Network Meta-Analysis of Non-Conventional Therapies for Improving Upper Limb Motor Impairment Poststroke.

BACKGROUND: Network meta-analysis is a method that can estimate relative efficacy between treatments that may not have been compared directly within the literature. The purpose of this study is to present a network meta-analysis of non-conventional interventions to improve upper extremity motor impairment after stroke. METHODS: A literature search was conducted in 5 databases from their inception until April 1, 2021. Terms were used to narrow down articles related to stroke, the upper extremity, and interventional therapies. Randomized controlled trials written in English were eligible if; 50% poststroke patients; ≥18 years old; applied an intervention for the upper extremity, and/or used the Fugl-Meyer upper extremity scale as an outcome measure; the intervention had ≥3 randomized controlled trials with comparisons against a conventional care group; conventional care groups were dose matched for therapy time. A Bayesian network meta-analysis approach was taken to estimate mean difference (MD) and 95% CI. RESULTS: One hundred seventy-six randomized controlled trials containing 6781 participants examining 20 non-conventional interventions were identified for inclusion within the final model. Eight of the identified interventions proved significantly better than conventional care, with modified constraint induced movement therapy (MD, 6.7 [95% CI, 4.3-8.9]), high frequency repetitive transcranial magnetic stimulation (MD, 5.4 [95% CI, 1.9-8.9]), mental imagery (MD, 5.4 [95% CI, 1.8-8.9]), bilateral arm training (MD, 5.2 [95% CI, 2.2-8.1]), and intermittent theta-burst stimulation (MD, 5.1 [95% CI, 0.62-9.5]) occupying the top 5 spots according to the surface under the cumulative ranking curve. CONCLUSIONS: Overall, it would seem that modified constraint induced movement therapy has the greatest probability of being the most effective intervention, with high-frequency repetitive transcranial magnetic stimulation, mental imagery, and bilateral arm training all having similar probabilities of occupying the next spot in the rankings. We think this analysis can provide a guide for where future resources and clinical trials should be directed, and where a clinician may begin when considering alternative therapeutic interventions.

Differences in stroke rehabilitation motor and cognitive randomized controlled trials by world region: Number, sample size, and methodological quality.

BACKGROUND: Stroke rehabilitation research is important for informing clinical practice and directing health care resources. OBJECTIVE: To examine how motor- and cognitive-based stroke rehabilitation randomized controlled trials (RCTs) vary by world region, overall and over time, with respect to 1) publication volume, 2) sample size, and 3) methodological quality. METHODS: Using the Evidence-Based Review of Stroke Rehabilitation (EBRSR), all motor- and cognitive-based stroke rehabilitation RCTs were identified. The following data were extracted: first author, year of publication, country of origin, and sample size. Countries were categorized into seven regions, as defined by the World Bank. RESULTS: In total 1410 motor-based RCTs and 293 cognitive-based RCTs were published between 1972-2018. For motor RCTs, the East Asia/Pacific region accounted for the largest volume of RCTs (n = 530; 37.6%), followed closely by the Europe/Central Asia region (n = 445; 31.6%). Conversely, the largest producer for cognitive RCTs was Europe/Central Asia (n = 167; 57.0%), followed by East Asia/Pacific (n = 62; 21.2%). For both motor and cognitive RCTs, there was no significant difference between world regions with respect to mean sample size or methodological quality. CONCLUSIONS: Efforts should be directed towards improving methodological quality and increasing sample sizes of stroke rehabilitation-related studies.

Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation following Stroke. Part One: Rehabilitation and Recovery Following Stroke; 6th Edition Update 2019.

The sixth update of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Reintegration following Stroke. Part one: Rehabilitation and Recovery Following Stroke is a comprehensive set of evidence-based guidelines addressing issues surrounding impairments, activity limitations, and participation restrictions following stroke. Rehabilitation is a critical component of recovery, essential for helping patients to regain lost skills, relearn tasks, and regain independence. Following a stroke, many people typically require rehabilitation for persisting deficits related to hemiparesis, upper-limb dysfunction, pain, impaired balance, swallowing, and vision, neglect, and limitations with mobility, activities of daily living, and communication. This module addresses interventions related to these issues as well as the structure in which they are provided, since rehabilitation can be provided on an inpatient, outpatient, or community basis. These guidelines also recognize that rehabilitation needs of people with stroke may change over time and therefore intermittent reassessment is important. Recommendations are appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. Unlike the previous set of recommendations, in which pediatric stroke was included, this set of recommendations includes primarily adult rehabilitation, recognizing many of these therapies may be applicable in children. Recommendations related to community reintegration, which were previously included within this rehabilitation module, can now be found in the companion module, Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.

