Perceptual problems have been shown to be common following both right and left hemiplegie stroke. These perceptual problems affect the patients' responses to rehabilitation and their ability to perform activities of daily living

(ADL),',5-11 suggesting that they should be treated if possible.

Two main approaches to the treatment of perceptual problems, which are suitable for use with adult brain-damaged patients, have been suggested by Zoltan and coworkers.12 These are the transfer of training and functional approaches.

The functional approach is the repetitive practise of particular tasks, usually activities of daily living, in order to make the patient more independent. The emphasis is on treating the symptom rather than the cause of the problem. For example, a patient with spatial relations problems will have difficulty dressing. By practising dressing, the patient will learn to dress but will still have the underlying spatial relations problems. The main advantage of the functional approach is that it is more practical and more understandable to the patient than the transfer of training approach. However, it is only concerned with treating the symptom resulting from a perceptual problem and therefore the patient is still likely to have the perceptual problem.

The main limitation of all the studies which investigated either treatment versus control groups or single-case experimental designs was that they did not include both right and left hemiplegic stroke patients of all ages and that they were mainly concerned with the treatment of neglect/inattention following only one treatment approach. As a result, for the present study, it was decided to include left and right hemiplegic stroke patients of all ages with any perceptual problems, not just neglect/inattention, and to compare the transfer of training and functional approaches in the treatment of these perceptual problems after stroke. The study was designed to represent the treatment likely to be available in normal clinical practice in the UK. Further details about the strategies used in both treatment approaches are to be published in a later article.

The objective of the study was to identify whether the transfer of training or functional approach to the treatment of perceptual problems gave a greater improvement in perceptual ability or functional ability. This was to be carried out by a randomized trial comparing the two treatment approaches.

Patients were selected from those admitted consecutively to the Nottingham Stroke Unit and the inclusion criteria for the study were as follows:

1) Patients had to be well enough to be assessed on the Rivermead Perceptual Assessment Battery8 (RPAB). This included being able to see and hear; being able to understand the English language enough to complete the assessments and follow the instructions; being free of marked psychiatric problems that would affect their ability to complete the RPAB.

2) Patients had to have sufficient functional use of one hand to complete the RPAB and to carry out perceptual. treatment activities, Le. sufficient ability to pick up and move objects/cards with one hand.

3) Patients had to give consent to participate in the treatment. If patients were unable to give verbal consent, permission for them to enter the study was sought from their nearest relative. Consent to participation in this study was then documented in the patients' medical. notes.

 

The procedure of the study was as follows (see flow chart in Figure 1):

1) All patients admitted to the Stroke Unit were assessed on the Stroke Unit by the ward occupational therapist (OT) or the research

OT, for perceptual ability using the full RPAB and for ADL ability using the Barthel ADL Index15 using the scoring by Collin et al.36 and Edmans ADL Index~31 within two weeks of admission to the Stroke Unit. This was completed by nonrandomized allocation of patients to the ward OT and research OT. Previous inter-rater reliability studies had shown good inter-rater reliability between these two raters. The ward physiotherapist assessed all patients on the Rivermead Motor Assessment (RMA) - Gross Function scale,38 on admission to the Stroke Unit.

2)Perceptual problems were identified on the basis of having a score which was two standard deviations or more below the mean on four or more subtests of the RPAB. If perceptual problems were identified, an explanation was, given to the patient about what these problems were and how they might affect the patient in everyday life. An explanation of the study was given and consent obtained.

3) When consent had been obtained, patients were then randomly allocated to either the transfer of training or functional approach for perceptual treatment. Envelopes had been prepared prior to the start of the study by the research OT with numbers taken from random number tables. Odd numbers signified that patients would follow the transfer of training approach and even numbers signified that patients would follow the functional approach. This was continued until there were 40 patients in each group.

4) Perceptual treatment was given for two and a half hours per week for six weeks, in addition to their general OT treatment. The perceptual treatment was given by a combination of the research OT and ward OT. The amount of treatment time was chosen as this was thought to be a realistic amount achievable in normal clinical practice.

5) Details for each patient of every attendance for any OT treatment were recorded in an OT register by the ward OT. The amount of time spent on each treatment was also recorded in this register, in terms of number of half hour units.

