Davide Corbetta

Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review

QUESTION In people after stroke, does virtual reality based rehabilitation (VRBR) improve walking speed, balance and mobility more than the same duration of standard rehabilitation? In people after stroke, does adding extra VRBR to standard rehabilitation improve the effects on gait, balance and mobility? DESIGN Systematic review with meta-analysis of randomised trials. PARTICIPANTS Adults with a clinical diagnosis of stroke. INTERVENTION Eligible trials had to include one these comparisons: VRBR replacing some or all of standard rehabilitation or VRBR used as extra rehabilitation time added to a standard rehabilitation regimen. OUTCOME MEASURES Walking speed, balance, mobility and adverse events. RESULTS In total, 15 trials involving 341 participants were included. When VRBR replaced some or all of the standard rehabilitation, there were statistically significant benefits in walking speed (MD 0.15 m/s, 95% CI 0.10 to 0.19), balance (MD 2.1 points on the Berg Balance Scale, 95% CI 1.8 to 2.5) and mobility (MD 2.3 seconds on the Timed Up and Go test, 95% CI 1.2 to 3.4). When VRBR was added to standard rehabilitation, mobility showed a significant benefit (0.7 seconds on the Timed Up and Go test, 95% CI 0.4 to 1.1), but insufficient evidence was found to comment about walking speed (one trial) and balance (high heterogeneity). CONCLUSION Substituting some or all of a standard rehabilitation regimen with VRBR elicits greater benefits in walking speed, balance and mobility in people with stroke. Although the benefits are small, the extra cost of applying virtual reality to standard rehabilitation is also small, especially when spread over many patients in a clinic. Adding extra VRBR time to standard rehabilitation also has some benefits; further research is needed to determine if these benefits are clinically worthwhile.

Survey of the Reporting Characteristics of Systematic Reviews in Rehabilitation

Background Systematic reviews (SRs) have become increasingly important for informing clinical practice; however, little is known about the reporting characteristics and the quality of the SRs relevant to the practice of rehabilitation health professionals. Objective The purpose of this study was to examine the reporting quality of a representative sample of published SRs on rehabilitation, focusing on the descriptive, reporting, and bias-related characteristics. Methods A cross-sectional study was conducted by searching MEDLINE for aggregative and configurative SRs indexed in 2011 that focused on rehabilitation as restorative of functional limitations. Two reviewers independently screened and selected the SRs and extracted data using a 38-item data collection form derived from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The data were analyzed descriptively. Results Eighty-eight SRs published in 59 journals were sampled. The median compliance with the PRISMA items was 17 (63%) out of 27 items (interquartile ratio=13–22 [48%–82%]). Two thirds of the SRs (n=66) focused on interventions for which efficacy is best addressed through a randomized controlled trial (RCT) design, and almost all of these SRs included RCTs (63/66 [95%]). More than two thirds of the SRs assessed the quality of primary studies (74/88 [84%]). Twenty-eight reviews (28/88 [32%]) meta-analyzed the results for at least one outcome. One half of the SRs reported positive statistically significant findings (46%), whereas a detrimental result was present only in one review. Conclusions This sample of SRs in the rehabilitation field showed heterogeneous characteristics and a moderate quality of reporting. Poor control of potential source of bias might be improved if more widely agreed-upon evidence-based reporting guidelines will be actively endorsed and adhered to by authors and journals.

Constraint‐induced movement therapy for upper extremities in people with stroke

Graeme J. Hankey MD, FRACP, FRCP Section Editor Constraint-induced movement therapy (CIMT) is a current approach to stroke rehabilitation that implies the forced and prolonged use of the affected arm by restraining the unaffected arm by enhancing the recovery of the residual motor power. The enhancement of the residual motor power by compulsory exercise is controversial. The objective was to assess the efficacy of CIMT for arm management in hemiparetic patients. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Library (Issue 1, 2008), the Cochrane Stroke Group trials register, MEDLINE, EMBASE, CINAHL, and PEDro (all to June 2008). We selected randomized trials comparing CIMT, modified CIMT, or forced use with other rehabilitative techniques or none in adults after …

Completeness of Outcomes Description Reported in Low Back Pain Rehabilitation Interventions: A Survey of 185 Randomized Trials

Purpose: To assess reporting completeness of the most frequent outcome measures used in randomized controlled trials (RCTs) of rehabilitation interventions for mechanical low back pain. Methods: We performed a cross-sectional study of RCTs included in all Cochrane systematic reviews (SRs) published up to May 2013. Two authors independently evaluated the type and frequency of each outcome measure reported, the methods used to measure outcomes, the completeness of outcome reporting using a eight-item checklist, and the proportion of outcomes fully replicable by an independent assessor. Results: Our literature search identified 11 SRs, including 185 RCTs. Thirty-six different outcomes were investigated across all RCTs. The 2 most commonly reported outcomes were pain (n=165 RCTs; 89.2%) and disability (n=118 RCTs; 63.8%), which were assessed by 66 and 44 measurement tools, respectively. Pain and disability outcomes were found replicable in only 10.3% (n=17) and 10.2% (n=12) of the RCTs, respectively. Only 40 RCTs (21.6%) distinguished between primary and secondary outcomes. Conclusions: A large number of outcome measures and a myriad of measurement instruments were used across all RCTs. The reporting was largely incomplete, suggesting an opportunity for a standardized approach to reporting in rehabilitation science.

Reporting of Rehabilitation Intervention for Low Back Pain in Randomized Controlled Trials: Is the Treatment Fully Replicable?

