Jerome Iruthayarajah

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.

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.

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

Study designMapping Review.ObjectiveThe 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.SettingNot applicable.MethodsA 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.ResultsIn 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).ConclusionsThe number of SCI RCTs and their associated sample size remains low; however, methodological quality has improved over time.

Risk factors for dysphagia after a spinal cord injury: a systematic review and meta-analysis

Study designSystematic review and meta-analysis.ObjectiveTo determine the risk factors predictive of dysphagia after a spinal cord injury (SCI).SettingNone.MethodsA comprehensive literature search was performed in five scientific databases for English articles that identified risk factors for dysphagia after a SCI in adult (≥19 years) individuals. Data extracted included: author name, year and country of publication, participant demographics, sample size, study design, method of dysphagia diagnosis, and risk factor percentages. Methodological quality of studies was assessed using the Newcastle–Ottawa Scale. For identified risk factors, risk percentages were transformed into risk ratios (RR) with 95% confidence intervals. Quantitative synthesis was performed for risk factors reported in two or more studies using restricted maximum-likelihood estimator random effects models.ResultsEleven studies met inclusion criteria of which ten studies were of moderate quality (n = 10). Significant risk factors included: age, injury severity, level of injury, presence of tracheostomy, coughing, voice quality, bronchoscopy need, pneumonia, mechanical ventilation, nasogastric tubes, comorbid injury, and a cervical surgery. Results of the quantitative synthesis indicated that the presence of a tracheostomy posed a threefold greater risk of the development of dysphagia (RR: 3.67); while, cervical surgery posed a 1.3 times greater risk of the development of dysphagia (RR: 1.30).ConclusionsKnowledge of these risk factors can be a resource for clinicians in the early diagnosis and appropriate medical management of dysphagia post SCI.

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

ABSTRACT 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.

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

ABSTRACT 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.

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.