ORCID Profile
0000-0001-6866-6341
Current Organisation
University of Nottingham
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Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2013
Publisher: Springer Science and Business Media LLC
Date: 16-03-2002
DOI: 10.1007/S00221-002-1113-X
Abstract: There is increasing evidence that the primary motor cortex is involved in the generation of electromyographic (EMG) oscillations at frequencies in the range of 15-30 Hz that are observed during performance of a precision grip task. Since the level of the corticomuscular coherence varies according to the nature of the object that is gripped, it seemed possible that somatosensory inputs from the hand might affect this coherence. The aim of this study was to investigate whether interrupting cutaneous inputs from the digits would affect the coherence between hand muscles during precision grip of a compliant object. Subjects performed a precision grip hold-r -hold task before, during and after digital nerve anaesthesia of the index finger and thumb. There were marked deficits in the performance of the task, particularly during the initial formation of the grip and first hold period. Local digital nerve anaesthesia reduced but did not abolish 14-31 Hz coherence between EMG activity recorded from different hand and forearm muscles. Coherence was measured during the second hold phase of the task. Digital nerve anaesthesia did not affect the predominant frequencies in the EMG power spectra compiled from the same phase of the task. We conclude that during a precision grip task, cutaneous input enhances oscillatory synchrony between pairs of hand muscles.
Publisher: National Institute for Health and Care Research
Date: 11-2021
DOI: 10.3310/HSDR09220
Abstract: In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness. A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes. Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England. Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff ( n = 117) and patients ( n = 30) from six purposely selected early supported discharge services. Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness. A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway. Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory. The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness. Current Controlled Trials ISRCTN15568163. This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research Vol. 9, No. 22. See the NIHR Journals Library website for further project information.
Publisher: SAGE Publications
Date: 04-09-2013
Abstract: To explore the perspectives of healthcare professionals and commissioners working with a stroke Early Supported Discharge service in relation to: (1) the factors that facilitate or impede the implementation of the service, and (2) the impact of the service. Cross-sectional qualitative study using semi-structured interviews. Data were analysed by two researchers using a thematic analysis approach. Two Early Supported Discharge services in Nottinghamshire. Purposive s ling identified 35 key informants including practitioners, managers and commissioners. The identified facilitators to the implementation of evidence-based services were: (1) the adaptability of the intervention to the healthcare context, (2) the role of rehabilitation assistants and (3) cross-service working arrangements. Perceived challenges included: (1) lack of clarity regarding the referral decision making process, (2) delays in securing social care input and (3) lack of appropriate follow-on services in the region. Most respondents perceived the impact of the services to be: (1) reducing in-hospital stay, (2) aiding the seamless transfer of care from hospital to the community and (3) providing intensive stroke specific therapy. Commissioners called for greater evidence of service impact and clarity regarding where it fits into the stroke pathway. Early Supported Discharge services were perceived as successful in providing home-based, stroke specific rehabilitation. Teams would benefit from capitalising on identified facilitators and developing strategies to address the challenges. The remit and impact of the services should be clear and demonstrable, with teams strengthening links with other health and social care providers.
Publisher: SAGE Publications
Date: 21-06-2020
Abstract: To determine the feasibility of recruiting to and delivering a biopsychosocial intervention for carers of stroke survivors. Feasibility randomised controlled study with nested qualitative interview study. The intervention was delivered in the community in either a group or one-to-one format. Carers and stroke survivors within one year of stroke onset. A carer targeted intervention delivered by a research psychologist in six structured two-hour sessions or usual care control. The intervention combined education about the biological, psychological and social effects of stroke with strategies and techniques focussing on adjustment to stroke and caregiving. Stroke survivors in both groups received baseline and follow-up assessment but no intervention. Recruitment rate, study attrition, fidelity of intervention delivery, acceptability and sensitivity of outcome measures used (health related quality of life, anxiety and depression and carer burden six months after randomisation). Of the 257 carers approached, 41 consented. Six withdrew before randomisation. Eighteen participants were randomised to receive the intervention and 17 to usual care. Attendance at sessions was greater when treated one-to-one. Feedback interviews suggested that participants found the intervention acceptable and peer support particularly helpful in normalising their feelings. Thirty participants were assessed at follow-up with improvements from baseline on all health measures for both groups. Our results suggest that a biopsychosocial intervention was acceptable to carers and can be delivered in group and one-to-one formats. Timing of approach and mode of intervention delivery is critical and requires tailoring to the carers in idual needs.
