Shannon Janzen

Time to Rethink Long-Term Rehabilitation Management of Stroke Patients

Abstract Background: It has long been assumed that stroke patients plateau in their recovery within 3 to 6 months of their stroke, and evidence for rehabilitation during the chronic stage is limited. As a consequence, rehabilitation resources for the management of chronic stroke are minimal. Objective: The primary objective was to identify randomized controlled trials (RCTs) across the continuum of stroke rehabilitation for interventions initiated 6 months or more following the onset of stroke. The secondary objective was to determine whether treatments provided post 6 months are effective in improving outcomes among stroke survivors. Methods: Multiple databases were used to identify all RCTs published from 1970 to June 2012 in the English language where the stroke rehabilitation interventions were initiated more than 6 months after the onset of the stroke. Data abstraction was performed using a standardized data abstraction form that included general citation information, study participant characteristics, methodology, outcomes assessed, and overall findings. Results: The results of our analysis revealed 339 RCTs. The mean number of subjects per study was 73. Two hundred fifty-six RCTs were related to motor recovery, 39 to cognitive function, and only 19 to psychosocial issues and community reintegration. The majority of the RCTs demonstrated a significant positive benefit. Conclusions: There is a robust evidence-base for stroke rehabilitation interventions in chronic stroke. This research synthesis reveals a paradox, whereby an impressive evidencebase contrasts with the limited optimism and resources available for rehabilitation in chronic stroke.

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.

Systematic review and meta-analysis of constraint-induced movement therapy in the hemiparetic upper extremity more than six months post stroke.

Abstract Objective: To conduct a systematic review and meta-analysis of the available evidence on the effectiveness of constraint-induced movement therapy (CIMT) in the hemiparetic upper extremity (UE) among individuals who were more than 6 months post stroke. Methods: A literature search of multiple databases (PubMed, CINAHL, and EMBASE) was conducted to identify articles published in the English language up to and including July 2012. Studies were included for review if (1) ≥50% of the sample had sustained a stroke, (2) the research design was a randomized controlled trial (RCT), (3) the mean time since stroke was ≥6 months for both the treated and control groups, (4) the treatment group received CIMT, (5) the control group received a form of traditional rehabilitation, and (6) functional improvement was assessed both pre and posttreatment. Methodological quality was assessed using the PEDro tool with a score out of 10. Results: Sixteen RCTs (PEDro scores 4–8) met inclusion criteria and included a pooled sample size of 572 individuals with a mean age of 58.2 years (range, 30–87). The meta-analysis revealed a significant treatment effect on the amount of use and quality of movements subscales of the Motor Activity Log (P < .001, for both), Fugl-Meyer Assessment (P = .014), and Action Research Arm Test (P = .001); however, there was no significant treatment effect demonstrated by the Wolf Motor Function Test (P = .120) or FIM (P = .070). Conclusions: CIMT to improve UE function is an appropriate and beneficial therapy for individuals who have sustained a stroke more than 6 months previously.

Incog Recommendations for Management of Cognition Following Traumatic Brain Injury, Part V: Memory

Introduction:Traumatic brain injury results in complex cognitive sequelae. Impairments in memory are among the most common sequelae resulting in significant functional problems. An international team of researchers and clinicians (known as INCOG) was formed to develop recommendations for the management of impairments in memory. Methods:The experts met to select appropriate recommendations and then reviewed available literature to ensure recommendations were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials were developed. The team then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to the best practice recommendations. Results:The recommendations for rehabilitation of memory impairments support the integration of internal and external compensatory strategies implemented using appropriate instructional techniques that consider functional relevance and important patient characteristics. Restorative strategies have regained significant popularity, given broader access to computer technology; however, evidence for efficacy of these techniques remains weak and the choice in using these should be guided by special considerations. Conclusion:There is good evidence for the integration of internal and external compensatory memory strategies that are implemented using instructional procedures for rehabilitation for memory impairments. The evidence for the efficacy of restorative strategies currently remains weak.

