Boudewijn J. Kollen

Effects of Robot-Assisted Therapy on Upper Limb Recovery After Stroke: A Systematic Review

Objective. The aim of the study was to present a systematic review of studies that investigate the effects of robot-assisted therapy on motor and functional recovery in patients with stroke. Methods. A database of articles published up to October 2006 was compiled using the following Medline key words: cerebral vascular accident, cerebral vascular disorders, stroke, paresis, hemiplegia, upper extremity, arm, and robot. References listed in relevant publications were also screened. Studies that satisfied the following selection criteria were included: (1) patients were diagnosed with cerebral vascular accident; (2) effects of robot-assisted therapy for the upper limb were investigated; (3) the outcome was measured in terms of motor and/or functional recovery of the upper paretic limb; and (4) the study was a randomized clinical trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for motor recovery and functional ability (activities of daily living [ADLs]) using fixed and random effect models. Ten studies, involving 218 patients, were included in the synthesis. Their methodological quality ranged from 4 to 8 on a (maximum) 10-point scale. Results. Meta-analysis showed a nonsignificant heterogeneous SES in terms of upper limb motor recovery. Sensitivity analysis of studies involving only shoulder-elbow robotics subsequently demonstrated a significant homogeneous SES for motor recovery of the upper paretic limb. No significant SES was observed for functional ability (ADL). Conclusion. As a result of marked heterogeneity in studies between distal and proximal arm robotics, no overall significant effect in favor of robot-assisted therapy was found in the present meta-analysis. However, subsequent sensitivity analysis showed a significant improvement in upper limb motor function after stroke for upper arm robotics. No significant improvement was found in ADL function. However, the administered ADL scales in the reviewed studies fail to adequately reflect recovery of the paretic upper limb, whereas valid instruments that measure outcome of dexterity of the paretic arm and hand are mostly absent in selected studies. Future research into the effects of robot-assisted therapy should therefore distinguish between upper and lower robotics arm training and concentrate on kinematical analysis to differentiate between genuine upper limb motor recovery and functional recovery due to compensation strategies by proximal control of the trunk and upper limb.

Probability of Regaining Dexterity in the Flaccid Upper Limb Impact of Severity of Paresis and Time Since Onset in Acute Stroke

BACKGROUND AND PURPOSE To improve the accuracy of early postonset prediction of motor recovery in the flaccid hemiplegic arm, the effects of change in motor function over time on the accuracy of prediction were evaluated, and a prediction model for the probability of regaining dexterity at 6 months was developed. METHODS In 102 stroke patients, dexterity and paresis were measured with the Action Research Arm Test, Motricity Index, and Fugl-Meyer motor evaluation. For model development, 23 candidate determinants were selected. Logistic regression analysis was used for prognostic factors and model development. RESULTS At 6 months, some dexterity in the paretic arm was found in 38%, and complete functional recovery was seen in 11.6% of the patients. Total anterior circulation infarcts, right hemisphere strokes, homonymous hemianopia, visual gaze deficit, visual inattention, and paresis were statistically significant related to a poor arm function. Motricity Index leg scores of at least 25 points in the first week and Fugl-Meyer arm scores of 11 points in the second week increasing to 19 points in the fourth week raised the probability of developing some dexterity (Action Research Arm Test >or=10 points) from 74% (positive predictive value [PPV], 0.74; 95% confidence interval [CI], 0.63 to 0.86) to 94% (PPV, 0.83; 95% CI, 0.76 to 0.91) at 6 months. No change in probabilities of prediction dexterity was found after 4 weeks. CONCLUSIONS Based on the Fugl-Meyer scores of the flaccid arm, optimal prediction of arm function outcome at 6 months can be made within 4 weeks after onset. Lack of voluntary motor control of the leg in the first week with no emergence of arm synergies at 4 weeks is associated with poor outcome at 6 months.

