Posts Tagged Cochrane
[BLOG POST] Stroke rehabilitation: maximizing arm and hand function after stroke – Evidently Cochrane
Stroke is the leading cause of disability in developed countries. The effects of stroke on the upper extremities are a major cause of functional impairment. This impairment of the upper extremity often leads to loss of independence with activities of daily living and of important occupations. There has been much research along different schools of thought that are intended to help people regain function and range of motion in their hand and arm after stroke. A quick search through the Cochrane Library would lead you to over a dozen Systematic Reviews of different interventions for the upper limb for people with stroke: these include: Constraint-induced movement therapy, Mental practice, Mirror therapy, Virtual reality, Repetitive task practice, Electrical stimulation, and Occupational therapy for stroke … the list goes on.
So while it’s great that we are accumulating more and more evidence all the time, the challenge for therapists is that we just don’t have the time to spend scouring through the research, trying to find which one of these interventions is most effective for regaining upper limb function. Thankfully, Pollock and colleagues did the work for us and published a Cochrane Corner Overview paper titled “Interventions for Improving Upper Limb Function after Stroke.”
What was different about this study?
First, this study was called an “Overview” because it is basically a systematic review of systematic reviews of stroke on the upper extremity. In total, it included 40 systematic reviews (19 Cochrane Reviews and 21 non-Cochrane reviews with 18,078 participants) looking at improving arm function after stroke. That is a lot of research by any means. Their intent was to summarize the best evidence and, whenever possible, provide a side by-side comparison of interventions to give healthcare providers a succinct overview of the typical interventions for stroke to rehabilitate the upper limb.
So what did they find?
Good news and bad news. The bad news is they found that:
- “There is no high quality evidence for any interventions that are currently routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions.” In other words, the evidence is insufficient to show which of the interventions are the most effective for improving upper limb function.
The good news is that they did find:
- “Moderate quality evidence suggests that each of the following interventions may be effective: Constraint-Induced Movement Therapy (CIMT), Mental Practice, Mirror Therapy, interventions for sensory impairment, Virtual Reality and a relatively high dose of Repetitive Task Practice.”
- Moderate quality evidence also indicates that unilateral arm training (exercise for the affected arm) may be more effective than bilateral arm training (doing the same exercise with both arms at the same time).
- Some evidence shows that a greater dose of an intervention is better than a lesser dose.
- “Effective collaboration is urgently needed to support definitive randomized controlled trials of interventions used routinely within clinical practice. Evidence related to dose is particularly needed because this has widespread clinical and research implications.”
What do we know about how intense therapy should be?
Until recently, the Scottish Intercollegiate Guidelines Network 2010 (SIGN) guideline on stroke management and rehabilitation recommended considering Constraint Induced Movement. However, Repetitive Task Training was not routinely recommended for improving upper limb function, and increased intensity of therapy for improving upper limb function in stroke patients was also not recommended.
The NICE Guidelines Stroke Rehabilitation in Adults 2013 in the UK recommended that therapists consider Constraint Induced Movement Therapy, and offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to people who have the ability to participate.
A recent article in Advances in Clinical Neuroscience and Rehabilitation, called The Future of Stroke Rehabilitation: Upper Limb Recovery, points out that there is real concern that the dose and intensity of upper limb rehabilitation after stroke is just too low. The article brings some research results that at least two to three hours of arm training a day, for six weeks, reduced impairment and improved function by clinically meaningful amounts when started one to two months after stroke. However, anything less than this does not appear to provide much benefit overall.
The newly released AHA/ASA Guidelines for Stroke 2016 pulls all the updated evidence together, and states that when it comes to upper limb therapy following stroke, the research suggests that a higher dose is better. These new guidelines state that the patients who perform more than three hours of therapy daily made significantly more functional gains than those receiving less than three hours. The AHA/ASA Guidelines states that there is preliminary evidence suggesting the ideal setting appears to be the inpatient rehabilitation setting. Additionally, rehabilitation is best performed by an interprofessional team that can include a physician with expertise in rehabilitation, nurses, physical therapists, occupational therapists, speech/language therapists, psychologists, and orthotists.
What are the implications for therapists?
In order to truly have evidence based practice, we first need to identify the highest quality evidence. One of the main goals of the Cochrane Overview was to direct therapists to the highest quality evidence when making day-to-day clinical decisions. As we know, each person and each stroke is different. So for therapists, this overview suggests that that we can and should look closely into the evidence for and consider using Constraint-Induced Movement Therapy (CIMT), Mental Practice, Mirror Therapy, Interventions for Sensory Impairment, Virtual Reality and Repetitive Task Training in our practice. Preliminary evidence also suggests that we need to provide at least three hours of therapy a day in the post-acute setting.