Publisher: Informa UK Limited
Date: 07-10-2021
DOI: 10.1080/09638288.2021.1983043
Abstract: To evaluate different stroke early supported discharge (ESD) services in different geographical settings using cost-consequence analysis (CCA), which presents information about costs and outcomes in the form of a balance sheet. ESD is a multidisciplinary service intervention that facilitates discharge from hospital and includes delivery of stroke specialist rehabilitation at home. Data were collected from six purposively s led services across the Midlands, East and North of England. All services, rural and urban, provided stroke rehabilitation to patients in their own homes. Cost data included direct and overhead costs of service provision and staff travel. Consequence data included service level adherence to an expert consensus regarding the specification of ESD service provision. We observed that the most rural services had the highest service cost per patient. The main costs associated with running each ESD service were staff costs. In terms of the consequences, there was a positive association between service costs per patient and greater adherence to meeting the evidence-based ESD service specification agreed by an expert panel. This study found that rural services were associated with higher costs per patient, which in turn were associated with greater adherence to the expert consensus regarding ESD service specification. We suggest additional resources and costs are required in order for rural services to meet evidence-based criteria.Implications for rehabilitationThe main costs of an early supported discharge (ESD) service for stroke survivors were staff costs and these were positively associated with greater levels of rurality.Greater costs were associated with greater adherence to ESD core components, which has been previously found to enhance the effectiveness of ESD service provision.The cost-consequence analysis provides a descriptive summary for decision-makers about the costs of delivering ESD, suggesting additional resources and costs are required in order for rural services to meet evidence-based criteria.
Publisher: BMJ
Date: 08-2023
DOI: 10.1136/BMJOPEN-2022-071217
Abstract: In the UK, over 20% of stroke survivors leave hospital with severe disability. Limited evidence-based clinical guidance is available to support the rehabilitation of these in iduals. Our previous research has focused on establishing consensus regarding the core components of home-based rehabilitation for this under investigated group. This study explores the barriers of providing rehabilitation and identifies strategies to overcome them. Three focus group interviews were conducted with n=20. The context coding framework was employed to organise the transcribed data and to facilitate inductive and deductive analysis and synthesis. Online, MSTeams, UK. A purposive s le of 20 National Health Service clinical staff participants, from 3 multidisciplinary teams providing home-based stroke rehabilitation for this population (n=7, 6 and 7). High levels of need were reported across multiple domains for survivors including continence, communication and physical function. Interventions often required multiagency collaboration in order to optimise the available resources and specialist skills. There was lack of clarity regarding who was ultimately responsible for providing components of rehabilitation for stroke survivors with severe disability. Teams provide rehabilitation for this population but are insufficiently commissioned or resourced to fully meet their needs. In-complete and disjointed pathways with resultant healthcare inequalities were commonly reported. Teams used a variety of strategies to overcome these barriers and optimise rehabilitation opportunities. These included upskilling a erse range of partners to capitalise on the skills and resources across health, social care and voluntary sector boundaries employing multiagency collaboration. Teams established and engaged networks of stakeholders in order to advocate on behalf of stroke survivors. Collaboration and partnership working is important in the delivery of rehabilitation for stroke survivors with severe disability. Commissioners need to be aware that cross-agency multidisciplinary expertise is required, if rehabilitation opportunities are to be realised and existing health inequalities addressed.