Impact of Time on Improvement of Outcome After Stroke

Background and Purpose— Longitudinal conducted studies show that neurologic and functional recovery show faster recovery in the first weeks poststroke. The aim of the present study was to study the effects of progress of time on observed improvements in motor strength, synergisms, and activities during the first 16 weeks poststroke. Methods— Based on data from a previous study, 101 patients with first-ever ischemic middle cerebral artery strokes were prospectively investigated during the first 16 weeks after stroke. Progress of time was categorized into 8 biweekly time intervals and was used as the independent covariate in a first-order longitudinal regression model. The biweekly time change (progress of time) was related to improvement in upper and lower limb motor recovery assessed with Fugl-Meyer score and Motricity Index, reduction in visuospatial inattention based on the letter cancellation task, and improvement in walking ability, dexterity, and activities of daily living measured with the Functional Ambulation Categories, Action Research Arm test, and Barthel Index. Results— Time explained a significant change of 8.4 (42%) measurement units on the Barthel Index for the first 10 weeks poststroke, 1.1 (22%) measurement units on Functional Ambulation Categories, and 19% on the Action Research Arm test for the first 6 and 8 weeks poststroke. Approximately 25% (for Fugl-Meyer–arm) to 26% (for Motricity Index–arm) of the significant change in measurements units was explained by time alone for the upper limb compared with 33% for Fugl-Meyer–leg and 39% for Motricity Index–leg of the lower limb. Time accounted for a reduction of 16% in the letter cancellation task. Observed associations did not change after controlling for covariates such as age, gender, hemisphere of stroke, type of stroke, or intervention. Conclusion— Progress of time is an independent covariate that reflects spontaneous recovery of body functions and activities explaining ≈16% to 42% of the observed improvements in the first 6 to 10 weeks after stroke onset.

The Effectiveness of the Bobath Concept in Stroke Rehabilitation: What is the Evidence?

Background and Purpose— In the Western world, the Bobath Concept or neurodevelopmental treatment is the most popular treatment approach used in stroke rehabilitation, yet the superiority of the Bobath Concept as the optimal type of treatment has not been established. This systematic review of randomized, controlled trials aimed to evaluate the available evidence for the effectiveness of the Bobath Concept in stroke rehabilitation. Method— A systematic literature search was conducted in the bibliographic databases MEDLINE and CENTRAL (March 2008) and by screening the references of selected publications (including reviews). Studies in which the effects of the Bobath Concept were investigated were classified into the following domains: sensorimotor control of upper and lower limb; sitting and standing, balance control, and dexterity; mobility; activities of daily living; health-related quality of life; and cost-effectiveness. Due to methodological heterogeneity within the selected studies, statistical pooling was not considered. Two independent researchers rated all retrieved literature according to the Physiotherapy Evidence Database (PEDro) scale from which a best evidence synthesis was derived to determine the strength of the evidence for both effectiveness of the Bobath Concept and for its superiority over other approaches. Results— The search strategy initially identified 2263 studies. After selection based on predetermined criteria, finally, 16 studies involving 813 patients with stroke were included for further analysis. There was no evidence of superiority of Bobath on sensorimotor control of upper and lower limb, dexterity, mobility, activities of daily living, health-related quality of life, and cost-effectiveness. Only limited evidence was found for balance control in favor of Bobath. Because of the limited evidence available, no best evidence synthesis was applied for the health-related quality-of-life domain and cost-effectiveness. Conclusions— This systematic review confirms that overall the Bobath Concept is not superior to other approaches. Based on best evidence synthesis, no evidence is available for the superiority of any approach. This review has highlighted many methodological shortcomings in the studies reviewed; further high-quality trials need to be published. Evidence-based guidelines rather than therapist preference should serve as a framework from which therapists should derive the most effective treatment.

Therapy Impact on Functional Recovery in Stroke Rehabilitation: A critical review of the literature

Summary Optimal functional recovery is the ultimate goal in stroke rehabilitation. Evidence-based practice requires scientific evaluation of existing treatment programmes as well as research into new therapeutic strategies and comprehensive services. A number of studies have reported that stroke patients admitted to specialised stroke units are more likely to benefit from medical and paramedical treatment than patients on general wards. To date multiple clinical studies demonstrate no clear difference in effectiveness between therapeutic approaches in stroke rehabilitation. However, deficiencies in designs of randomised trials compromise methodological quality. Detecting minor treatment effects in stroke rehabilitation requires adequate statistical power, homogeneity in stroke population and the application of responsive tests. Accurate and reliable predictors of functional recovery are needed to set realistic and attainable treatment goals. However, spontaneous neurological recovery is most likely to be responsible for most functional recovery. Additional rehabilitation-induced effects may be generated due to biological variability. Comprehensive functional therapy incorporating elements of intensive and task-specific strategies is most likely to result in therapeutic effects.

