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Rehabilitation providers and policymakers need valid evidence to make informed decisions about the healthcare needs of the population. Whenever possible, these decisions should be informed by randomized controlled trials (RCTs). However, there are circumstances when evidence needs to be generated rapidly, or when RCTs are not ethical or feasible. These situations apply to studying the effects of complex interventions, including rehabilitation as defined by Cochrane Rehabilitation. Therefore, we explore using the target trial emulation framework by Hernán and colleagues to obtain valid estimates of the causal effects of rehabilitation when RCTs cannot be conducted. Target trial emulation is a framework guiding the design and analysis of non-randomized comparative effectiveness studies using observational data, by emulating a hypothetical RCT. In the context of rehabilitation, we outline steps for applying the target trial emulation framework using real world data, highlighting methodological considerations, limitations, potential mitigating strategies, and causal inference and counterfactual theory as foundational principles to estimating causal effects. Overall, we aim to strengthen methodological approaches used to estimate causal effects of rehabilitation when RCTs cannot be conducted.
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Pesquisa Comparativa da Efetividade , Ensaios Clínicos Controlados Aleatórios como Assunto , Reabilitação , HumanosRESUMO
This article was published in volume 58, issue 6 of publishing year 2022, with a mistake in Table II. The correct Table II is the one included in this erratum.
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This study aimed to synthesize evidence from studies that addressed the influence of bias domains in randomized controlled trials on rehabilitation intervention effect estimates and discuss how these findings can maximize the trustworthiness of an RCT in rehabilitation. We screened studies about the influence of bias on rehabilitation intervention effect estimates published until June 2023. The characteristics and results of the included studies were categorized based on methodological characteristics and summarized narratively. We included seven studies with data on 227,806 RCT participants. Our findings showed that rehabilitation intervention effect estimates are likely exaggerated in trials with inadequate/unclear sequence generation and allocation concealment when using continuous outcomes. The influence of blinding was inconsistent and different from the rest of medical science, as meta-epidemiological studies showed overestimation, underestimation, or neutral associations for different types of blinding on rehabilitation treatment effect estimates. Still, it showed a more consistent pattern when looking at patient-reported outcomes. The impact of attrition bias and intention to treat has been analyzed only in two studies with inconsistent results. The risk of reporting bias seems to be associated with overestimation of treatment effects. Bias domains can influence rehabilitation treatment effects in different directions. The evidence is mixed and inconclusive due to the poor methodological quality of RCTs and the limited number and quality of studies looking at the influence of bias and treatment effects in rehabilitation. Further studies about the influence of bias in RCTs on rehabilitation intervention effect estimates are needed.
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Ensaios Clínicos Controlados Aleatórios como Assunto , Humanos , Viés , Estudos EpidemiológicosRESUMO
OBJECTIVE: This study aims to establish the effect of electromagnetic diathermy therapies (e.g., shortwave, microwave, capacitive resistive electric transfer) on pain, function, and quality of life in treating musculoskeletal disorders. METHODS: We conducted a systematic review according to the PRISMA statement and Cochrane Handbook 6.3. The protocol has been registered in PROSPERO: CRD42021239466. The search was conducted in PubMed, PEDro, CENTRAL, EMBASE, and CINAHL. RESULTS: We retrieved 13,323 records; 68 studies were included. Many pathologies were treated with diathermy against placebo, as a standalone intervention or alongside other therapies. Most of the pooled studies did not show significant improvements in the primary outcomes. While the analysis of single studies shows several significant results in favour of diathermy, all comparisons considered had a GRADE quality of evidence between low and very low. CONCLUSIONS: The included studies show controversial results. Most of the pooled studies present very low quality of evidence and no significant results, while single studies have significant results with a slightly higher quality of evidence (low), highlighting a critical lack of evidence in the field. The results did not support the adoption of diathermy in a clinical context, preferring therapies supported by evidence.