While updated guidelines and reviews of the best available evidence are very helpful, we must always use our clinical reasoning and judgement to decide which intervention is most appropriate in our particular practice setting. The guidelines suggest that it benefits the patients when we work synergistically to facilitate an increased intensity of therapy by combining our efforts within the interprofessional team. Finally, to be truly effective we should strive to translate the evidence into functional interventions to ultimately make meaningful improvements in everyday lives of our patients.
Stroke rehabilitation: maximizing arm and hand function after stroke by Danny Minkow is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Based on a work at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010820.pub2/full. Images have been purchased for Evidently Cochrane from istock.comand may not be reproduced.
Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F. Cochrane Overview: interventions for improving upper limb function after stroke. Stroke 2015;46:e57-8. doi:10.1161/STROKEAHA.114.008295. Available from: http://stroke.ahajournals.org/content/46/3/e57.full.pdf+html
Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F. Interventions for improving upper limb function after stroke. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010820. DOI: 10.1002/14651858.CD010820.pub2.
Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning. Edinburgh: SIGN; 2010. (SIGN publication no. 118). [cited June 2010]. Available from: http://www.sign.ac.uk/pdf/sign118.pdf
The Stroke Association. “Web Upper Limb Video. UK Stroke Forum: Cochrane overview of interventions to improve upper limb function after stroke”. YouTube videocast, 24:28. YouTube, 18 December, 2015. Web. 9 May 2016. https://www.youtube.com/watch?v=7XuSLrB319Q.
National Clinical Guideline Centre; National Institute for Health and Care Excellence (commissioner). Stroke rehabilitation: long term rehabilitation after stroke. London: National Clinical Guideline Centre, Royal College of Physicians; 2013 (NICE CG162). [Issued June 2013]. Available from: https://www.nice.org.uk/guidance/cg162
Ward NS, Kelly K, Brander F. The future of stroke rehabilitation: upper limb recovery. Advances in Clinical Neuroscience & Rehabilitation2015; 15(4): 6-8. Available from: http://www.acnr.co.uk/2015/09/the-future-of-stroke-rehabilitation-upper-limb-recovery/.
Clarke D, Forster A, Drummond A, Tyson S, Rodgers H, Jones F, Harris R. Delivering optimum intensity of rehabilitation in hospital and at home: what do we know? [PowerPoint slides]. Oral presentation at Key Advances in Stroke Rehabilitation conference, London, 12thJune 2013. Available from: http://www.medineo.org
Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016;47(6):e98-e169. doi: 10.1161/STR.0000000000000098. Available from: http://stroke.ahajournals.org/content/47/6/e98.full.pdf+html
[Cochrane Review] Activity monitors for increasing physical activity in adult stroke survivors – Full Text
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To summarise the available evidence regarding the effectiveness of commercially available wearable devices and smart phone applications for increasing physical activity levels for people with stroke.
Description of the condition
Between 1990 and 2010 absolute numbers of people living with stroke increased by 84% worldwide, and stroke is now the third leading cause of disability globally (Feigin 2014). As such, the disease burden of stroke is substantial. It has been estimated that 91% of the burden of stroke is attributable to modifiable risk factors such as smoking, poor diet, and low levels of physical activity (Feigin 2016). A low level of physical activity (less than four hours per week) is the second highest population-attributable risk factor for stroke, second only to hypertension (O’Donnell 2016). The promotion of physical activity, which has been defined as body movement produced by skeletal muscles resulting in energy expenditure (Caspersen 1985), is therefore an important health intervention for people with stroke.
The association between health and physical activity is well established. Prolonged, unbroken bouts of sitting is a distinct health risk independent of time engaged in regular exercise (Healy 2008). There is evidence from cross-sectional and longitudinal studies that high sitting time and low levels of physical activity contribute to poor glycaemic control (Owen 2010). Three systematic reviews and meta-analyses of observational studies have confirmed that, after adjusting for other demographic and behavioural risk factors, physical activity is inversely associated with all-cause mortality in men and women (Nocon 2008; Löllgen 2009; Woodcock 2011). Yet despite this knowledge, populations worldwide are becoming more sedentary, and physical inactivity has been labelled a global pandemic (Kohl 2012).