INCOG Recommendations for management of cognition following traumatic brain injury. Part II: Attention and information processing speed

Introduction:Traumatic brain injury, due to its diffuse nature and high frequency of injury to frontotemporal and midbrain reticular activating systems, may cause disruption in many aspects of attention: arousal, selective attention, speed of information processing, and strategic control of attention, including sustained attention, shifting and dividing of attention, and working memory. An international team of researchers and clinicians (known as INCOG) convened to develop recommendations for the management of attentional problems. Methods:The experts selected recommendations from published guidelines and then reviewed literature to ensure that recommendations were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials were developed. The team then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to these best practices. Results:The recommendations and discussion highlight that metacognitive strategy training focused on functional everyday activities is appropriate. Appropriate use of dual task training, environmental modifications, and cognitive behavioral therapy is also discussed. There is insufficient evidence to support mindfulness meditation and practice on de-contextualized computer-based tasks for attention. Administration of the medication methylphenidate should be considered to improve information-processing speed. Conclusion:The INCOG recommendations for rehabilitation of attention provide up-to-date guidance for clinicians treating people with traumatic brain injury.

INCOG recommendations for management of cognition following traumatic brain injury, part I: posttraumatic amnesia/delirium.

Introduction:After traumatic brain injury (TBI) and emergence from coma, the majority of people experience posttraumatic amnesia (PTA), characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention, and sometimes agitation and delusions. An international team of researchers and clinicians developed recommendations for assessment and management of PTA. Methods:The experts met to select recommendations, then reviewed literature to ensure they were current. The team then prioritized recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations. Results:Evidence in support of assessment and management strategies during PTA is weak. It is recommended that duration of PTA be assessed prospectively using a validated tool. Consideration should also be given to use of a delirium assessment tool. No cognitive or pharmacological treatments are known to reduce PTA duration. Recommendations for environmental manipulations to reduce agitation during PTA are made. Minimizing use of neuroleptic medication is supported by animal research and 1 retrospective study. Conclusions:The duration of PTA is an important predictor of late outcome after TBI and should be monitored prospectively with a standardized tool. Neuroleptic medication should be avoided. There is a significant need for controlled studies evaluating the impact of therapy during PTA.

Resistance Training for Gait Speed and Total Distance Walked During the Chronic Stage of Stroke: A Meta-Analysis

Abstract Objective: To conduct a meta-analysis examining the effectiveness of resistance training on comfortable gait speed and total distance walked when initiated in the chronic stage of stroke. Methods: MEDLINE, CINAHL, EMBASE, and Scopus databases were searched from 1980 to June 2012. Studies were selected if they met the following criteria: (1) they were randomized controlled trials; (2) individuals in the studies were entered into the studies at or over 6 months post stroke; (3) resistance training was initiated during the chronic stage of stroke; and (4) study participants were ≥18 years of age. A standardized mean difference (SMD ± SE and 95% confidence interval [CI]) was calculated for at least 1 of the following outcomes in each study: comfortable gait speed and/or 6-minute walk test (6MWT). Treatment effect sizes were interpreted as follows: small, >0.2; moderate, >0.5; or large, >0.8. Study quality was assessed using the Physiotherapy Evidence Database (PEDro) tool. Results: Ten randomized controlled trials met inclusion criteria. Significant improvement was seen for gait speed with a small effect size (0.295 ± 0.118; 95% CI, 0.063–0.526; P < .013) and a pooled post mean speed of 0.79 m/s, and for the 6MWT (0.247 ± 0.111; 95% CI, 0.030–0.465; P = .026) with a pooled post mean total distance walked of 271.9 m. Conclusion: This meta-analysis demonstrated that providing lower limb resistance training to community-dwelling individuals who are 6 months post stroke has the capacity to improve comfortable gait speed and total distance walked.

A meta-analysis of functional outcome among older adults with traumatic brain injury