Evaluating the effectiveness of aquatic therapy on mobility, balance, and level of functional independence in stroke rehabilitation: a systematic review and meta-analysis.

OBJECTIVE: To meta-analyze and systematically review the effectiveness of aquatic therapy in improving mobility, balance, and functional independence after stroke. DATA SOURCES: Articles published in Medline, Embase, CINAHL, PsycINFO, and Scopus up to 20 August 2019. STUDY SELECTION: Studies met the following inclusion criteria: (1) English, (2) adult stroke population, (3) randomized or non-randomized prospectively controlled trial (RCT or PCT, respectively) study design, (4) the experimental group received >1 session of aquatic therapy, and (5) included a clinical outcome measure of mobility, balance, or functional independence. DATA EXTRACTION: Participant characteristics, treatment protocols, between-group outcomes, point measures, and measures of variability were extracted. Methodological quality was assessed using Physiotherapy Evidence Database (PEDro) tool, and pooled mean differences (MD) ± standard error and 95% confidence intervals (CI) were calculated for Functional Reach Test (FRT), Timed Up and Go Test (TUG), gait speed, and Berg Balance Scale (BBS). DATA SYNTHESIS: Nineteen studies (17 RCTs and 2 PCTs) with a mean sample size of 36 participants and mean PEDro score of 5.6 (range 4-8) were included. Aquatic therapy demonstrated statistically significant improvements over land therapy on FRT (MD = 3.511 ± 1.597; 95% CI: 0.381-6.642; P = 0.028), TUG (MD = 2.229 ± 0.513; 95% CI: 1.224-3.234; P < 0.001), gait speed (MD = 0.049 ± 0.023; 95% CI: 0.005-0.094; P = 0.030), and BBS (MD = 2.252 ± 0.552; 95% CI: 1.171-3.334; P < 0.001). CONCLUSIONS: While the effect of aquatic therapy on mobility and balance is statistically significant compared to land-based therapy, the clinical significance is less clear, highly variable, and outcome measure dependent.

Referral patterns of stroke rehabilitation inpatients to a model system of outpatient services in Ontario, Canada: a 7-year retrospective analysis.

BACKGROUND: While several studies have tracked the care paths of patients in the early phases of stroke recovery, studies examining the transition from inpatient to outpatient rehabilitation are lacking. Examining this transition allows for improved understanding and refinement of the process whereby patients are referred and admitted to programs. The objective of this study was to examine the referral patterns of stroke rehabilitation inpatients to outpatient stroke therapy services, their demographics, and clinical profile. METHODS: This study examined patients who: (1) were admitted to an inpatient stroke rehabilitation unit between January 1, 2009 and March 1, 2016, (2) had a stroke diagnosis, (3) had an inpatient length of stay of > 1 day, and (4) lived within the geographical boundaries of the South West Local Health Integration Network which allowed them access to both hospital-based and home-based stroke rehabilitation outpatient programs. Patient data was collected from the National Rehabilitation Reporting System, as well as three hospital outpatient administrative databases. These databases were cross-referenced to determine each patient's pathway. Those referred to an outpatient therapy program, and those who attended the outpatient programs, were compared to those who were not, and did not, respectively. RESULTS: 1497 inpatients were included in the analysis. Upon discharge, 1037 (69.3%) of patients had an outpatient clinic, follow-up appointment scheduled; of those, 902 (87.0%) patients attended at least one outpatient clinic visit. 891 (59.5%) were referred to one of the interdisciplinary outpatient stroke rehabilitation programs; of those, an outpatient therapy program was attended by 80.9% of patients (n = 721). Of those receiving outpatient therapy services, the number of patients attending the in-hospital versus home-based program were equal, 360 and 361 individuals, respectively. CONCLUSION: This study allows for a better understanding of the transition between inpatient and outpatient stroke care. There is a paucity of this type of information in stroke rehabilitation literature to date. This study acts as a starting point in improving rehabilitation planning across the continuum of care.

The effect of theta-burst stimulation on unilateral spatial neglect following stroke: a systematic review.