However, the ability to complete the RPAB and to respond to treatment, may be influenced by factors other than perceptual ability. Therefore to identify these problems and to investigate their effect, the results of the other assessments used by the physiotherapists, speech and language therapist and psychologist were then collated by the research OT. The assessments were chosen as those already being routinely carried out by the Stroke Unit staff of each discipline, most of which had evidence of validity and reliability. These assessments included clinical assessment by the speech and language therapist of auditory comprehension, expressive language, articulatory dyspraxia, reading comprehension and dysarthria; sensory assessment by the physiotherapist using the Nottingham Sensory Assessment l'; cognitive assessment by the psychologist of premorbid IQ level using the Shortened National Adult Reading, TeSt40,41 memory using the Wechsler Memory Scale - Revised ~42 reasoning using Word Fluency from the Multilingual Aphasia Examination 43 and Cognitive EstimateS~44 limb dyspraxia using the apraxia test by Kertesz and Ferro41 and anxiety and depression using the Hospital Anxiety and Depression Scale .41

The patients were identified from those admitted to the Nottingham Stroke Unit between May 1992 and July 1994, excluding February and March 1994, when the ward OT was on sick leave. During this time 158 patients were admitted. There were 80 suitable patients for the study.

Seventy eight patients were excluded for the following reasons: 63 had no perceptual problems, nine were transferred back to medical, surgical or health care of the elderly wards before assessment and random allocation, one did not have a stroke, one had a marked psychiatric overlay, three did not understand English and one died. The selection of suitable patients took 25 months to complete.

No patients withdrew from the study but one patient (in the functional approach group) died before completing his six weeks of perceptual treatment.

The biographical characteristics and impairments of the patients in each treatment group are shown in Table 1.

Comparison of these characteristics between the two treatment groups showed no significant difference using a t-test on age (t = 0.82, p > 0.05), using chi-squared tests on sex, side of stroke, handedness, presence of a carer, IQ level, presence of dysphasia, dysarthria, articulatory dyspraxia, reasoning problems, memory problems, depression, anxiety, limb dyspraxia, sensory problems (chi-squared = 0.00-1.47, p > 0.05).

There was a significant difference between groups using t-tests on time post stroke to entry to the study (t = 2.12, p < 0.05) with the transfer of training group patients being slightly longer post stroke than the functional group.

Mann-Whitney U-tests were used to determine the probability of a difference occurring by chance between the transfer of training and functional groups on initial and final RPAB total scores, Barthel ADL Index and Edmans ADL

Index total scores, and RMA gross function scores. The results are shown in Table 3.

These showed no significant difference between groups on initial or final RPAB total scores, Barthel ADL Index or Edmans ADL Index total scores, or gross function scores.

If a patient scored two standard deviations or more below the mean of the normal sample in the RPAB manual on individual RPAB subtests, a criterion score of 1 was given for that subtest.

The numbers of patients in each group scoring below their expected levels (criterion levels) on individual RPAB subtests on the initial and final assessment are shown in Table 4.

The investigation of individual. subtests of the RPAB, comparing the initial and final assessments for the transfer of training group and then the functional group, again showed that both groups had a similar pattern. of test scores. In both groups, right/left copying shapes, right/left copying words and cube copying were the most difficult tasks. To compare the difference between initial and final assessments for each group, Wilcoxon matched pairs, signed ranks testswere calculated between the individual RPAB subtest scores on initial and final assessments. for each treatment group. Details are shown in Table 6.

The transfer of training group showed a significant improvement (z = 2.01-3.33, p < 0.05-0.001) between initial and final assessments on all except five subtests (picture matching, series, animal halves, missing artiele and 3D copying) (z = 0.7,9-1.85, p > 0.05).

The functional group showed a significant improvement (z = 1.99-3.71, p < 0.05-0.001) between initial and final assessments on all except seven subtests (colour matching, size recognition, animal halves, missing artiele, sequencing pictures, 3D copying and self-identification) (z = 1.11-1.86, p > 0.05).

The perceptual and functional total scores were compared between initial and final assessments for all patients (n = 80). Wilcoxon matched pairs signed ranks tests were calculated between initial and final assessments for RPAB, Barthel ADL Index (as assessed by nurses and OTs),

Edmans ADL Index (as assessed by nurses and OTs) and RMA gross function total scores. The RPAB total scores showed a highly significant improvement over time (z = 6.02, p < 0.001) as did the Barthel ADL Index total scores (nurses, z = 6.72, p < 0.001, OT, z = 7.20, p < 0.001), Edmans ADL Index (nurses, z = 7.01, p < 0.001, OT, z = 7.65, p < 0.001) and RMA gross function (z = 6.62, p < 0.001).

