Posts Tagged systematic review
[Abstract] The Effect of Noninvasive Brain Stimulation on Poststroke Cognitive Function: A Systematic Review
Introduction. Cognitive impairment after stroke has been associated with lower quality of life and independence in the long run, stressing the need for methods that target impairment for cognitive rehabilitation. The use of noninvasive brain stimulation (NIBS) on recovery of language functions is well documented, yet the effects of NIBS on other cognitive domains remain largely unknown. Therefore, we conducted a systematic review that evaluates the effects of different stimulation techniques on domain-specific (long-term) cognitive recovery after stroke.
Methods. Three databases (PubMed, EMBASE, and PsycINFO) were searched for articles (in English) on the effects of NIBS on cognitive domains, published up to January 2018.
Results. A total of 40 articles were included: randomized controlled trials (n = 21), studies with a crossover design (n = 9), case studies (n = 6), and studies with a mixed design (n = 4). Most studies tested effects on neglect (n = 25). The majority of the studies revealed treatment effects on at least 1 time point poststroke, in at least 1 cognitive domain. Studies varied highly on the factors time poststroke, number of treatment sessions, and stimulation protocols. Outcome measures were generally limited to a few cognitive tests.
Conclusion. Our review suggests that NIBS is able to alleviate neglect after stroke. However, the results are still inconclusive and preliminary for the effect of NIBS on other cognitive domains. A standardized core set of outcome measures of cognition, also at the level of daily life activities and participation, and international agreement on treatment protocols, could lead to better evaluation of the efficacy of NIBS and comparisons between studies.
Purpose: To evaluate the effectiveness of the Bobath concept in sensorimotor rehabilitation after stroke.
Materials and methods: A systematic literature review was conducted on the Bobath concept from the first publication available to January 2018, consulting PUBMED, CENTRAL, CINAHL and PEDro databases. Fifteen clinical trials were selected in two consecutive screenings. Two independent researchers rated the studies according to the PEDro scale from which a best evidence synthesis was derived to determine the strength of the evidence.
Results: The Bobath concept is not more effective than other approaches used in post-stroke rehabilitation. There is moderate evidence for the superiority of other therapeutic approaches such as forced use of the affected upper limb and constraint-induced movement therapy for motor control of the upper limb.
Conclusions: The Bobath concept is not superior to other approaches for regaining mobility, motor control of the lower limb and gait, balance and activities of daily living of patients after stroke. There is moderate evidence regarding the superior results of other approaches in terms of the motor control and dexterity of the upper limb. Due to the limitations concerning the methodological quality of the studies, further well-designed studies are needed.
- Implications for rehabilitation
- The Bobath concept is not superior to other approaches for patients after stroke.
- The treatments that incorporate overuse of the affected upper limb via intensive treatments with high-repetitions with or without robotic aids present greater effectiveness in the motor control of the upper limb and dexterity.
[ARTICLE] Technology-based cognitive training and rehabilitation interventions for individuals with mild cognitive impairment: a systematic review
Individuals with mild cognitive impairment (MCI) are at heightened risk of developing dementia. Rapid advances in computing technology have enabled researchers to conduct cognitive training and rehabilitation interventions with the assistance of technology. This systematic review aims to evaluate the effects of technology-based cognitive training or rehabilitation interventions to improve cognitive function among individuals with MCI.
We conducted a systematic review using the following criteria: individuals with MCI, empirical studies, and evaluated a technology-based cognitive training or rehabilitation intervention. Twenty-six articles met the criteria.
Studies were characterized by considerable variation in study design, intervention content, and technologies applied. The major types of technologies applied included computerized software, tablets, gaming consoles, and virtual reality. Use of technology to adjust the difficulties of tasks based on participants’ performance was an important feature. Technology-based cognitive training and rehabilitation interventions had significant effect on global cognitive function in 8 out of 22 studies; 8 out of 18 studies found positive effects on attention, 9 out of 16 studies on executive function, and 16 out of 19 studies on memory. Some cognitive interventions improved non-cognitive symptoms such as anxiety, depression, and ADLs.