In addition to overcoming the sedentary lifestyles and habits prevalent in many modern societies, people with stroke have additional barriers to physical activity such as weakness, sensory dysfunction, reduced balance, and fatigue (Billinger 2014). Directly after a stroke, people should be admitted to hospital for co-ordinated care and commencement of rehabilitation (SUTC 2013). Early rehabilitation after stroke is frequently focused on the recovery of physical independence (Pollock 2014). Recovery after stroke is enhanced by active practice of specific tasks, and greater improvements are seen when people with stroke spend more time in active practice (Veerbeek 2014). Yet findings from research conducted around the world indicate that people in the first few weeks and months after stroke are physically inactive in hospital settings with around 80% of the day spent inactive (sitting or lying) (West 2012). These high levels of inactivity are concerning because recovering the ability to walk independently is an important goal of people with stroke. The reported paucity of standing and walking practice in the early phase after stroke potentially limits the opportunities of people with stroke to optimise functional recovery, particularly for standing and walking goals. Further, physical inactivity may lead to an increased risk of hospital-acquired complications, such as pressure ulcers, pneumonia, and cardiac compromise (Lindgren 2004).
Physical activity levels of people with stroke remain lower than their age-matched counterparts even when they return to living in the community (English 2016). Community-dwelling stroke survivors spend the vast majority of their waking time sitting down (English 2014). Promisingly, early research suggests that increasing physical activity in people with stroke is feasible, and that an increase in physical activity levels after stroke may have a positive impact on fatigue, mood, community participation, and quality of life (QoL) (Graven 2011; Duncan 2015).
In this guest blog for World Occupational Therapy Day, which falls on 27th October, OT Danny Minkow explains what it is and looks at the evidence on how it can help people after a stroke.
Imagine for a moment you are in the recovery room in a hospital. You have survived a stroke. A therapist knocks and enters your room. He says, “Good morning, my name is Danny, and I’m here for your occupational therapy. Do you know what occupational therapy is?” Unfortunately, many people say, “No, I don’t know what occupational therapy is” or, even more commonly, “Are you here to help me find work?”
So what is occupational therapy?
Occupational therapists (OTs) help people maximize their independence with an emphasis on useful or functional activities. Increasing range of motion and building muscle are important, but OTs try to find what the patient finds meaningful and what activities they need to perform. OTs also view the person within the context of their living and working environment. In general, OTs help people across their lifespan, from premature babies to the elderly, in a variety of settings and conditions.
For now, let’s stick with stroke since it’s one of the leading causes of adult disability, has been well researched, and many stroke survivors receive therapy from an occupational therapist.
One way that an OT could help someone recover from a stroke is by improving their ability to do day-to-day tasks. OTs call these tasks Activities of Daily Living. This could include things like bathing, toileting, dressing, eating, cooking, grooming, dressing, and even driving. Of course, these activities are typically important parts of a patient’s larger life roles, such as being a parent, home owner, a student, or being employed.
Since each person is different, the nature of the therapy would also depend on how the stroke has affected their life, what the person finds meaningful in their life role and what they would like to improve. So in reality, while the occupational therapist doesn’t help anyone find a job, they could help someone regain the ability to work after a trauma or in this case a stroke.
What is the evidence that occupational therapy helps?
All of this sounds lovely, but does it really work? Well, here’s some good news for all of us – teams at The Cochrane Collaboration have done some high quality research on occupational therapy for stroke. Cochrane teams look for the best available evidence on a topic and put it together in systematic reviews to establish what is known about a therapy or other health intervention.
This first Cochrane review included 9 studies with 1258 participants and looked at occupational therapy for patients with problems in activities of daily living after stroke. They found that patients who receive occupational therapy are less likely to decline and are more likely to be independent in their ability to perform personal activities of daily living. However, it wasn’t clear what the exact nature, duration, type, and intensity of the occupational therapy was needed in order to achieve the maximum benefit, so there is room for further research there.
As you can imagine, having a stroke could affect your ability to move your hands and arms. A fascinating systematic review of reviews by Langhorne, Coupar, and Pollock investigated which therapies worked best to promote motor recovery after stroke. Their results came mainly from 10 different Cochrane reviews for recovering movement and function for the arm and hand. The most promising intervention that improved the patient’s ability to manage activities of daily living for arm function is constraint-induced movement therapy. constraint-induced movement therapy is when the therapist would constrain or limit the movement of the non-affected arm and have the patient use the affected arm to do repetitive or functional tasks.