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INTRODUCTION: Until the last update in February 2022, the Cochrane Rehabilitation COVID-19 Evidence-based Response (REH-COVER) action identified an increasing volume of evidence for the rehabilitation management of COVID-19. Therefore, our aim was to identify the best available evidence on the effectiveness of interventions for rehabilitation for COVID-19-related limitations of functioning of rehabilitation interest in adults with COVID-19 or post COVID-19 condition (PCC). EVIDENCE ACQUISITION: We ran the searches on February 17th, 2023, in the following databases: PubMed, EMBASE, CENTRAL, CINHAL, and the Cochrane COVID-19 Study Register, applying a publication date restriction to retrieve only papers published in 2022. To retrieve papers published before 2022, we screened the reference lists of previous publications included in the REH-COVER action, covering papers from early 2020 to the end of 2022. This current review includes only randomised controlled trials and concludes the rapid living systematic reviews of the Cochrane Rehabilitation REH-COVER action. The risk of bias and certainty of evidence were evaluated in all studies using the Cochrane Risk of Bias tool and GRADE, respectively. We conducted a narrative synthesis of the evidence. PROSPERO registration number: CRD42022374244. EVIDENCE SYNTHESIS: After duplicate removal, we identified 18,950 individual records and 53 RCTs met the inclusion criteria. Our findings suggest that the effect of breathing and strengthening exercise programs on dyspnea and physical exercise capacity compared to no treatment in non-severe COVID-19 patients is uncertain. Multicomponent telerehabilitation may slightly increase physical exercise capacity compared to educational intervention in adults with PCC. There is, however, uncertainty about its effect on lung function and physical exercise capacity when compared to no treatment. Finally, the effect of inspiratory muscle training on maximal inspiratory pressure compared to no treatment in adults with PCC is uncertain. CONCLUSIONS: Interventions that are part of comprehensive pulmonary rehabilitation approaches may benefit dyspnea and exercise tolerance in adults with COVID-19 and PCC. The available evidence has several methodological limitations that limit the certainty of evidence and the clinical relevance of findings. Therefore, we cannot provide robust suggestions for practice. While high-quality RCTs are being conducted, clinicians should consider using high-quality evidence from other pulmonary conditions to rehabilitate patients with COVID-19 or PCC using context-specific interventions.
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COVID-19 , Humanos , Doença Crônica , COVID-19/epidemiologia , COVID-19/reabilitação , Dispneia , Exercício Físico , Modalidades de FisioterapiaRESUMO
INTRODUCTION: Rehabilitation focuses on impairments, activity limitations and participation restrictions being informed by the underlying health condition. In the current absence of direct "evidence on" rehabilitation interventions for people with post-COVID-19 condition (PCC), we can search and synthesize the indirect "evidence relevant to" coming from interventions effective for the symptoms of PCC in other health conditions. The World Health Organization (WHO) required this information to inform expert teams and provide specific recommendations in their Guidelines. With this overview of reviews with mapping, we aimed to synthesize in a map the Cochrane evidence relevant to rehabilitation for fatigue, post-exertional malaise and orthostatic intolerance due to PCC. EVIDENCE ACQUISITION: We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "fatigue," "orthostatic intolerance," "rehabilitation" and their synonyms in the Cochrane Library. We extracted and summarized the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence. EVIDENCE SYNTHESIS: Out of 1397 CSRs published between 2016 and 2021, we included 32 for fatigue and 4 for exercise intolerance. They provided data from 13 health conditions, with cancer (11 studies), chronic obstructive pulmonary disease (7 studies), fibromyalgia (4 studies), and cystic fibrosis (3 studies) being the most studied. Effective interventions for fatigue included exercise training and physical activities, telerehabilitation and multicomponent and educational interventions. Effective interventions for exercise intolerance included combined aerobic/anaerobic training and integrated disease rehabilitation management. The overall quality of evidence was low to very low and moderate in very few cases. We did not identify CSRs that specifically addressed post-exertional malaise or orthostatic intolerance. CONCLUSIONS: These results are the first step of indirect evidence able to generate helpful hypotheses for clinical practice and future research. They served as the basis for the three recommendations on treatments for these PCC symptoms published in the current WHO Guidelines for clinical practice.
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COVID-19 , Fibromialgia , Intolerância Ortostática , Humanos , Exercício Físico , Fadiga , Fibromialgia/terapia , Qualidade de Vida , Revisões Sistemáticas como AssuntoRESUMO
INTRODUCTION: Rehabilitation focuses on impairments, activity limitations and participation restrictions being informed by the underlying health condition. In the current absence of direct "evidence on" rehabilitation interventions for people with post COVID-19 condition (PCC), we can search and synthesize the indirect "evidence relevant to" coming from interventions effective on the symptoms of PCC in other health conditions. The World Health Organization (WHO) required this information to inform expert teams and provide specific recommendations in its Guidelines. With this overview of reviews with mapping we aimed to synthesize the Cochrane evidence relevant to rehabilitation for arthralgia due to PCC in a map. EVIDENCE ACQUISITION: We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "arthralgia," "joint pain," and "rehabilitation" and their synonyms in the Cochrane Library. We extracted and summarized all the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence. EVIDENCE SYNTHESIS: We found 200 CSRs published between 2016 and 2021, and included 11 in this overview. They provided data from 7 health conditions, with osteoarthritis (5 studies) being the most studied. Effective rehabilitation interventions included exercise training, transcranial magnetic stimulation, different types of electrical stimulation and Tai chi. The overall quality of evidence was mainly low to very low, and moderate in a few cases. CONCLUSIONS: These results provided the requested information to the WHO and served as the basis for one recommendation on treatments for arthralgia due to PCC in the current Guidelines for clinical practice. These results should be interpreted as a first step of indirect evidence able to generate helpful hypotheses for future research.