Technology-based cognitive training and rehabilitation interventions show promise, but the findings were inconsistent due to the variations in study design. Future studies should consider using more consistent methodologies. Appropriate control groups should be designed to understand the additional benefits of cognitive training and rehabilitation delivered with the assistance of technology.
Due to the aging of the world’s population, the number of people who live with dementia is projected to triple to 131 million by the year 2050 [1, 2]. Development of preventative strategies for individuals at higher risk of developing dementia is an international priority [3, 4]. Mild cognitive impairment (MCI) is regarded as an intermediate stage between normal cognition and dementia [5, 6]. Individuals with MCI usually suffer with significant cognitive complaints, yet do not exhibit the functional impairments required for a diagnosis of dementia. These people typically have a faster rate of progression to dementia than those without MCI , but the cognitive decline among MCI subjects has the potential of being improved [7, 8]. Previous systematic reviews of cognitive intervention studies, both cognitive training and cognitive rehabilitation, have demonstrated promising effects on improving cognitive function among subjects with MCI [3, 7, 9, 10].
Recently, rapid advances in computing technology have enabled researchers to conduct cognitive training and rehabilitation interventions with the assistance of technology. A variety of technologies, including virtual reality (VR), interactive video gaming, and mobile technology, have been used to implement cognitive training and rehabilitation programs. Potential advantages to using technology-based interventions include enhanced accessibility and cost-effectiveness, providing a user experience that is immersive and comprehensive, as well as providing adaptive responses based on individual performance. Many computerized cognitive intervention programs are easily accessed through a computer or tablet, and the technology can objectively collect data during the intervention to provide real-time feedback to participants or therapists. Importantly, interventions delivered using technology have shown better effects compared to traditional cognitive training and rehabilitation programs in improving cognitive function and quality of life [11–13]. The reasons for this superiority are not well-understood but could be related to the usability and motivational factors related to the real-time interaction and feedback received from the training system .
Three recent reviews of cognitive training and rehabilitation for use with individuals with MCI and dementia suggest that technology holds promise to improve both cognitive and non-cognitive outcomes [14–16]. The reviews conducted by Coyle, et al.  and Chandler, et al.  were limited by accessing articles from only two databases, and did not comprehensively cover available technologies. Hill, et al.  limited their review to papers published until July 2016 and included only older adults aged 60 and above. More technology-based intervention studies have been conducted since then, and only including studies with older adults 60 and above could limit the scope of the review given that adults can develop early-onset MCI in their 40s . Therefore, the purpose of this review is to 1) capture more studies using technology-based cognitive interventions by conducting a more comprehensive search using additional databases 2) understand the effect of technology-based cognitive interventions on improving abilities among individuals with MCI; and 3) examine the effects of multimodal technology-based interventions and their potential superiority compared to single component interventions.[…]
[ARTICLE] A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems – Full Text
Innovation and technological advances involve the offering of valuable products and services to improve the quality of life of citizens. In recent decades, the domain of telemedicine has reported advances in the control, monitoring and evaluation of various clinical conditions . In the field of rehabilitation, numerous studies and state-of-the-arts from informatics perspective  and different areas of application [3, 4], show the effectiveness and advantages of the use of remote rehabilitation (or tele-rehabilitation) [5, 6]. Tele-rehabilitation aims to reduce the time and costs of offering rehabilitation services. The main objective is to improve the quality of life of patients . Tele-rehabilitation cannot replace traditional neurological rehabilitation . It is considered as a partial replacement of face-to-face physical rehabilitation . Tele-rehabilitation uses mainly two groups of technologies: (1) wearable devices and (2) vision-based systems based on depth cameras and intelligent algorithms . In , the authors describe and analyze some characteristics and typical requirements tele-rehabilitation systems.