Study Design. Methodological review of randomized controlled trials (RCTs). Objective. To assess the quality of reporting of rehabilitation interventions for mechanical low back pain (LBP) in published RCTs. Summary of Background Data. Reporting of interventions in RCTs often focused on the outcome value and failed to describe interventions adequately. Methods. We systematically searched for all RCTs in Cochrane systematic reviews on LBP published in the Cochrane Database of Systematic Reviews until December 2013. The description of rehabilitation interventions of each RCT was evaluated independently by 2 of the investigators, using an ad hoc checklist of 7 items. The primary outcome was the number of items reported in sufficient details to be replicable in a new RCT or in everyday practice. Results. We found 11 systematic reviews, including 220 eligible RCTs, on LBP. Of those, 185 RCTs were included. The median publication year was 1998 (I-III quartiles, 1990 to 2004). The most reported items were the characteristics of participants (91.3%; 95% confidence interval [CI], 87.3–95.4), the intervention providers (81.1%; 95% CI, 75.4–86.7), and the intervention schedule (69.7%; 95% CI, 63–76). Based on the description of the intervention, less than one fifth would be replicable clinically. The proportion of trials providing all essential information about the participants and interventions increased from 14% (n = 7) in 1971 to 1980 to 20% (n = 75) in 2001 to 2010. Conclusion. Despite the remarkable amount of energy spent producing RCTs in LBP rehabilitation, the majority of RCTs failed to report sufficient information that would allow the intervention to be replicated in clinical practice. Improving the quality of intervention description is urgently needed to better transfer research into rehabilitation practices. Level of Evidence: 1

Constraint-induced movement therapy: trial sequential analysis applied to Cochrane collaboration systematic review results

BackgroundTrial sequential analysis (TSA) may establish when firm evidence about the efficacy of interventions is reached in a cumulative meta-analysis, combining a required information size with adjusted thresholds for conservative statistical significance. Our aim was to demonstrate TSA results on randomized controlled trials (RCTs) included in a Cochrane systematic review on the effectiveness of constraint-induced movement therapy (CIMT) for stroke patients.MethodsWe extracted data on the functional independence measure (FIM) and the action research arm test (ARAT) from RCTs that compared CIMT versus other rehabilitative techniques. Mean differences (MD) were analyzed using a random-effects model. We calculated the information size and the cumulative Z-statistic, applying the O’Brien-Fleming monitoring boundaries.ResultsWe included data from 14 RCTs. In the conventional meta-analysis (seven trials, 233 patients), the effect of CIMT on FIM was reported as significant (MD 2.88, 95% CI 0.08 to 5.68; P = 0.04). The diversity-adjusted required information size was 142 patients, and the cumulative Z-score did not cross the trial sequential monitoring boundary for benefit (adjusted 95% CI -0.02 to 5.78). The effect of CIMT on ARAT (nine trials, 199 patients) was reported as significant (MD 7.78, 95% CI 1.19 to 14.37; P = 0.02). However, the diversity-adjusted required information size was 252 patients, and the Z-score did not cross the trial sequential monitoring boundary for benefit (adjusted 95% CI -0.06 to 15.62).ConclusionsAlthough conventional meta-analyses of CIMT reached statistical significance, their overall results remain inconclusive and might be spurious. Researchers should not be overconfident on CIMT efficacy based on the results of meta-analyses and derived recommendations.

Mirror therapy for an adult with central post-stroke pain: a case report

BackgroundTreatment of central post-stroke pain (CPSP) after a thalamic-capsular stroke is generally based on pharmacological approach as it is low responsive to physiotherapy. In this case report, the use of mirror therapy (MT) for the reduction of CPSP in a subject after a stroke involving thalamus is presented.Case presentationFive years after a right lenticular-capsular thalamic stroke, despite a good recovery of voluntary movement that guaranteed independence in daily life activities, a 50-year-old woman presented with mild weakness and spasticity, an important sensory loss and a burning pain in the left upper limb. MT for reducing arm pain was administered in 45-min sessions, five days a week, for two consecutive weeks. MT consisted in performing symmetrical movements of both forearms and hands while watching the image of the sound limb reflected by a parasagittal mirror superimposed to the affected limb. Pain severity was assessed using visual analogue scale (VAS) before and after the intervention and at one-year follow-up. After the two weeks of MT, the patient demonstrated 4.5 points reduction in VAS pain score of the hand at rest and 3.9 points during a maximal squeeze left hand contraction. At one-year follow-up, pain reduction was maintained and also extended to the shoulder.ConclusionThis case report shows the successful application of a motor training with a sensory confounding condition (MT) in reducing CPSP in a patient with a chronic thalamic stroke.

Completeness of outcome description in studies for low back pain rehabilitation interventions: a survey of trials included in Cochrane reviews

95% CI 31.9% – 45.9%), and quality of life (45/185; 24,3%, 95% CI 18.1% – 30.5%) measured respectively by 70, 43, 41, 19 different measurement instruments (Figure 2). The procedure of blinding assessment was reported in 49.7% of the RCTs for pain (n= 82 RCTs) and 45% of RCTs for disability (n=53 RCTs). Pain, disability, range of motion, and quality of life outcomes were reported as fully replicable in 10.3% (n= 17 RCTs), 10.1% (n= 12 RCTs), 5.5% (n= 4 RCTs), and 6.6% (n= 3 RCTs) of the RCTs, respectively (Figure 3).