Publisher: SAGE Publications
Date: 03-2013
Abstract: To investigate patients’ and carers’ experiences of Early Supported Discharge services and inform future Early Supported Discharge service development and provision. Semi-structured interviews were completed with 27 stroke patients and 15 carers in the Nottinghamshire region who met evidence-based Early Supported Discharge service eligibility criteria. Participants were either receiving Early Supported Discharge or conventional services. Community stroke services in Nottinghamshire, UK. A thematic analysis process was applied to identify similarities and differences across datasets. Themes specific to participants receiving Early Supported Discharge services were: the home-based form of rehabilitation speed of response intensity and duration of therapy respite time for the carer rehabilitation exercises and provision of technical equipment disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Participants receiving Early Supported Discharge or conventional community services experienced difficulties related to: limited support in dealing with carer strain lack of education and training of carers inadequate provision and delivery of stroke-related information disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Accelerated hospital discharge and home-based rehabilitation was perceived positively by service users. The study findings highlight the need for Early Supported Discharge teams to address information and support needs of patients and carers and to monitor their impact on carers in addition to patients, using robust outcome measures.
Publisher: SAGE Publications
Date: 04-01-2018
Abstract: The objective of this “How to” research series article is to provide guidance on getting started in Health Services Research. The purpose of health services research is to contribute knowledge that can be used to help improve health systems and clinical services through influencing policy and practice. The methods used are broad, have varying levels of rigor, and may require different specialist skills. This paper sets out practical steps for undertaking health services research. Importantly, use of the highlighted techniques can identify solutions to address inadequate knowledge translation or promote greater access to evidence-based stroke care to optimize patient outcomes.
Publisher: SAGE Publications
Date: 16-12-2011
Abstract: To investigate two approaches to treating patients with persistent dressing problems and cognitive difficulties following stroke. Pilot randomized controlled trial. Inpatient stroke rehabilitation service. Seventy consecutive stroke patients with persistent dressing problems and accompanying cognitive difficulties at two weeks after their stroke. Patients were randomly allocated to six weeks of either a systematic neuropsychological approach, based on analysis of dressing problems and further cognitive testing, or to the control group who received conventional (functional) dressing practice. Both groups received treatment three times a week in accordance with two separately prepared manuals. Nottingham Stroke Dressing Assessment (NSDA), Line Cancellation, 10-hole peg transfer test, Object Decision, Gesture Imitation. Patients were assessed at six weeks after randomization by an independent assessor masked to group allocation. Both neuropsychological and functional groups improved performance on the NSDA over the treatment period (31% and 22%, respectively) but there was no significant difference between groups at six weeks. However, the neuropsychological group showed a significantly greater improvement on a line cancellation test of visual neglect ( t(62) = 2.1, P 0.05) and a planned subanalysis for those with right hemisphere damage showed a trend towards better dressing outcome ( P = 0.07, one-tailed). Results demonstrate the potential benefits of a systematic neuropsychological approach to dressing therapy, particularly for patients with right hemisphere damage. This study suggests the need for a phase III study evaluating the efficacy of a systematic neuropsychological approach in treating dressing difficulties, targeting patients with right hemisphere stroke and visuospatial impairments.
Publisher: SAGE Publications
Date: 07-2017
Abstract: The most difficult clinical questions in stroke rehabilitation are “What is this patient’s potential for recovery?” and “What is the best rehabilitation strategy for this person, given her/his clinical profile?” Without answers to these questions, clinicians struggle to make decisions regarding the content and focus of therapy, and researchers design studies that inadvertently mix participants who have a high likelihood of responding with those who do not. Developing and implementing biomarkers that distinguish patient subgroups will help address these issues and unravel the factors important to the recovery process. The goal of the present paper is to provide a consensus statement regarding the current state of the evidence for stroke recovery biomarkers. Biomarkers of motor, somatosensory, cognitive and language domains across the recovery timeline post-stroke are considered with focus on brain structure and function, and exclusion of blood markers and genetics. We provide evidence for biomarkers that are considered ready to be included in clinical trials, as well as others that are promising but not ready and so represent a developmental priority. We conclude with an ex le that illustrates the utility of biomarkers in recovery and rehabilitation research, demonstrating how the inclusion of a biomarker may enhance future clinical trials. In this way, we propose a way forward for when and where we can include biomarkers to advance the efficacy of the practice of, and research into, rehabilitation and recovery after stroke.