Factors associated with reduced early survival in the Oxford phase III medial unicompartment knee replacement

The aim of this study was to determine the prognostic value of preoperative patellofemoral osteoarthritis, BMI and age for implant survival of unicompartmental knee arthroplasty (UKA) performed in patients meeting strict admission criteria. The data and radiographs of 437 unilateral Oxford phase III procedures (Biomet, Bridgend, UK) were analysed. All procedures were carried out or supervised by 13 specialised knee surgeons in three different hospitals. The study group comprised 437 patients with a median follow of 2.6 years (0.1-7.9). The cumulative standard case survival rate at 5 years, when there were still 101 patients at risk, was 84.7% (CI-95%: 80.1-89.3%). Young age (<60 years) was associated with a 2.2-fold increased adjusted risk of revision (CI: 1.08-4.43; p=0.03). The preoperative presence of radiological features of patellofemoral osteoarthritis was associated with a 0.3-fold reduced adjusted risk of revision (CI: 0.11-0.89; p=0.03). BMI>30 kg/m(2), gender, the surgeon performing the operation (either as an individual or categorised by annual surgical UKA caseload, i.e., more or less than 10 UKAs) and the hospital in which surgery took place did not predict implant survival of UKA. We conclude that young patients (<60 years) experience an increased early risk of revision for UKA when compared to older patients (>60 years). Obesity (BMI>30 kg/m(2)) and preoperative patellofemoral osteoarthritis are not associated with a decreased implant survival and therefore should not be considered risk factors in this context.

The Impact of Recovery of Visuo-Spatial Neglect on Motor Recovery of the Upper Paretic Limb after Stroke

The aim of the current study was to investigate the longitudinal relationship between improvements of synergism and strength of the upper paretic limb and severity of visuo-spatial neglect during the first 52 weeks post-stroke. The longitudinal association between severity of VSN and motor impairment using Fugl Meyer motor score and Motricity Index of the arm was measured in an intensive repeated measurement design including 18 measurement sessions for each subject. Neglect was assessed using the letter cancellation test applied in a prospective cohort of 101 ischemic, first-ever, hemispheric stroke patients. All time-dependent measures were taken weekly, starting within 14 days post-stroke. From week 10 to 20 biweekly measurements are obtained. The longitudinal relationship of (bi)weekly time on improvement of motor functions and severity of neglect was investigated using random coefficient analysis and trend analyses. Fifty-one of the 101 stroke patients showed neglect at stroke onset. Less improvement of synergism and strength of the upper paretic limb was associated with more severe neglect. This association was most pronounced in the first 10 weeks post-stroke. The seemingly suppressive effect of neglect on upper-limb motor recovery appears to take place mainly during spontaneous neurological recovery of first 10 weeks post-stroke. This finding suggests that damage to large-scale white matter tracts of especially the perceptual-attention networks suppress recovery of other networks at distance in the brain suggesting a common underlying mechanism.

Which aspects of safety culture predict incident reporting behavior in neonatal intensive care units? A multilevel analysis.

Objectives:Safety culture assessments are increasingly used to evaluate patient-safety programs. However, it is not clear which aspects of safety culture are most relevant in understanding incident reporting behavior, and ultimately improving patient safety. The objective of this study was to examine which aspects of safety culture predict incident reporting behavior in the neonatal intensive care unit (NICU), before and after implementation of a voluntary, nonpunitive incident reporting system. Design:Survey study based on a translated, validated version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. This survey incorporates two outcome measures, 11 dimensions of patient-safety culture as well as demographic data. Setting:Eight tertiary care NICUs and one surgical pediatric ICU. Subjects:All unit personnel. Intervention:Implementation of a specialty-based, voluntary, nonpunitive incident reporting system. Measurements and Main Results:The survey was conducted before (t = 0) and after (t = 1 yr) the intervention. Primary outcome: number of self-reported incidents in the past 12 months. Overall response rate was 80% (n = 700) at t = 0 and 76% (n = 670) at t = 1 yr. Based on a multivariate multilevel regression prediction model, the number of self-reported incidents increased after the intervention and was positively associated with a nonpunitive response to error and negatively associated with overall perceptions of safety and hospital management support for patient safety. Conclusions:A nonpunitive approach to error, hospital management support for patient safety, and overall perceptions of safety predict incident reporting behavior in the NICU. The relation between these aspects of safety culture and patient outcome requires further scrutiny and therefore remains an important issue to address in future research.