Design and conception of tele-rehabilitations platforms that do not consider guidelines, metrics, patterns, principles, or practice success factors can affect the access to the service, the effectiveness, quality, and usefulness. It can cause problems of confusion, error, stress, and abandonment of the rehabilitation plan. Therefore, guaranteeing the correct use of these applications implies to incorporate different studies of usability in the life cycle of the interactive system. For this reason, aspects of human factors engineering in tele-rehabilitation systems have been studied with the aim of providing accessible, efficient, usable and understandable systems [11, 12].
User-centered agile development (UCD) approaches allows developers to specify and design the set of interfaces of any interactive system in a flexible and effective way [13, 14]. The agile development life cycle centered on user experience (UX-ADLC) allows iteratively evaluating system interfaces based on the results of the previous iteration. The evaluation also includes the errors and usability problems encountered . Thus, usability studies are an essential aspect of technology development . This is the reason why designers need to meet usability and user experience objectives while adhering to agile principles of software development. Formative and summative usability tests are methods of evaluating software products widely adopted in user-centered design (UCD)  and agile UX development lifecycle. Both approaches are frequently used in the development of software applications. Rapid formative usability should be carried out so as to fulfill UX goals while satisfying end users’ needs. Formative usability is used as an iterative test-and-refine method performed in the early steps of a design process, in order to detect and fix usability problems . Summative usability allows for assuring, in later phases of the design, the quality of the user experience (UX) for a software product in development. The focus is on short work periods (or iterations) where usability tests (formative and summative) must be contemplated. This means that quick formative usability tests should be carried out to fulfill UX goals .
The ISO 9241-11 standard  is a framework for understanding and applying the concept of usability to situations in which people use interactive systems and other types of systems (including built environments), products (including industrial and consumer products) and services (including technical and personal services). Likewise, the usability standard ISO 9241-11 facilitates the measurement of the use of a product with the aim of achieving specific objectives with effectiveness, efficiency and satisfaction in a context of specific use .
Usability can be studied through software evaluation methods widely accepted in user centered design (UCD) . It can be formative or summative . Formative usability consists of a set of iterative tests carried out in the early stages of the design process. The aim of the tests is to refine and improve the software product, as well as to detect and solve potential usability problems. As a complement, the summative usability allows to obtain an evaluation of the user experience (UX) for a software product in development. Formative usability facilitates decision making during the design and development of the product, while summative usability is useful when studying user experience (UX).
Tullis and Stetson  evaluated the effectiveness of the most used questionnaires to measure the summative usability. The authors found that the System Usability Scale (SUS)  and the IBM Computer System Usability Questionnaire (CSUQ)  are the most effective. SUS provides a quick way for measuring the usability through user experience. It consists of a 10-item questionnaire with 5-likert scale range from “Strong Agree” to “Strongly Disagree.” The CSUQ focuses on three main aspects: (1) the utility, which refers to the opinion of users regarding the ease of use, the ease of learning, the speed to perform the operations, the efficiency in completing tasks and subjective feeling; (2) the quality of the information which studies the subjectivity of the user regarding the management of system errors, the clarity of the information and the intelligibility; and finally, (3) the quality of the interface which measures the affective component of the user’s attitude in the use of the system.
Large part of the tasks in the tele-rehabilitation systems are carried out by patients who require to treat a temporary disability. Considering the special needs of these users, usability evaluations alone cannot guarantee an appropriate design of the system. On the contrary, accessibility studies can provide the mechanisms to offer the same means of use to all users of any interactive system. A study combining usability and accessibility was presented in . The study analyzes how remote and/or video monitoring technologies affect the accessibility, effectiveness, quality and usefulness of the services offered by tele-rehabilitation systems. To do this, the authors provide an overview of the fundamentals necessary for the analysis of usability, in addition to analyzing the strengths and limitations of various tele-rehabilitation technologies, considering how technologies interact with the clinical needs of end users such as accessibility, effectiveness, quality and utility of the service .