OBJECTIVE The objective of this study was to determine rates of functional outcomes, based on Glasgow Outcome Scale scores, among older adults (>60 years) after a traumatic brain injury. METHODS An extensive database search was conducted. To be included all articles were published in English, included individuals 60 years or older, explicitly stated in-hospital GCS scores and GOS scores within one year post-TBI. Data was pooled on patient characteristics, mortality rates, time to death, and study design. RESULTS A total of 11 studies were included in this review. Among individuals with severe TBI, favourable, unfavourable, and fatal outcomes were observed in 7.9% (CI 5.3%-11.8%), 13.8% (CI 10.0%-18.8%) and 79.3% (CI 73.2%-84.4%), respectively. Among those with moderate TBI, favourable, unfavourable, and fatal outcomes were observed in 32.2% (CI 18.0%-50.7%), 29.5% (CI 16.5%-47.0%), and 42.5% (CI 26.1%-60.7%), respectively. Among those with mild TBI, favourable, unfavourable, and fatal outcomes were observed in 80.5% (CI 53.2%-93.7%), 7.0% (CI 1.9%-22.7%), and 10.7% (CI 3.1%-30.9%), respectively. CONCLUSION This study has demonstrated the significant interaction between GCS and GOS among older adults. Although older adults may require aggressive and comprehensive treatment to achieve these favourable outcomes, high rates of unfavourable outcome should not justify the use of conservative treatment.

Examining the effectiveness of intrathecal baclofen on spasticity in individuals with chronic spinal cord injury: A systematic review

Abstract Objective To review the available evidence on the effectiveness of intrathecal baclofen in the treatment of spasticity in individuals with spinal cord injuries (SCIs) at least 6 months post-injury or diagnosis. Data sources A literature search of multiple databases (Pub Med, CINAHL, EMBASE) was conducted to identify articles published in the English language. Study selection Studies were included for review if: (1) more than 50% of the sample size had suffered a traumatic or non-traumatic SCI; (2) there were more than three subjects; (3) subjects received continuous intrathecal baclofen via an implantable pump aimed at improving spasticity; and (4) all subjects were ≥6 months post-SCI, at the time of the intervention. Data extraction Data extracted from the studies included patient and treatment characteristics, study design, method of assessment, and outcomes of the intervention. Data synthesis Methodological quality was assessed using the PEDro for randomized-controlled trials (RCTs) and the Downs and Black (D&B) tool for non-RCTs. A level of evidence was assigned to each intervention using a modified Sackett scale. Conclusion The literature search resulted in 677 articles. No RCTs and eight non-RCTs (D&B scores 13–24) met criteria for inclusion, providing a pooled sample size of 162 individuals. There was substantial level 4 evidence that intrathecal baclofen is effective in reducing spasticity. Mean Ashworth scores reduced from 3.1–4.5 at baseline to 1.0–2.0 (P < 0.005) at follow-up (range 2–41 months). Average dosing increased from 57–187 µg/day at baseline to 218.7–535.9 µg/day at follow-up. Several complications from the use of intrathecal baclofen or pump and catheter malfunction were reported.

Cardiovascular conditioning for comfortable gait speed and total distance walked during the chronic stage of stroke: a meta-analysis.

Abstract Objective: To examine the effectiveness of cardiovascular conditioning on comfortable gait speed and total distance walked when initiated in the chronic stage of stroke through a meta-analysis. Methods: MEDLINE, CINAHL, EMBASE, and Scopus databases were searched from 1980 to June 2012. A study was selected if (1) it was a randomized controlled trial; (2) individuals in the study were entered into the study at or over 6 months post stroke; (3) cardiorespiratory training was initiated during the chronic stage of stroke; and (4) study participants were ≥18 years of age. A standardized mean difference (SMD ± SE and 95% confidence interval [CI]) was calculated for comfortable gait speed and/or 6-minute walk test (6MWT). Results from all studies were then pooled using a random effects model. Treatment effect sizes were interpreted as small, >0.2; moderate, >0.5; or large, >0.8. Methodological quality of studies was assessed using the Physiotherapy Evidence Database (PEDro) tool. Results: Seven studies met inclusion criteria. The analysis demonstrated a moderate and significant effect on 6MWT post treatment (SMD = 0.581 ± 0.277; 95% CI, -0.037 to 1.125; P = .036) with an improvement of 111.4 m to a pooled average of 357.7 m. No significant improvement in comfortable gait speed was noted post treatment (SMD = 0.159 ± 0.124; 95% CI, -0.085 to 0.402; P = .202) or at follow-up (SMD = 0.248 ± 0.256; 95% CI, -0.253 to 0.750; P = .332). Conclusion: Cardiovascular conditioning resulted in clinically relevant gains in walking distance of over 100 m post treatment on the 6MWT when initiated during the chronic stage of stroke. These results demonstrate that individuals in the chronic stage of stroke can still benefit from interventions to improve gait and mobility. This has important implications for outpatient and community-based programs.