OBJECTIVE:: To evaluate the effectiveness of theta-burst stimulation for the treatment of stroke-induced unilateral spatial neglect. DATA SOURCES:: A systematic literature search was conducted from the inception of each database to 30 June 2018 using CINAHL, EMBASE, PubMed, PsycINFO, and Scopus. REVIEW METHODS:: Articles were included if theta-burst stimulation was used to treat neglect following a stroke. The additional a priori inclusion criteria were as follows: (1) ⩾3 adult (⩾18 years) participants, (2) ⩾50% stroke population, and (3) peer-reviewed journal articles published in English. Extracted data included study and treatment characteristics, results, and adverse events. RESULTS:: Nine studies met the inclusion criteria, generating a total of 148 participants. Eight studies evaluated a continuous stimulation protocol and one study investigated an intermittent stimulation protocol. Overall, both protocols significantly improved neglect severity when compared against placebo or active controls ( P < 0.05). Adding smooth pursuit training to theta-burst stimulation did not improve neglect relative to when the stimulation was delivered alone ( P > 0.05). There was inconsistent reporting of neglect terminology, outcome measures, and adverse events. The treatment characteristics were heterogeneous among the trials. CONCLUSION:: This systematic review found that theta-burst stimulation seems to improve post-stroke unilateral spatial neglect, but because the evidence is limited to a few small studies with varied and inconsistent protocols and use of terminology, no firm conclusion on effectiveness can be drawn.

Cognitive behavioural therapy for aggression among individuals with moderate to severe acquired brain injury: a systematic review and meta-analysis.

BACKGROUND: Aggression is common after an acquired brain injury (ABI). Cognitive behavioural therapy (CBT) is a form of psychotherapy, in which therapists help patients to identify their maladaptive behaviours. OBJECTIVE: The objective of this systematic review and meta-analysis was to evaluate the effectiveness of CBT interventions in treating aggression in an ABI population. METHODS: A systematic literature search was conducted using: PubMed/MEDLINE, CINAHL, EMBASE and PsycINFO from database inception to August 2016. English articles were included if: at least 50% of the study sample had a moderate to severe ABI, there were at least three adult human participants, and use of a CBT intervention for the treatment of aggression. RESULTS: Seven articles met inclusion criteria: one RCT, an RCT crossover and five pre-post trials. Of these, four articles were included in a pre-post meta-analysis for treatment efficacy on subscales of the State Trait Anger Expression Inventory (STAXI) and STAXI-2 outcome measures. The meta-analysis found CBT was effective in moderating the external behaviours of aggression, but not internal anger. CONCLUSION: The differences in outcomes may be related to the differential management of anger expression and anger suppression. CBT shows promise, but further studies with comparator groups are needed before conclusions about its efficacy can be made.

A mapping review of randomized controlled trials in the spinal cord injury research literature.

STUDY DESIGN: Mapping Review. OBJECTIVE: The objective of this study was to map out and characterize the quantity and quality of all published spinal cord injury (SCI) randomized controlled trials (RCTs) with respect to number, sample size, and methodological quality between January 1970 and December 2016. SETTING: Not applicable. METHODS: A literature search of multiple research databases was conducted. Studies adhering to the following criteria were included: the research design was an RCT; written in English; participants were >18 years; and the sample was >50% SCI. Data were extracted pertaining to author(s), year of publication, country of origin, initial and final sample size, intervention, and control. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) tool. Data was assessed overall and by each year of publication. RESULTS: In total, 466 RCTs were published 1971-2016 on 29 primary topic areas, with Bladder (n = 78, 16.7%) most common, followed by Pain (n = 54, 11.6%), and Lower Limb (n = 45, 9.7%). Studies were published in 172 unique journals, with the most common being Spinal Cord (n = 68, 14.6%). The most common producer of studies was the United States (n = 191, 41.0%). RCT publications increased linearly until 2012 when the rate tripled, resulting in 40.8% published 2012-2016. A total of 247 (59.4%) RCTs had <30 subjects; there was no change in sample size over time (p = 0.770). The overall mean PEDro score was 5.56 (1.68); scores improved from 5.0 (1.4) in 1976 to 6.3 (1.9) in 2016 (F = 2.230, p < 0.001). CONCLUSIONS: The number of SCI RCTs and their associated sample size remains low; however, methodological quality has improved over time.

Are Comorbid Pain and Depressive Symptoms Associated with Rehabilitation of Individuals with Spinal Cord Injury?