For many people, the Web is a fundamental part of everyday life. Therefore, a fundamental aspect to ensure the inclusivity of a Website is its accessibility. For example, people who cannot use their arms to write on their computer can use a mouth pencil . Or someone who cannot listen well can use subtitles to understand a video. Also, a person who has a low vision can use a screen reader to listen what is written on the screen . Therefore, Web accessibility means that people with disabilities can use the Web without any type of barriers . There are several standards related to accessibility that provide guidelines and recommendations . Some of the most important, according to the International Organization for Standardization (ISO), are the following ones:
ISO 9241: covers ergonomics of human-computer interaction.
ISO 14915 (software ergonomics for multimedia user interfaces): multimedia controls and navigation structure.
ISO CD 9241-151 (software ergonomics for World Wide Web user interfaces): designs of Web user interfaces.
ISO TS 16071 (guidance on accessibility for human-computer interface): recommendations for the design of systems and software applications that allows a greater accessibility to computer systems for users with disabilities.
ISO CD 9241-20: accessibility guideline for information communication, equipment and services.
The Web Accessibility Initiative (WAI)  from the World Wide Web Consortium (W3C)  develops Web Content Accessibility Guidelines (WCAG)  2.0 (at present 2.1) that covers a wide range of recommendations for making Web contents more accessible. These guidelines were considered a standard in 2012, the ISO/IEC 40500. Complementary to these guidelines are the W3C User Agent Accessibility guidelines  (UAAG) and Authoring tool Accessibility guidelines  (ATAG), which addresses the current technological capabilities to modify the presentation based on the device capabilities and the preferences of the user.
The World Wide Web Consortium (W3C) provides international standards to make the Web as accessible as possible. It comprises the Web 2.0 Content Accessibility Guidelines (WCAG 2.0) , also known as the ISO 40500 , which are adapted to the European Standard called EN 301549 .
The current version of the accessibility guidelines is “Web Content Accessibility Guidelines 2.1” (WCAG 2.1) . WCAG 2.1 consists of 4 principles, 13 guidelines and 76 compliance criteria. The four principles refer to .
Principle 1—perceptibility: refers to the good practices regarding the presentation of information and user interface components. It consists of 4 guidelines and 29 compliance criteria.
Principle 2—operability: the components of the user interface and navigation must be operable. It includes 5 guidelines and 29 compliance criteria.
Principle 3—comprehensibility: the information and user interface management must be understandable. It has 3 guidelines and 17 compliance criteria.
Principle 4—robustness: the content must be robust enough to rely on the interpretation of a wide variety of user agents, including assistive technologies. It includes a guideline and three compliance criteria.
Usability and accessibility can be combined to achieve the development of more accessible, efficient, equitable and universal tele-rehabilitation systems. This chapter presents a systematic literature review of summative and formative usability studies as well as accessibility studies in the context of tele-rehabilitation systems. The remaining of the manuscript is composed of four sections. Section 2 presents the method used to proceed with the systematic review. Section 3 is a description of the most relevant papers in usability applied to tele-rehabilitation. Section 4 describes the results regarding the accessibility. And Section 5 draws conclusions on the main findings of this literature review.[…]
[Abstract] Effectiveness of Technology-Based Distance Physical Rehabilitation Interventions for Improving Physical Functioning in Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials
To study the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning in stroke.
A systematic literature search was conducted in 6 databases from January 2000 to May 2018.
Inclusion criteria applied the patient, intervention, comparison, outcome, study design framework as follows: (P) stroke; (I) technology-based distance physical rehabilitation interventions; (C) any comparison without the use of technology; (O) physical functioning; (S) randomized controlled trials (RCTs). The search identified in total 693 studies, and the screening of 162 full-text studies revealed 13 eligible studies.
The studies were screened using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and assessed for methodological quality and quality of evidence. Meta-analysis was performed if applicable.
A total of 13 studies were included, and online video monitoring was the most used technology. Seven outcomes of physical functioning were identified-activities of daily living (ADL), upper extremity functioning, lower extremity functioning, balance, walking, physical activity, and participation. A meta-analysis of 6 RCTs indicated that technology-based distance physical rehabilitation had a similar effect on ADL (standard mean difference 0.06; 95% confidence interval: -0.22 to 0.35, P=.67) compared to the combination of traditional treatments (usual care, similar and other treatment). Similar results were obtained for other outcomes, except inconsistent findings were noted for walking. Methodological quality of the studies and quality of evidence were considered low.