Publisher: Informa UK Limited
Date: 06-12-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2011
DOI: 10.1161/STROKEAHA.110.606285
Abstract: Research evidence supporting Early Supported Discharge (ESD) services has been summarized in a Cochrane Systematic Review. Trials have shown that ESD can reduce long-term dependency and admission to institutional care and reduce the length of hospital stay. No adverse impact on the mood or well-being of patients or carers has been reported. With the implementation of many national and international stroke initiatives, we felt it timely to reach consensus about ESD among trialists who contributed to the review. We used a modified Delphi approach with 10 ESD trialists. An agreed list of statements about ESD was generated from the Cochrane review and three rounds of consultation completed. ESD trialists rated statements regarding team composition, model of team work, intervention, and success. Consensus of opinion ( % agreement) was obtained on 47 of the 56 statements. Multidisciplinary, specialist stroke ESD teams should plan and co-ordinate both discharge from hospital and provide rehabilitation in the community. Specific eligibility criteria (safety, practicality, medical stability, and disability) need to be followed to ensure this service is provided for mild to moderate stroke patients who can benefit from ESD. Length of stay in hospital, patient and carer outcome measures and cost, need to be routinely audited. We have created a consensus document that can be used by commissioners and service providers in implementing ESD services. Our aim is to promote the use of recommendations derived from research findings to facilitate successful implementation of stroke services nationally and internationally.
Publisher: Wiley
Date: 12-2001
DOI: 10.1111/J.1469-7793.2001.00651.X
Abstract: 1. The involvement of the motor cortex during human walking was evaluated using transcranial magnetic stimulation (TMS) of the motor cortex at a variety of intensities. Recordings of EMG activity in tibialis anterior (TA) and soleus muscles during walking were rectified and averaged. 2. TMS of low intensity (below threshold for a motor-evoked potential, MEP) produced a suppression of ongoing EMG activity during walking. The average latency for this suppression was 40.0 +/- 1.0 ms. At slightly higher intensities of stimulation there was a facilitation of the EMG activity with an average latency of 29.5 +/- 1.0 ms. As the intensity of the stimulation was increased the facilitation increased in size and eventually a MEP was clear in in idual sweeps. 3. In three subjects TMS was replaced by electrical stimulation over the motor cortex. Just below MEP threshold there was a clear facilitation at short latency (approximately 28 ms). As the intensity of the electrical stimulation was reduced the size of the facilitation decreased until it eventually disappeared. We did not observe a suppression of the EMG activity similar to that produced by TMS in any of the subjects. 4. The present study demonstrates that motoneuronal activity during walking can be suppressed by activation of intracortical inhibitory circuits. This illustrates for the first time that activity in the motor cortex is directly involved in the control of the muscles during human walking.
Publisher: SAGE Publications
Date: 24-12-2012
DOI: 10.1111/J.1747-4949.2012.00974.X
Abstract: Despite the recent advances in stroke rehabilitation research, the translation of research evidence into practice remains a challenge. The purpose of this article is to communicate practical experience and describe research methodologies used to promote change and implementation of stroke rehabilitation research in three international settings. In England, the development of an evidence-based consensus document, combined with qualitative and quantitative methods, was used to promote practice change in community-based stroke services. The Canadian research program involved synthesis of evidence, creation of user friendly information, and development of multimodal knowledge transfer strategies to promote change at an in idual clinician level. Australian researchers followed a multistep process, involving audit and feedback, identification of barriers, and tailored education to improve implementation of one clinical guideline recommendation. Reducing the evidence–practice gap requires the development of active management strategies. This article highlights the importance of close collaboration between stakeholders – both in terms of the transfer of evidence into clinical practice and for optimizing future Phase IV implementation research endeavours.