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Artralgia , COVID-19 , Humanos , Revisões Sistemáticas como AssuntoRESUMO
BACKGROUND: Robot-assisted arm therapy (RAT) has been used mainly in stroke rehabilitation in the last 20 years with rising expectations and growing evidence summarized in systematic reviews (SRs). OBJECTIVE: The aim of this study is to provide an overview of SRs about the effectiveness, within the ICF domains, and safety of RAT in the rehabilitation of adult with stroke compared to other treatments. METHODS: The search strategy was conducted using search strings adapted explicitly for each database. A screening base on title and abstract was realized to find all the potentially relevant studies. The methodological quality of the included SRs was assessed using AMSTAR-2. A pre-determined standardized form was used to realize the data extraction. RESULTS: 18 SRs were included in this overview. Generally, positive effects from the RAT were found for motor function and muscle strength, whereas there is no agreement for muscle tone effects. No effect was found for pain, and only a SR reported the positive impact of RAT in daily living activity. CONCLUSION: RAT can be considered a valuable option to increase motor function and muscle strength after stroke. However, the poor quality of most of the included SRs could limit the certainty around the results.
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Robótica , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral , Humanos , Braço , Revisões Sistemáticas como AssuntoRESUMO
INTRODUCTION: Currently, no evidence exists on specific treatments for post COVID-19 condition (PCC). However, rehabilitation interventions that proved effective for similar symptoms in other health conditions could be applied to people with PCC. With this overview of systematic reviews with mapping, we aimed to describe the Cochrane evidence on rehabilitation interventions proposed for dysphagia, dysphonia and olfactory dysfunction in different health conditions that can be relevant for PCC. EVIDENCE ACQUISITION: We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "dysphagia," "swallowing disorder," "dysphonia," "voice disorder," "olfactory dysfunction," "smell changes" and "rehabilitation" in the Cochrane Library. We extracted and summarized the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence. EVIDENCE SYNTHESIS: We found 170 CSRs published between 2016 and 2021 and 1 was included. It provided data on dysphagia in acute and subacute stroke. Interventions included were acupuncture, neuromuscular electrical stimulation, transcranial magnetic stimulation and behavioral interventions, and swallowing therapy, with very low- to moderate-quality evidence. We did not find any CSR on dysphonia and olfactory disease. CONCLUSIONS: These results are the first step of indirect evidence able to generate helpful hypotheses for clinical practice and future research. They served as the basis for the three recommendations on treatments for these PCC symptoms published in the current WHO Guidelines for clinical practice.
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COVID-19 , Transtornos de Deglutição , Disfonia , Transtornos do Olfato , Humanos , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/reabilitação , Disfonia/etiologia , Transtornos do Olfato/etiologia , Revisões Sistemáticas como AssuntoRESUMO
INTRODUCTION: Currently, no evidence exists on specific treatments for post COVID-19 condition (PCC). However, rehabilitation interventions that are effective for similar symptoms in other health conditions could be applied to people with PCC. With this overview of systematic reviews with mapping, we aimed to describe the Cochrane evidence on rehabilitation interventions proposed for cognitive impairment, anxiety and depression in different health conditions that can be relevant for PCC. EVIDENCE ACQUISITION: We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "cognitive impairment," "depressive disorder," "anxiety disorder," their synonyms and variants, and "rehabilitation" in the Cochrane Library. We extracted and summarized the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence. EVIDENCE SYNTHESIS: We found 3596 CSRs published between 2016 and 2021, and we included 17 on cognitive impairment and 37 on anxiety and depression. For cognitive impairment, we found 7 CSRs on participants with stroke, 3 with cancer, 2 with Parkinson's disease, and one each for five other health conditions. Each intervention improved a different domain, and included exercises, cognitive and attention-specific training, and computerized cognition-based training (from very low to high-quality evidence). For anxiety and depression, we found 10 CSRs including participants with cancer, 8 with stroke, 3 with chronic obstructive pulmonary disease, and 2 or 1 each in 11 other health conditions. Exercise training, physical activity and yoga resulted effective in several pathologies (very low- to moderate-quality evidence). In specific diseases, we found effective acupuncture, animal-assisted therapy, aromatherapy, educational programs, home-based multidimensional survivorship programs, manual acupressure massage, memory rehabilitation, non-invasive brain stimulation, pulmonary rehabilitation, and telerehabilitation (very low- to moderate-quality evidence). CONCLUSIONS: These results are the first step of indirect evidence able to generate helpful hypotheses for clinical practice and future research. They served as the basis for the three recommendations on treatments for these PCC symptoms published in the current WHO Guidelines for clinical practice.