The findings suggest that the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning might be similar compared to traditional treatments in stroke. Further research should be performed to confirm the effectiveness of technology-based distance physical rehabilitation interventions for improving physical functioning of persons with stroke.
[ARTICLE] Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery – Full Text
Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients’ mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.
The World Health Organization (WHO) estimates that stroke events in EU countries are likely to increase by 30% between 2000 and 2025 (Truelsen et al., 2006). The most common deficit after stroke is hemiparesis of the contralateral upper limb, with more than 80% of stroke patients experiencing this condition acutely and more than 40% chronically (Cramer et al., 1997). Common manifestations of upper extremity motor impairment include muscle weakness or contracture, changes in muscle tone, joint laxity, and impaired motor control. These impairments induce disabilities in common activities such as reaching, picking up objects, and holding onto objects (for a review on precision grip deficits, see Bleyenheuft and Gordon, 2014).
Motor paresis of the upper extremity may be associated with other neurological manifestations that affect the recovery of motor function and thus require focused therapeutic intervention. Deficits in somatic sensations (body senses such as touch, temperature, pain, and proprioception) after stroke are common with prevalence rates variously reported to be 11–85% (Carey et al., 1993; Yekutiel, 2000; Hunter, 2002). Functionally, the motor problems resulting from sensory deficits after stroke can be summarized as (1) impaired detection of sensory information, (2) disturbed motor tasks performance requiring somatosensory information, and (3) diminished upper extremity rehabilitation outcomes (Hunter, 2002). Sensation is essential for safety even if there is adequate motor recovery (Yekutiel, 2000). Also, up to 50% of patients experience pain of the upper extremity during the first year after stroke, especially shoulder pain and complex regional pain syndrome-type I (CRPS-type I), which may impede adequate early rehabilitation (Jönsson et al., 2006; Kocabas et al., 2007; Sackley et al., 2008; Lundström et al., 2009). Furthermore, joint subluxation and muscle contractures can lead to nociceptive musculoskeletal pain (de Oliveira et al., 2012). Among other complications of stroke the neglect syndrome (Ringman et al., 2004) and spasticity (Sommerfeld et al., 2004; Welmer et al., 2010) affect motor and functional outcomes.
The neurological recovery after stroke displays a nonlinear, logarithmic pattern (Figure (Figure1;1; Kwakkel et al., 2006; Langhorne et al., 2011). The greater part of recovery is reported to take place in the first 3 months following stroke (Wade et al., 1983). However, there is evidence that recovery is not limited to this time period; hand and upper extremity recovery has been reported many years after stroke (Carey et al., 1993; Yekutiel and Guttman, 1993). Improvement probably occurs through a complex combination of spontaneous and learning-dependent processes including: restitution, substitution, and compensation (Kwakkel et al., 2004; Langhorne et al., 2011). Until the third month after stroke onset, a variable spontaneous neurological recovery can be considered a confounder of rehabilitation intervention (Kwakkel et al., 2006). In the past, the observation of spontaneous recovery after stroke has misled some authors to believe that recovery of upper extremity function is intrinsic and that little can be done by therapists to influence it (Wade et al., 1983; Heller et al., 1987). Progresses in functional outcome appearing after 3 months seem largely dependent on learning adaptation strategies (Kwakkel et al., 2004). Evidence suggests that neurological repair through brain reorganization supporting true recovery or, alternatively through compensation, may also take place in the subacute and chronic phase after stroke (Krakauer, 2006).
-The types of technology of reviewed articles include games, telerehabilitation, robotic devices, virtual reality devices, sensors, and tablets.
-Two main human factors in designing home-based technologies for stroke rehabilitation are discussed: designing for engagement (including external and internal motivation) and designing for the home environment (including understanding the social context, practical challenges, and technical proficiency).