Shelialah Pereira

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.

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.

Rehabilitation of Individuals With Severe Stroke: Synthesis of Best Evidence and Challenges in Implementation

Abstract Purpose: The rehabilitation of patients who are recovering from severe stroke is associated with a substantial use of resources but limited potential for functional improvement. As a result, these individuals are not perceived as being ideal candidates for inpatient stroke rehabilitation. The objective of this review was to describe the evidence for and discuss some of the challenges of providing inpatient rehabilitation services for individuals with severe stroke. Methods: A literature search was conducted to identify relevant studies. Studies were included if (a) inpatient rehabilitation was compared to other rehabilitation settings and (b) the study population included individuals with severe stroke-related disability. Following data abstraction, the methodological quality of randomized controlled trials (RCTs) that met inclusion criteria was assessed using the PEDro scale. Results: Fourteen studies (including 4 RCTs) met inclusion criteria. Despite making limited functional improvement, persons with severe strokes who received inpatient rehabilitation had reduced mortality, decreased lengths of hospital stay, and increased likelihood of discharge home when compared to those who received rehabilitation in other settings. Rehabilitation on specialized stroke units resulted in better outcomes than other forms of inpatient rehabilitation for this group. Conclusion: Inpatient rehabilitation is beneficial for individuals with severe stroke. However, for this group, it may be necessary to rethink the emphasis on functional improvement and focus more on discharge planning. These individuals may still have restricted access to rehabilitation as a result of limited resources, the perception that they have poor rehabilitation potential, limited understanding of the goals of rehabilitation for this population, and a lack of research.

Evidence to practice: botulinum toxin in the treatment of spasticity post stroke.

Abstract Introduction: Spasticity is a significant problem following stroke. Although there is extensive research examining the efficacy of botulinum toxin as a treatment, there are challenges in implementing its use. Methods: The results from previously published randomized controlled trials and systematic reviews examining the use of botulinum toxin as a treatment for poststroke spasticity of the upper and lower limb and the shoulder are summarized. Several barriers to implementation are discussed. Results: There is strong evidence that denervation of muscles, in the lower extremity and upper extremity post stroke, with botulinum toxin reduces focal spasticity. There is also strong evidence that it is associated with a small but significant improvement in gait velocity based on a recent meta-analysis. However, evidence that botulinum toxin injections are associated with improved function and improved quality of life is not as compelling. There is evidence that botulinum toxin injected into the subscapularis muscle can reduce spastic shoulder pain and improve passive range of motion of the hemiplegic shoulder. There are a number of challenges with botulinum toxin, including uncertainty over its role in improving motor dysfunction following stroke, the determination of which subsets of patients may benefit, the cost of treatment, and the identification of meaningful outcome measures. Conclusions: Botulinum toxin has been shown to be an effective treatment in reducing tone and managing spasticity post stroke. However, its effectiveness in improving function has been more controversial.

Functional Electrical Stimulation for Improving Gait in Persons With Chronic Stroke

Abstract Background: The long-term management of stroke is an area of increasing clinical interest, and it is important to identify therapeutic interventions that are effective in the chronic phase post stroke. Objective: To conduct a systematic review on the effectiveness of functional electrical stimulation (FES) in improving lower extremity function in chronic stroke. Methods: Multiple databases (PubMed, CINAHL, EMBASE, and Scopus) were searched for relevant articles. Studies were included for review if (1) ≥50% of the study population has sustained a stroke, (2) the study design was a randomized controlled trial (RCT), (3) the mean time since stroke was ≥6 months, (4) FES or neuromuscular electrical stimulation (NMES) was compared to other interventions or a control group, and (5) functional lower extremity outcomes were assessed. Methodological quality was assessed using the PEDro tool. A standardized mean difference (SMD ± SE and 95% confidence interval [CI]) was calculated for the 6-minute walk test (6MWT). Pooled analysis was conducted for treatment effect of FES on the 6MWT distance using a fixed effects model. Results: Seven RCTs (PEDro scores 5–7) including a pooled sample size of 231 participants met inclusion criteria. Pooled analysis revealed a small but significant treatment effect of FES (0.379 ± 0.152; 95% CI, 0.081 to 0.677; P = .013) on 6MWT distance. Conclusion: FES may be an effective intervention in the chronic phase post stroke. However, its therapeutic value in improving lower extremity function and superiority over other gait training approaches remains unclear.