They also found:
- Limited evidence for mental practice therapy. This is basically mentally rehearsing the activity
- Small amount of evidence for biofeedback for stroke. This allows a person to see or hear how their body is responding
- Some evidence that robotic-assisted arm training can help to regain function, but not strength
- Very limited evidence for interventions to improve hand function
This suggests that overall therapy to regain arm movement and function after a stroke will involve some form of intensive, repetitive task-specific practice.
Helping you at home
Community-dwelling stroke survivors might receive their therapy in their home. These home visits may be conducted by a multidisciplinary team that could include an occupational therapist and/or a physiotherapist (physical therapist). This review of therapy-based rehabilitation services for patients living at home more than one year after stroke looked at 14 studies, involving 1617 participants and they found that people who had a recent stroke were more independent in activities of daily living and more likely to maintain these abilities if they received therapy services at home. I can imagine that the therapist is more likely to notice day-to-day activities of the patient when they observe them living their lives as usual. They could also find household hazards when they visit someone living in their actual home for therapy.
Many stroke survivors live at a care home (such as a nursing home). This population differs from the community-dwelling population who remain in their own homes. For example, they are more likely to have high levels of immobility, incontinence, and confusion, along with other health conditions. This review of occupational therapy for care home residents with stroke was able to include only one study involving 118 participants, comparing occupational therapy and standard care. The authors concluded that since it only included one study, the effectiveness of occupational therapy for the population of stroke survivors residing in care homes is not clear. This is another area where more research is clearly needed.
Can OT improve your thinking ability?
Finally, having a stroke can also affect how a person ‘thinks’. This means a stroke can impact how someone learns new things, concentrates, or even makes decisions. This impairment can affect a person’s ability to perform everyday activities. Occupational therapists might use strategies to help someone relearn a task (remediation), or compensate by using devices to help people remember to do something. This could include using an alarm clock or medicine container. A review of occupational therapy for cognitive impairment in stroke patients included one trial with 33 participants. The authors concluded there isn’t evidence yet to establish the effectiveness of occupational therapy for cognitive impairment in people who have had a stroke. One more area for future research for OTs!
Occupational therapy is different for each person
So overall, Occupational therapists are uniquely positioned to help people recover from a stroke. The challenge with researching occupational therapy is that by its nature, occupational therapy as an intervention is client-centered. So it’s going to be different for each person, based on the challenges they face as an individual as well as what roles and activities they find meaningful. It’s a strength for the field, being so patient-centric and tailored to their needs, but it makes it really difficult to research, isolate, measure, and quantify occupational therapy as an ‘intervention’ for real life application. Also, part of the challenge is to prescribe accurately exact protocols for other therapists to implement. This may also be part of the reason why so many people don’t seem to know what occupational therapists actually do.
So where does this leave us? Well, I gave you the long answer on what occupational therapy is and how it can help people with stroke. Even though more research is needed, the good news is that there is promising evidence that working with an occupational therapist will help in recovering from a stroke. If you do end up receiving occupational therapy for any reason, at least now you will know a bit more about it and feel comforted knowing that you are in good hands.
What do you think? Tell us how an occupational therapist has helped you or someone you know!
You can find out more about World Occupational Therapy Day from the World Federation of Occupational Therapists website. In the UK, the British Association of Occupational Therapists and College of Occupational Therapists (@BAOTCOT) is leading Occupational Therapy Week from 3 – 9 November 2014 and you can find out more here.
Legg L, Drummond A, Langhorne P. Occupational therapy for patients with problems in activities of daily living after stroke. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003585. DOI: 10.1002/14651858.CD003585.pub2.
American Occupational Therapy Association. Occupational therapy practice framework: domain and process. (3rd ed.). American Journal of Occupational Therapy 2014; 68(Suppl 1): S1-S48. http://dx.dor.org/10.5014/ajot.2014.682006
Langhorne P, Coupar F, Pollock A. Motor Recovery after Stroke: A Systematic Review. Lancet Neurology 2009; 8(8): 741–54. doi:10.1016/S1474-4422(09)70150-4.
Aziz NA, Leonardi-Bee J, Phillips MF, Gladman J, Legg LA, Walker M. Therapy-based rehabilitation services for patients living at home more than one year after stroke. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD005952. DOI: 10.1002/14651858.CD005952.pub2.
Fletcher-Smith JC, Walker MF, Cobley CS, Steultjens EMJ, Sackley CM. Occupational therapy for care home residents with stroke. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010116. DOI: 10.1002/14651858.CD010116.pub2.