Course of bereavement over 8-10 years in first degree relatives and spouses of people who committed suicide: longitudinal community based cohort study

Objective To identify factors predicting the long term course of complicated grief, depression, and suicide ideation in a community based sample of relatives bereaved through suicide. Design Longitudinal cohort study. Included in the multilevel regression models were sociodemographic and personality features, mental health history, records of received help, long term complicated grief, depression, and suicide ideation. Setting Community based sample located in the northern part of the Netherlands. Participants 153 first degree relatives and spouses of 74 people who had committed suicide. Main outcome measures Complicated grief, depression, and suicide ideation assessed at 2.5 months, 13 months and 96-120 months (8-10 years) by means of self report questionnaires. Results Complicated grief, depression, and suicide ideation were mutually associated in relatives and spouses of people who had committed suicide. A history of attempted suicide was associated with long term suicide ideation (odds ratio 5.5, 95% confidence interval 1.8 to 16.7; P=0.003). Depression was more likely to be predicted by female sex and low mastery, whereas complicated grief was more likely to be predicted by the trauma of losing a child. The risk of both complicated grief and depression decreased over time; for complicated grief the change corresponded with a Cohen’s d effect size of 0.36 at 13 months and 0.89 at 96-120 months; for depression these figures were 0.28 at 13 months and 0.94 at 96-120 months. The long term course of bereavement was not affected by family based cognitive behavioural therapy, support from a general practitioner, and/or mental healthcare. Mutual support was associated with an increased risk of complicated grief: B regression coefficient=6.4 (95% confidence interval 1.8 to 11.0; P=0.006). Throughout this long term study, selection bias might have affected some outcomes. Conclusion In relatives bereaved by suicide, suicide ideation is associated with an increased risk of long term complicated grief and depression. The risk of complicated grief and depression decreases over time. Although mutual support is associated with an increased risk of complicated grief, we could not draw conclusions about a causal relation.

Diagnostic Accuracy of the Barthel Index for Measuring Activities of Daily Living Outcome After Ischemic Hemispheric Stroke: Does Early Poststroke Timing of Assessment Matter?

Background and Purpose— This study investigated the diagnostic accuracy of the Barthel Index (BI) in 206 stroke patients, measured within 72 hours, for activities of daily living at 6 months and determined whether the timing of BI assessment during the first days affects the accuracy of predicting activities of daily living outcome at 6 months. Methods— Receiver operating characteristic curves were constructed to determine the area under the curve and optimal cutoff points for BI at Days 2, 5, and 9. OR, sensitivity, specificity, positive predictive value, and negative predictive value were calculated to predict BI ≥19. Results— The area under the curve ranged from 0.785 on Day 2 to 0.837 and 0.848 on Days 5 and 9. Comparison of the receiver operating characteristic curves showed that the area under the curve was significantly different between Days 2 and 5 (P<0.001) and between Days 2 and 9 (P<0.001). No significant difference was found between Days 5 and 9 (P=0.08). Using a BI cutoff score of 7, the positive predictive value gradually increased from 0.696 on Day 2 to 0.817 on Day 2 to 0.864 on Day 9, whereas negative predictive value declined from 0.778 on Day 2 to 0.613 on Day 9. Conclusions— Assessment of the BI early poststroke showed good discriminative properties for final outcome of BI at 6 months. However, Day 5 proved to be the earliest time for making an optimal prediction of final outcome of activities of daily living. The BI should be measured at the end of the first week in hospital-based stroke units for early rehabilitation management.