motor areas in those receiving intensive, task-specific UL training in the first month poststroke compared with those receiving standard care. Methods. This was a single-blinded, longitudinal, randomized controlled trial in adult patients with an acute, first-ever ischemic stroke; 23 participants were randomized to standard care (n = 12) or an additional 30 hours of task-specific UL training in the first month poststroke beginning week 1. Patients were assessed at 1 week, 1 month, and 3 months poststroke. The primary outcome was change in brain activation as measured by functional magnetic resonance imaging. Results. When compared with the standard-care group, the intensive-training group had increased brain activation in the anterior cingulate and ipsilesional supplementary motor areas and a greater reduction in the extent of activation (P =.02) in the contralesional cerebellum. Intensive training was associated with a smaller deviation from mean recovery at 1 month (Pr>F0 = 0.017) and 3 months (Pr>F = 0.006), indicating more consistent and predictable improvement in motor outcomes. Conclusion. Early, more-intensive, UL training was associated with greater changes in activation in putative motor (supplementary motor area and cerebellum) and attention (anterior cingulate) regions, providing support for the role of these regions and functions in early recovery poststroke.

Background. Evidence indicates that Stroke Units decrease mortality and morbidity. An Acute Stroke Unit (ASU) provides specialised, hyperacute care and thrombolysis. John Hunter Hospital, Australia, admits 500 stroke patients each year and has a 4-bed ASU. Aims. This study investigated hospital admissions over a 5-year period of all strokes patients and of all patients admitted to the 4-bed ASU and the involvement of allied health professionals. Methods. The study retrospectively audited 5-year data from all stroke patients admitted to John Hunter Hospital (n=2525) and from nonstroke patients admitted to the ASU (n=826). The study's primary outcomes were admission rates, length of stay (days), and allied health involvement. Results. Over 5 years, 47% of stroke patients were admitted to the ASU. More male stroke patients were admitted to the ASU (chi2=5.81; P=0.016). There was a trend over time towards parity between the number of stroke and nonstroke patients admitted to the ASU. When compared to those admitted elsewhere, ASU stroke patients had a longer length of stay (z=-8.233; P=0.0000) and were more likely to receive allied healthcare. Conclusion. This is the first study to report 5 years of ASU admissions. Acute Stroke Units may benefit from a review of the healthcare provided to all stroke patients. The trends over time with respect to the utilisation of the John Hunter Hospitall's ASU have resulted in a review of the hospitall's Stroke Unit and allied healthcare. © 2014 Isobel J. Hubbard et al.