A systematic review of studies reporting multivariable models to predict functional outcomes after post-stroke inpatient rehabilitation

Abstract Purpose: This systematic review summarizes the utility of variables available at acute discharge after stroke for predicting functional independence at discharge from inpatient rehabilitation. Methods: A systematic review of four electronic databases (Medline, EMBASE, PsycINFO and CINAHL) was conducted to identify studies reporting multivariable models predicting post-rehabilitation Barthel Index (BI) or Functional Independence Measure (FIM®) scores. In studies meeting inclusion criteria, the frequency with which candidate predictors were found statistically significant was calculated and summarized. Results: A total of 3260 articles were screened, of which 27 were included and 63 multivariable models of discharge BI or FIM® were reported. In all, 126 candidate predictors of BI or FIM® were explored. Variables found to be significant most frequently included admission functional level (BI or FIM®), National Institute of Health Stroke Scale (NIHSS), dysphasia, impulsivity, neglect, previous stroke, and age. Conclusions: Only a selected group of variables have repeatedly proven to be significant predictors of functional ability after post-stroke inpatient rehabilitation. Implications for Rehabilitation This review identifies, and summarizes, studies that have used a multivariable model to predict Barthel Index (BI) or Functional Independence Measure (FIM®) after post-stroke inpatient rehabilitation. Clinicians making decisions about admission to inpatient rehabilitation should consider age and a measure of stroke severity, functional status and progress to date. Variables that have been demonstrated to be useful most commonly included age, admission functional level (BI or FIM), National Institute of Health Stroke Scale, dysphasia, impulsivity, neglect, and previous stroke.

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.

Evidence for therapeutic interventions for hemiplegic shoulder pain during the chronic stage of stroke: a review.

Abstract Objective: To determine the effectiveness of therapeutic interventions targeting hemiplegic shoulder pain (HSP) more than 6 months post stroke. Methods: A literature search of multiple databases (PubMed, CINAHL, Ovid, and EMBASE) was conducted to identify articles published in the English language from 1980 to April 2012. Studies were included if (1) all participants were adults who had sustained a stroke; (2) research design was a randomized controlled trial (RCT) that examined the effectiveness of any treatment for HSP; (3) all participants had experienced stroke at least 6 months previously; and (4) an assessment of pain had been conducted before and after treatment using a standardized method. The following data were extracted: patient characteristics (ie, age, gender, time since stroke), sample size, study design, measurement of pain pre and post treatment, and adverse events. Results: Ten RCTs (PEDro scores 4–9) met inclusion criteria and included a total sample size of 388 individuals with a mean age of 53.2 years (range, 43.6–73.2). Mean time post stroke was 18.4 months. Three studies addressed the use of botulinum toxin type A (BTx-A); 2 studies examined electrical stimulation; 3 studies focused on intraarticular glenohumeral corticosteroid injections; 1 studied subacromial corticosteroid injections; and 1 study looked at massage therapy. Conclusions: Positive outcomes were noted with the use of corticosteroid injections and electrical stimulation and conflicting results were seen regarding the use of BTx-A. Overall, these targeted therapies provide benefit in the treatment of HSP in individuals who are more than 6 months post stroke.

Aphasia and return to work in younger stroke survivors

Background: Younger stroke patients (i.e., typically those between 18 and 65 years of age) experience fewer stokes than older patients. However, younger stroke survivors are more likely to live longer with disability, have dependants, and be engaged in full- or part-time employment. Aphasia post stroke occurs in 10% of younger survivors, and can significantly impact the ability to resume previous activities of daily living. Unfortunately traditional rehabilitation often does not account for language impairments that impact vocational status. Aims: This review reports the rate of successful return to work (RTW) for younger stroke survivors with aphasia. Aphasia is consistently regarded as a barrier to an individuals ability to RTW post stroke. However, the degree to which working-age stroke survivors with aphasia successfully RTW remains unknown. In addition, conflicting evidence has been found as to the predictive nature of communication impairments on RTW. Main Contribution: The primary outcome in which we were interested was the degree to which younger survivors with aphasia return to work. Secondary outcomes were the type of assessment used, the definition of work, and the age of the study sample. Nine studies were identified (aphasia N = 415, total N = 1612). The average rate of successful RTW for young survivors with aphasia was 28.4% compared to 44.7% for all young stroke survivors. Conclusions: Younger survivors with aphasia were less likely to RTW post stroke than those without aphasia. Strategies to reduce this disparity, such as specialised vocational rehabilitation, should be made available to this population.

Are Recommendations Regarding Inpatient Therapy Intensity Following Acute Stroke Really Evidence-Based?

Abstract Background: Recommendations regarding the daily minimum dose of therapy that patients should receive following stroke are included in many clinical practice guidelines. We examined the related literature to determine whether a specific evidence-based recommendation could be supported. Method: Six clinical practice guidelines were retrieved and examined to determine what recommendation, if any, had been made regarding the daily provision of therapy during inpatient rehabilitation. All studies cited by the guideline authors to support their recommendations were identified and retrieved. Studies in which treatment was (a) focused on motor recovery, (b) initiated during inpatient rehabilitation, and (c) provided within 3 months of stroke onset were reviewed in greater detail. Results: Three of the 6 identified guidelines recommended daily minimum amounts of therapy, ranging from 45 to 60 minutes each day of occupational (OT) and physiotherapy (PT), and 3 made general statements indicating that increased intensity of therapy was either recommended or was not recommended. Among the 6 guidelines, 37 studies had been cited to support the recommendations. Of these, 15 were reviewed in detail. On average, patients in the control condition received 48 minutes of therapy per day while those in the experimental group received 63% more, or 78 minutes per day. Patients in the experimental group performed significantly better on the primary outcome in only 5 (33%) studies. Conclusions: We believe the evidence base cannot support a specific recommendation related to therapy intensity during inpatient rehabilitation following stroke.