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Terapia Assistida com Animais , COVID-19 , Disfunção Cognitiva , Neoplasias , Acidente Vascular Cerebral , Humanos , Ansiedade/etiologia , Transtornos de Ansiedade , Disfunção Cognitiva/etiologia , Depressão/etiologia , Depressão/terapia , Revisões Sistemáticas como AssuntoRESUMO
INTRODUCTION: Rehabilitation focuses on impairments, activity limitations and participation restrictions being informed by the underlying health condition. In the current absence of direct "evidence on" rehabilitation interventions for people with post COVID-19 condition (PCC), we can search and synthesize the indirect "evidence relevant to" coming from interventions effective on the symptoms of PCC in other health conditions. The World Health Organization (WHO) required this information to inform expert teams and provide specific recommendations in their Guidelines. With this overview of reviews with mapping we aimed to synthesize in a map the Cochrane evidence relevant to rehabilitation for dyspnea due to PCC. EVIDENCE ACQUISITION: We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "dyspnea" and its synonyms in the Cochrane Library. We extracted and summarized all the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence. EVIDENCE SYNTHESIS: We found 371 CSRs published between 2016 and 2021 and included 15 in this overview. We found eight studies on chronic obstructive pulmonary disease, two on cancer, and one for bronchiectasis, chronic respiratory disease, cystic fibrosis, idiopathic pulmonary fibrosis and interstitial lung disease. Effective interventions included pulmonary rehabilitation, also in combination with exercise training, non-invasive ventilation, upper limb training and multicomponent integrated interventions, with very low- to moderate-quality evidence. CONCLUSIONS: These results are the first step of indirect evidence to generate helpful hypotheses for clinical practice and future research on dyspnea in adults with PCC. They served as the basis for one recommendation on treatments for dyspnea as a PCC symptom published in the current WHO Guidelines for clinical practice.
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Dispneia , Síndrome de COVID-19 Pós-Aguda , Adulto , Humanos , Dispneia/etiologia , Dispneia/reabilitação , Síndrome de COVID-19 Pós-Aguda/complicações , Síndrome de COVID-19 Pós-Aguda/reabilitação , Revisões Sistemáticas como AssuntoRESUMO
BACKGROUND: This review examined the effectiveness of behavioral interventions for adults with post-traumatic stress disorder (PTSD) triggered by physical injury or medical trauma. It discusses implications in support of rehabilitation management for COVID-19 survivors diagnosed with PTSD. METHODS: This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Interim Guidance from the Cochrane Rapid Reviews Methods Group. The authors searched for randomized control trials in PubMed, Embase, and CENTRAL databases up to 31 March 2021. RESULTS: Five studies (n = 459) met the inclusion criteria. Each study measured a different comparison of interventions. The certainty of the evidence was judged to be very low for all outcomes. Post-traumatic stress disorder symptom reduction was found to be in favor of trauma-focused cognitive-behavioral therapy, cognitive therapy, and cognitive-behavioral therapy. Cognitive function improvements were observed in favor of the cognitive processing therapy control intervention. CONCLUSIONS: Overall, there is uncertainty about whether behavioral interventions are effective in reducing PTSD symptoms and improving functioning and quality of life when the disorder is triggered by a physical or medical trauma rather than a psychological trauma. Further research should investigate their efficacy in the context of rehabilitation management and gather evidence on this population.