Although these results showed a highly significant change over time, some patients' perceptual ability improved and some deteriorated or remained at the initial level.

The number of patients whose criterion total score (i.e. the number of RPAB subtests in which the patient scored below their expected level) improved or did not improve over the six weeks was investigated.

This showed that 27 transfer of training group patients and 25 functional group patients (65%) improved, whilst 13 transfer of training group patients and 15 functional group patients (35%) did not improve. There was no significant difference between treatment groups in the proportion that improved or did not improve (chi-squared = 0.22, p > 0.05). Details concerning the differences between the improvers and the nonimprovers are to be published in a later paper.

It is important to the rehabilitation of stroke patients to know whether the presence of perceptual problems has any effect on functional performance. Therefore, to identify the relationship between perceptual and functional abilities, Spearman rank correlation coefficients were calculated between the RPAB total scores and the Barthel ADL Index and Edmans ADL Index total scores on initial and final assessments for all patients (n = 80).

These indicated a highly significant relationship between perceptual and ADL abilities on both initial and final assessments. Details are shown in Table 7.

As previously mentioned, it has been shown that perceptual problems affect the patients' response to rehabilitation. This current study also showed a highly significant correlation between perceptual and functional abilities, which although correlation does not imply cause, suggests that maybe it is not possible to treat one without affecting the other, Le. treatment of perceptual problems may affect functional ability and treatment of functional difficulties may affect perceptual ability.

The choice of strategies used in treatment may have been a reason for this lack of difference between the two treatment approaches. The basic strategies used in treatment were similar for both groups. This included strategies such asprogressing from simple to complex tasks; staging components of each task; the choice of instructions, cues or prompts; and the use of demonstration, imitation, gesture, repetition, reinforcement, mental stimulation and a systematic method. It may be that the choice of the strategies used in treatment has more effect than the approaches to treatment. In other words, it may be more important to decide how treatment is to be given rather than what treatment is to be given.

Another reason could be either that there is no difference between the two approaches or that there were insufficient subjects in each group to show a difference. Maybe a difference would have been found between treatment approaches if larger numbers of patients had been included.

The significant improvement in perceptual scores achieved by patients in earlier treatment group may have been because the treatments were effective in treating these problems. It could also have been due to differences in scoring by the different assessors, Le. between the ward OT, research OT and independent assessor. However, inter-rater reliability studies on the scoring between the ward OT and research OT, and between the ward OT and independent assessor, prior to the start of the study showed there was good inter-rater reliability on all subtests of the RPAB. Inter-rater differences in scoring were therefore not responsible for the apparent improvement in scores.

Another factor that may affect the assessment of patients and the apparent improvement over the six weeks is spontaneous recovery. Motor and functional recovery is generally considered to be greatest during the first three months. after a stroke. However, it is uncertain whether spontaneous recovery affects perceptual ability in the same way. The current study showed that patients achieved a significant improvement in both perceptual and functional abilities over the six weeks. These patients ranged from 14 to 84 days post stroke, i.e. 2-12 weeks, suggesting that they may be -at a stage to achieve maximum spontaneous recovery.

The apparent improvement that patients made in perceptual ability in the current study may have been due to other treatments or general multidisciplinary treatment. A major limitation of this study was that it was carried out on a specialist stroke unit. On the Nottingham Stroke Unit, staff of all disciplines and grades had previously been taught what perceptual problems were, how to recognize them and how to adapt their treatment and care of these patients according to the perceptual problems identified. Consequently, the Nottingham Stroke Unit staff of all disciplines and grades had a heightened awareness of perceptual problems and their treatment, resulting in staff adapting their treatment accordingly.

This intensive multidisciplinary treatment received by patients whilst on the Stroke Unit made it more difficult to show the effectiveness of only one aspect of a patients' treatment. In hindsight, it may have been better to carry out this study on a different ward where staff had less knowledge of perceptual problems or when the patients were outpatients and therefore receiving less rehabilitation.

Ethical approval had been given to carry out this study to compare the two treatment approaches. However, prior to this study, perceptual treatment was normally offered to patients on this Stroke Unit. It was therefore considered unethical to withdraw this treatment to permit a control group to be studied. The monitoring of a control group would have provided information for comparison with the treatment groups.

We would like to thank the Stroke Association for funding this study, through a project grant to JA Edmans. We would also like to thank the staff of the Division of Stroke Medicine, University of Nottingham, for their support throughout the study.

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