Hoffmann T, Bennett S, Koh CL, McKenna KT. Occupational therapy for cognitive impairment in stroke patients. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD006430. DOI: 10.1002/14651858.CD006430.pub2.
Langhorne P, Bernhardt J, Kwakkel G. Stroke Rehabilitation. Lancet 2011; 377(9778): 1693–1702. doi:10.1016/S0140-6736(11)60325-5.
British Association of Occupational Therapists and College of Occupational Therapists. Live Life Your Way. Web. http://www.cot.co.uk/. Accessed 2 September 2014.
[Abstract] Multi-disciplinary rehabilitation for acquired brain injury in adults of working age (Cochrane review) [with consumer summary]
Turner-Stokes L, Pick A, Nair A, Disler PB, Wade DT
Cochrane Database of Systematic Reviews 2015;Issue 12
BACKGROUND: Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, in which older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults has not been established, perhaps because this scenario presents different methodological challenges in research.
OBJECTIVES: To assess the effects of multi-disciplinary rehabilitation following ABI in adults 16 to 65 years of age.
SEARCH METHODS: We ran the most recent search on 14 September 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID MEDLINE Daily and OVID OLDMEDLINE, Embase Classic+Embase (OVIDSP), Web of Science (ISI WOS) databases, clinical trials registers, and we screened reference lists.
SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation versus routinely available local services or lower levels of intervention; or trials comparing an intervention in different settings, of different intensities or of different timing of onset. Controlled clinical trials were included, provided they met pre-defined methodological criteria.
DATA COLLECTION AND ANALYSIS: Three review authors independently selected trials and rated their methodological quality. A fourth review author would have arbitrated if consensus could not be reached by discussion, but in fact, this did not occur. As in previous versions of this review, we used the method described by van Tulder 1997 to rate the quality of trials and to perform a ‘best evidence’ synthesis by attributing levels of evidence on the basis of methodological quality. Risk of bias assessments were performed in parallel using standard Cochrane methodology. However, the van Tulder system provided a more discriminative evaluation of rehabilitation trials, so we have continued to use it for our primary synthesis of evidence. We subdivided trials in terms of severity of brain injury, setting and type and timing of rehabilitation offered.
MAIN RESULTS: We identified a total of 19 studies involving 3,480 people. Twelve studies were of good methodological quality and seven were of lower quality, according to the van Tulder scoring system. Within the subgroup of predominantly mild brain injury, ‘strong evidence’ suggested that most individuals made a good recovery when appropriate information was provided, without the need for additional specific interventions. For moderate to severe injury, ‘strong evidence’ showed benefit from formal intervention, and ‘limited evidence’ indicated that commencing rehabilitation early after injury results in better outcomes. For participants with moderate to severe ABI already in rehabilitation, ‘strong evidence’ revealed that more intensive programmes are associated with earlier functional gains, and ‘moderate evidence’ suggested that continued outpatient therapy could help to sustain gains made in early post-acute rehabilitation. The context of multi-disciplinary rehabilitation appears to influence outcomes. ‘Strong evidence’ supports the use of a milieu-oriented model for patients with severe brain injury, in which comprehensive cognitive rehabilitation takes place in a therapeutic environment and involves a peer group of patients. ‘Limited evidence’ shows that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but studies serve to highlight the particular practical and ethical restraints imposed on randomisation of severely affected individuals for whom no realistic alternatives to specialist intervention are available.
AUTHORS’ CONCLUSIONS: Problems following ABI vary. Consequently, different interventions and combinations of interventions are required to meet the needs of patients with different problems. Patients who present acutely to hospital with mild brain injury benefit from follow-up and appropriate information and advice. Those with moderate to severe brain injury benefit from routine follow-up so their needs for rehabilitation can be assessed. Intensive intervention appears to lead to earlier gains, and earlier intervention whilst still in emergency and acute care has been supported by limited evidence. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation benefit from access to out-patient or community-based services appropriate to their needs. Group-based rehabilitation in a therapeutic milieu (where patients undergo neuropsychological rehabilitation in a therapeutic environment with a peer group of individuals facing similar challenges) represents an effective approach for patients requiring neuropsychological rehabilitation following severe brain injury. Not all questions in rehabilitation can be addressed by randomised controlled trials or other experimental approaches. For example, trial-based literature does not tell us which treatments work best for which patients over the long term, and which models of service represent value for money in the context of life-long care. In the future, such questions will need to be considered alongside practice-based evidence gathered from large systematic longitudinal cohort studies conducted in the context of routine clinical practice.
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