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COVID-19 , Terapia Cognitivo-Comportamental , Transtornos de Estresse Pós-Traumáticos , Adulto , Terapia Comportamental , Terapia Cognitivo-Comportamental/métodos , Humanos , Qualidade de Vida , Transtornos de Estresse Pós-Traumáticos/psicologiaRESUMO
INTRODUCTION: In experimental trials, new methods are tested against the "best" or "usual" care. To appraise control group (CG) interventions provided as "usual care," we focused on stroke as a leading cause of disability demanding rehabilitation as a complex intervention. EVIDENCE ACQUISITION: For this methodological appraisal, we conducted a systematic review of RCTs without timespan limitation. The PICO included stroke survivors, rehabilitation, control group intervention, lower limb function. To assess the risk of bias, we used the Cochrane risk of bias tool (RoB). We identified the terminology describing the CG Program (CGP), performed a knowledge synthesis and conducted a frequency analysis of provided interventions. EVIDENCE SYNTHESIS: We included 155 publications. 13.6% of the articles did not describe the CG, and 11.6% indicated only the professionals involved. In the remaining 116 studies, three studies provided an intervention according to specific guidelines, 106 different "usual care" CGPs were detected, with nine proposed twice and two between four and five times. The most adopted terminology to state "usual care" was "conventional physiotherapy." CONCLUSIONS: This study shows that usual care in CG does not actually exist, as both specific terminology and consistency within CGP contents are missing. Reporting guidelines should give better assistance on this issue. These results should be verified in other fields.
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Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral , Grupos Controle , Humanos , Reabilitação do Acidente Vascular Cerebral/métodos , SobreviventesAssuntos
COVID-19 , COVID-19/epidemiologia , Humanos , SARS-CoV-2 , Revisões Sistemáticas como AssuntoRESUMO
INTRODUCTION: This paper updates and summarizes the current evidence informing rehabilitation of patients with COVID-19 and/or describing the consequences of the disease and its treatment. EVIDENCE ACQUISITION: Studies published from May 1st to June 30th, 2021 were selected, excluding descriptive studies and expert opinions. Papers were categorized according to study design, research question, COVID-19 phase, limitations of functioning of rehabilitation interest, and type of rehabilitation service involved. From this edition, we improved the quality assessment using the Joanna Briggs Institute checklists for observational studies and the Cochrane Risk of Bias Tool for randomized-controlled clinical trials (RCTs). EVIDENCE SYNTHESIS: Twenty-five, out of 3699 papers, were included. They were three RCTs, 13 cross-sectional studies and nine cohort studies. Twenty studies reported data on symptom prevalence (N.=13) or disease natural history (N.=7); and five studies reported intervention effectiveness at the individual level. All study participants were COVID survivors and 48% of studies collected information on participants 6 months or longer after COVID-19 onset. The most frequent risks of bias for RCTs concerned weaknesses in allocation concealment, blinding of therapists, and lack of intention-to-treat analysis. Most analytical studies failed to identify or deal with confounders, describe or deal with dropouts or eventually perform an appropriate statistical analysis. CONCLUSIONS: Most studies in this updated review targeted the prevalence of limitations of functioning of rehabilitation interest in COVID-19 survivors. This is similar to past review findings; however, data in the new studies was collected at longer follow-up periods (up to one year after symptom onset) and in larger samples of participants. More RCTs and analytical observational studies are available, but the methodological quality of recently published studies is low. There is a need for good quality intervention efficacy and effectiveness studies to complement the rapidly expanding evidence from observational studies.
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COVID-19 , Viés , Estudos de Coortes , Estudos Transversais , Humanos , SARS-CoV-2RESUMO
BACKGROUND: Multiple organ dysfunction syndrome, defined as altered organ function in critically ill patients, is a possible consequence of COVID-19. Investigating the current evidence is therefore crucial in this pandemic, as early rehabilitation could be effective for the functioning of patients with multiple organ failure. This rapid review assesses the effectiveness of rehabilitation interventions in adults with multiple organ dysfunction syndrome. METHODS: A rapid review was conducted including only randomised control trials, published until 30 November 2020. All databases were investigated and the results synthesized narratively, evaluating the risk of bias and quality of evidence in all included studies. RESULTS: A total of 404 records were identified through database searches. After removal of duplicates 346 articles remained. After screening, 3 studies (90 participants) met the inclusion criteria. All studies reported positive effects of neuromuscular electrical stimulation on muscle mass preservation compared with no treatment or standard physio-therapy. CONCLUSION: The lack of evidence on the effectiveness of rehabilitation interventions does not allow any firm conclusion to be drawn. Neuromuscular electrical stimulation might be a possible rehabilitation intervention to prevent muscle volume loss and improve function in patients with multiple organ dysfunction syndrome. However, further studies are needed to support these preliminary findings.