Publisher: SAGE Publications
Date: 12-02-2013
Abstract: Recovery from stroke requires the provision of specialist rehabilitative care, yet there is a lack of research evidence on optimal methods of delivery and inequitable service provision across countries. Following consensus on Early Supported Discharge, our aim was to define core components of evidence-based community stroke services. We used a modified Delphi approach with a purposive s le of 26 UK-based expert panellists (10 academics, 15 stroke service leads or commissioners, one stroke survivor). Statements based on research literature and policy documents were generated by an independent, mixed academic and service improvement team of nine. In three rounds of consultation panellists indicated their level of agreement with statements. Free text comments were analysed thematically. Consensus of opinion ( % agreement) was obtained on 76 of 80 statements. Panellists agreed that stroke specialist care tailored to clinical need should be provided following discharge from hospital. Flexible care pathways should be commissioned and provided through strategic and collaborative leadership across health and social care. Teams need to deliver stroke specialist rehabilitation, handing over responsibility to non-specialist services when patient rehabilitation goals have been met. Lack of consensus on whether to provide services exclusively for stroke patients and the need of support for carers highlights areas for further research. Consensus on the provision of evidence-based community stroke rehabilitation has been reached. Commissioning services with a clearly defined remit, which can deliver tailored care to in idual stroke patients, is a challenge that needs further exploration.
Publisher: Informa UK Limited
Date: 12-04-2020
Publisher: SAGE Publications
Date: 31-03-2015
Abstract: Randomised controlled trials have shown the benefits of Early Supported Discharge (ESD) of stroke survivors. Our aim was to evaluate whether ESD is still beneficial when operating in the complex context of frontline healthcare provision. We conducted a cohort study with quasi experimental design. A total of 293 stroke survivors (transfer independently or with assistance of one, identified rehabilitation goals) within two naturally formed groups were recruited from two acute stroke units: ‘ESD’ n=135 and ‘Non ESD’ n=158 and 84 caregivers. The ‘ESD’ group accessed either of two ESD services operating in Nottinghamshire, UK. The ‘Non ESD’ group experienced standard practices for discharge and onward referral. Outcome measures (primary: Barthel Index) were administered at baseline, 6 weeks, 6 months and 12 months. The ESD group had a significantly shorter length of hospital stay ( P=0.029) and reported significantly higher levels of satisfaction with services received ( P .001). Following adjustment for age differences at baseline, participants in the ESD group ( n=71) had significantly higher odds (compared to the Non ESD group, n=85) of being in the ⩾90 Barthel Index category at 6 weeks (OR = 1.557, 95% CI 2.579 to 8.733), 6 months (OR = 1.541, 95% CI 2.617 to 8.340) and 12 months (OR 0.837, 95% CI 1.306 to 4.087) respectively in relation to baseline. Carers of patients accessing ESD services showed significant improvement in mental health scores ( P .01). The health benefits of ESD are still evident when evidence based models of these services are implemented in practice.
Publisher: BMJ
Date: 12-2021
DOI: 10.1136/BMJOPEN-2021-052593
Abstract: In the UK, over 20% of patients leaving hospital after a stroke will be severely disabled. Despite this, limited clinical guidance is available to teams tasked with providing support for this complex population at home. Additionally, many areas across the UK are not commissioned to treat this patient cohort, leaving them with no specialist support on discharge. To establish core components of home-based rehabilitation for survivors of stroke with severe disability, based on expert panel consensus. Virtual nominal group technique (vNGT) across the UK. Experts in the field of stroke rehabilitation (n=14) including researchers, clinicians and those with lived experience. Two vNGT were completed using a freely available online platform, Microsoft Teams. The technique’s five stages were completed virtually introduction, silent idea generation, round robin, clarifications and scoring. Statements were analysed for consensus, those achieving consensus underwent content analysis to form rich overarching consensus statements. A combined total of 421 statements achieved positive consensus ( % in agreement), which formed 11 overarching consensus statements. These outline key components of home-based rehabilitation for survivors of stroke with severe disability including the structure and members of the team, as well as the skills and knowledge required. The consensus statements highlight the complexity of managing patients with severe stroke disability following discharge from hospital. This study has the potential to support the provision of services for this patient group, providing a benchmark for commissioners and clinicians as well as setting expectations for stroke survivors and their carers. What remains unknown is how many services currently offer this service to patients with severe disability.
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Rebecca Fisher.