Objective: To examine the difference in functional outcomes and therapy intensity among individuals with spinal cord injury (SCI) with comorbid depression and pain symptoms compared to those without these symptoms. Methods: A retrospective chart review was conducted of 100 patients admitted to a specialized SCI inpatient rehabilitation unit. Standard demographic factors were collected. Patients were divided into 2 groups: those with comorbid depression and pain symptoms and those without. Outcomes were compared between the 2 groups using analysis of covariance (ANCOVA). Age, gender, level of injury, severity of injury, and FIM® admission were included in the model as covariates. Main outcomes included FIM® discharge, length of stay (LOS), intensity of therapy (total physical therapy time [PTt] and total occupational therapy time [OTt]), living arrangement, and vocational status. Results: No significant difference was seen between the 2 groups in FIM® discharge or OTt; however, those in the comorbidity group required significantly greater PTt than those without (p = .002). Those in the comorbid group also spent longer in inpatient rehabilitation (p = .005). The groups did not differ in postdischarge living arrangements or vocational status. Conclusion: Inpatient rehabilitation physical therapy and LOS differ substantially among individuals with comorbid depression and pain symptoms. This comorbidity may have a negative impact on functional recovery such that individuals may require more physical therapy time and longer LOS. This may also point to the increased resources required to manage individuals with SCI and comorbid depression and pain symptoms.

Pharmacological management of agitation among individuals with moderate to severe acquired brain injury: A systematic review.

OBJECTIVE: To conduct a systematic review examining the effectiveness of pharmacological management of agitation among individuals with acquired brain injury (ABI). DATA SOURCES: MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published in English from 1980 to January 2016. STUDY SELECTION: Studies were included for analysis all participants had moderate to severe ABI, n ≥ 3, and a pharmacological intervention was provided for the treatment of agitation and its effectiveness was assessed. DATA EXTRACTION: Data extracted included participant demographics, inclusion and exclusion criteria, study design, outcome measure(s), and results. Study quality was assessed using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs). A level of evidence was assigned to each intervention using a modified Sackett scale. DATA SYNTHESIS: Among 165 retrieved studies, 19 met inclusion criteria. The included studies consisted of 6 RCTs and 13 observational studies. Antipsychotic medications were studied predominately (n = 6), followed by anticonvulsants (n = 4) and dopaminergic (n = 4), antidepressants (n = 3), and beta-blockers (n = 2). Dopaminergic medications, specifically amantadine, had the highest level of evidence (Level 1a). The antipsychotic lithium carbonate was shown to be effective but was not recommended for use due to high risk of neurotoxicity. CONCLUSIONS: Studies consistently demonstrated that pharmacological treatment was effective in reducing agitation post ABI; however, there was insufficient information to develop a conclusion due to the limited number of studies and overall weakness of evidence for each individual medication.

The use of virtual reality for balance among individuals with chronic stroke: a systematic review and meta-analysis.

BACKGROUND: Virtual reality (VR) is becoming a popular alternative to traditional upper and lower limb rehabilitation following a stroke. OBJECTIVE: To conduct a systematic review and meta-analysis on the effectiveness of VR interventions for improving balance in a chronic stroke (≥6 months) population. DATA SOURCES: A literature search of Pubmed, Scopus, CINAHL, Embase, Psycinfo, and Web of Science databases was conducted. STUDY SELECTION: English randomized controlled trials published up to September 2015 assessing balance with VR in chronic stroke participants. DATA EXTRACTION: Mean and standard deviations from outcome measures were extracted. Pooled standard mean differences ± standard error were calculated for the Berg Balance Scale (BBS) and the Timed Up and Go test (TUG). RESULTS: In total, 20 studies were selected which assessed the Nintendo® Wii Fit balance board (n = 7), treadmill training and VR (n = 7), and postural training using VR (n = 6). Significant improvements were found for VR interventions evaluating the BBS (n = 12; MD = 2.94 ± 0.57; p < 0.001) and TUG (n = 13; MD = 2.49 ± 0.57; p < 0.001). Sub-analyses revealed postural VR interventions had a significant effect on BBS (n = 5) and TUG (n = 3) scores (BBS: MD = 3.82 ± 0.79; p < 0.001 and TUG: MD = 3.74 ± 0.97; p < 0.001). VR and treadmill training (n = 5) had a significant effect on TUG scores (MD = 2.15 ± 0.89, p = 0.016). CONCLUSION: Overall, VR interventions compared to conventional rehabilitation had significant improvements. The meta-analyses also suggest that the Nintendo® Wii Fit balance board may not be effective, although further confirmatory studies are necessary. Results should be interpreted with caution due to differences in therapy intensities and effect sizes within the included studies.

Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015.

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.