Research project: Development of an integrated service model incorporating innovative technology for the rehabilitation of the upper limb following stroke, (Assistive Technologies in Rehabilitation Following Stroke (ATRAS)

NIHR Programme Grant study

The aim of this integrated programme of research is to provide an evidence-based clinical service for upper limb rehabilitation for people who have had a stroke and will focus on the rehabilitation they receive in the first year. In England over 110,000 people a year have a stroke and over 300,000 people are disabled as a result. Two recent Department of Health documents, the National Stroke Strategy and the National Service Frameworks (NSF), emphasise the benefits of specialist inpatient rehabilitation forming an essential link in the facilitation of patients back into the community, thus enabling them to participate in society. The National Stroke Strategy highlights that only 50 % of people receive sufficient rehabilitation in the first 6 months after their stroke and only 20% in the next 6 months. In the upper limb approximately half of all patients who start a rehabilitation programme will have marked impairment of the hemiplegic arm with only 14% regaining useful function. Improvement in the current services for upper limb rehabilitation following stroke (ULRFS) will be achieved by introducing innovative treatment modalities into clinical practice.

Recently a number of approaches for ULRFS have utilised Assistive Technologies (ATs) rather than conventional physiotherapy. ATs are defined as ‘any product or service designed to enable independence for disabled and older people’ [1], and includes; botulinum toxin, constraint induced movement therapy, functional electrical stimulation, orthotics, biofeedback and robotics. There are few structured reviews of ATs or clinical trials assessing combinations of these different modalities to enable them to be incorporated into evidence based care pathways.

In the first two years of this programme the research team will simultaneously determine; the current provision of services for ULRFS in England, the ATs that exist and the evidence to support them via systematic reviews and through consultation (an interactive exhibition, focus groups and questionnaires) with people who have had a stroke, their carers, health professionals and those purchasing and providing health services, we aim to understand the benefits and barriers to new technologies being used in the NHS from the ‘users’ perspective. This information will then be used to determine which AT or combination of ATs has the greatest probability of significantly improving ULRFS, is cost effective and acceptable for use by patients and in the NHS. A repeated measures; multi-centre clinical trial will be designed to determine whether the combination of ATs is significantly better than each in isolation. Economic evaluation will be an integral component of this trial so that any new care pathway proposed, based on the results of the trial, can be compared with existing services. The survey of current treatments and the systematic literature review will be updated annually and at the conclusion of the trial will be used in combination with the trial results to develop the new care pathway. This approach will ensure that the care pathway is evidence based, cost effective and relevant to the NHS. The final, essential objective of this programme is to ensure that the results of this programme are disseminated throughout the NHS and patient groups. Papers will be submitted to high impact journals and presentations will be made at key scientific meetings. An international conference will be organised to present the results of the entire programme. One key outcome is the design and delivery of specific training courses for NHS staff to enable them to deliver the new care pathway. Two such courses will run at the end of the funding period.

The multidisciplinary research team, comprising of Stroke and Rehabilitation physicians, therapists and clinical engineers from both the NHS and universities, is well qualified in both quantitative and qualitative research and is able to deliver this ambitious programme within the specified time frame. The core of the team worked together on the EU funded Thematic Network, SPASM, which objectively assessed methods of quantifying spasticity.  In addition three research fellows are required throughout the five year programme and four therapists are needed to undertake the treatment aspects of the clinical trial. Research governance and methodological expertise are an essential component of this programme and will be provided by the Salisbury R&D Office, and the Wessex Institute (health economics) and Clinical Trials Unit at Southampton University. The team has considerable experience of translating research findings into changes in clinical practice, developing innovative treatment regimes and establishing and delivering training courses.

A Steering Committee of national and international experts has been appointed and will oversee the programme. User involvement is a key component and The Stroke Association and Different Strokes have been involved throughout the design of this application and will be represented on the Steering Committee. They will be actively involved recruiting patients and carers, and disseminating information to ensure that the outcomes of the programme meet the needs of patients and their members.

Project team

Dr Ann-Marie Hughes, Dr Sara Demain, Lisa Tedesco-Triccas, Ruth Turk, Prof Lucy Yardley (Psychology), Dr Paul Chappell (Faculty of Physical and Applied Sciences, University of Southampton)

External staff

Professor Ian Swain (PI), Dr Anand Pandyan (University of Keele), Dr Damian, Jenkinson (Bournemouth and Christchurch Hospital), Dr Caroline Ellis-Hill (Bournemouth University)

Affiliated groups

National Clinical FES Centre (Salisbury NHS Foundation Trust)
Rehabilitation and Health Technologies (RHT)
University of Keele
University of Bournemouth
Bournemouth and Christchurch Hospital

Project funder

NIHR