Effectiveness of Virtual Reality- and Gaming-Based Interventions for Upper Extremity Rehabilitation Poststroke: A Meta-analysis.

OBJECTIVE: To investigate the efficacy of virtual reality (VR)- and gaming-based interventions for improving upper extremity function poststroke, and to examine demographic and treatment-related factors that may moderate treatment response. DATA SOURCES: A comprehensive search was conducted within the PubMed, CINAHL/EBSCO, SCOPUS, Ovid MEDLINE, and EMBASE databases for articles published between 2005 and 2019. STUDY SELECTION: Articles investigating gaming and VR methods of treatment for upper extremity weakness were collected with the following study inclusion criteria: (1) participants aged 18 years or older with upper extremity deficits; (2) randomized controlled trials or prospective study design; (3) Downs-Black rating score of ≥18; and (4) outcome measure was the Wolf Motor Functioning Test, the Fugl-Meyer, or the Action Research Arm Test. DATA EXTRACTION: Thirty-eight articles met inclusion criteria. The primary outcome was proportional improvement on the Wolf Motor Functioning Test, Fugl-Meyer, or Action Research Arm Test. The following individual or treatment factors were extracted: VR or gaming dose, total treatment dose, chronicity (> or <6mo), severity of motor impairment, and presence of a gaming component. DATA ANALYSIS: Random effects meta-analysis models were utilized to quantify (1) the proportional recovery that occurs after VR or gaming; (2) the comparative treatment effect of VR or gaming vs conventional physiotherapy; and (3) whether the benefit of virtual reality differed based on participant characteristics or elements of the treatment. RESULTS: On average, VR or gaming interventions produced an improvement of 28.5% of the maximal possible improvement. Dose and severity of motor impairment did not significantly influence rehabilitation outcomes. Treatment gains were significantly larger overall (10.8%) when the computerized training involved a gaming component vs just visual feedback. VR or gaming interventions showed a significant treatment advantage (10.4%) over active control treatments. CONCLUSIONS: Overall, VR- or gaming-based upper extremity rehabilitation poststroke appears to be more effective than conventional methods. Further in-depth study of variables affecting improvement, such as individual motor presentation, treatment dose, and the relationship between them, are needed.

Prophylactic efficacy of fluoxetine, escitalopram, sertraline, paroxetine, and concomitant psychotherapy in major depressive disorder: outcome after long-term follow-up.

The acute efficacy of selective serotonin reuptake inhibitors (SSRIs) in the treatment of major depressive disorder (MDD) is well established; however their role in longer-term prevention of recurrence remains unconfirmed. This study aims at examining: the prophylactic efficacy of four commonly used SSRIs in MDD in a naturalistic setting with long-term follow-up, the effect of concomitant cognitive behavioral therapy (CBT), and the predictors of outcome. In a prospective cohort study, 387 patients who either remitted or responded following treatment with four different SSRIs-fluoxetine, escitalopram, sertraline and paroxetine-were followed up over several years. During an average follow-up period of 34.5 months, 76.5% of patients experienced MDD recurrence. Escitalopram and fluoxetine showed a numerically higher prophylactic efficacy than paroxetine and sertraline but the difference was statistically insignificant. The prophylactic efficacy for SSRI-only treatment was limited, with a recurrence rate of 82.0%, compared to 59.0% of patient recurrence rate in concomitant Cognitive Behavioral Therapy (CBT). The relatively small size of the CBT group and the lack of randomization may undermine the extrapolation of its findings to clinical practice. Nevertheless, the study preliminary data may help in defining the clinical utility of antidepressants and CBT in the prophylaxis from MDD recurrence.

The discrepancy between patients and informants on clinician-rated measures in major depressive disorder: implications for clinical trials and clinical practice.

Clinician-rated measures are used in clinical trials and measurement-based clinical care settings to assess baseline symptoms and treatment outcomes of major depressive disorder (MDD), with a widely held dictum that they are sufficient in assessing the patient's clinical status. In this study, we examined clinician-rated measures of depressive and global symptom severity, obtained by interviewing patients as well as informants in an attempt to examine the potential difference or similarity between these two sources of information. The sample consisted of 89 treatment seeking, DSM-IV diagnosed MDD outpatients treated between 1995 and 2004. The clinician-rated measures used included the Montgomery Åsberg Depression Rating Scale (MADRS), and the Clinical Global Impression Scale (CGI) for Severity. The scores of the clinician-rated measures collected from patients' interviews were compared with those collected from informants' interviews. Clinician-rated scores, collected by interviewing patients, were significantly higher and indicative of greater symptom severity when compared with those collected by interviewing informants. This was true for both the MADRS before (P<0.0001) and after treatment scores (P<0.0001), as well as the CGI before (P<0.0001) and after treatment scores (P<0.0001). Consistently involving informants and the time/burden it takes for them to participate might not be practical in MDD clinical trials or everyday clinical care. The discrepancies observed between the clinician-rated scores obtained from patients and informants emphasize the importance of incorporating collateral information during the assessment and rating of depressive symptom severity in both clinical trials as well as in clinical practice.