Swati Mehta

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.

A systematic review of the therapeutic interventions for heterotopic ossification after spinal cord injury

Study design:Systematic review.Objective:To conduct a systematic review of the effectiveness of interventions used to prevent and treat heterotopic ossification (HO) after spinal cord injury (SCI).Setting:St Josephs Parkwood Hospital, London, Ontario, Canada.Methods:MEDLINE, CINAHL, EMBASE and PsycINFO databases were searched for articles addressing the treatment of HO after SCI. Studies were selected by two reviewers and were only included for analysis if at least 50% of the subjects had an SCI, there were at least three SCI subjects and if the study subjects participated in a treatment or intervention. Study quality was assessed by two independent reviewers using the Downs and Black evaluation tool for all studies, as well as the PEDro assessment scale for randomized control trials only. Levels of evidence were assigned using a modified Sackett scale.Results:A total of 13 studies met the inclusion criteria. The selected articles were divided into prevention or treatment of post-SCI HO. Nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, and pulse low-intensity electrogmagnetic field (PLIMF) therapy were reviewed as prophylactic measures. Bisphosphonates, radiotherapy and excision were reviewed as treatments of post-SCI HO.Conclusions:Pharmacological treatments of HO after SCI had the highest level of research evidence supporting their use. Of these, NSAIDs showed greatest efficacy in the prevention of HO when administered early after an SCI, whereas bisphosphonates were the intervention with strongest supportive evidence once HO had developed. Of the non-pharmacological interventions, PLIMF was supported by the highest level of evidence; however, more research is needed to fully understand its role.

Mortality among older adults after a traumatic brain injury: A meta-analysis

Primary objective: To examine mortality rates among older adults (≥60 years) post-traumatic brain injury (TBI). Research design: Systematic review and meta-analysis. Methods and procedures: Using multiple databases, a literature search was conducted for articles on mortality after TBI published up to July 2011. Information on patient characteristics (age, Glasgow Coma Scale (GCS), injury aetiology, etc.), mortality rates, time to death and study design was extracted and pooled. Main outcomes and results: Twenty-four studies had an overall mortality rate of 38.3% (CI 27.1–50.9%). The odds of mortality for those over 75 years compared to those of 65–74 years was 1.734 (CI = 1.311–2.292; p < 0.0001). Pooled mortality rates for mild (GCS 13–15), moderate (GCS 9–12) and severe (GCS 3–8) head injuries were 12.3% (CI = 6.1–23.3%), 34.3% (CI = 19.5–53.0%) and 65.3% (CI = 53.1–75.9), respectively. Odds ratios comparing severe to mild and moderate to mild head injuries were 12.69 (CI = 5.29–30.45; p < 0.0001) and 5.31 (CI = 3.41-8.29; p < 0.0001), respectively. There was no significant difference in the odds of death between severe and moderate injuries (p = 0.116). Conclusions: These mortality rates associated with moderate and severe injuries may be attributed to complications, chronic disease prevalence, conservative management techniques or the consequences of biological ageing.

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.

Therapeutic interventions for aphasia initiated more than six months post stroke: a review of the evidence

Abstract Background: Aphasia effects up to 38% of acute stroke patients. For many of these individuals, this condition persists far beyond the acute phase. The purpose of this review is to evaluate the effectiveness of therapeutic interventions for aphasia initiated more than 6 months post stroke. Methods: A literature search was conducted for articles in which aphasia treatments were initiated more than 6 months post stroke. Searches were conducted in multiple databases including MEDLINE, Scopus, CINAHL, and EMBASE. Results: A total of 21 randomized controlled trials (RCTs) met the inclusion criteria. There is good evidence to suggest that the use of computer-based treatments, constraint-induced therapy, intensity of therapy, group language therapies, and training conversation/communication partners are effective treatments for chronic aphasia. Repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and the use of the drugs piracetam, donepezil, memantime, and galantamine have also demonstrated evidence that they are effective treatments of aphasia 6 months or more post stroke onset. Neither filmed language instruction nor the drug bromocriptine has been shown to be effective in treating chronic aphasia. Conclusions: There is evidence to support the use of a number of treatments for chronic aphasia post stroke. Further research is required to fully support the use of these interventions and to explore the effectiveness of other aphasia interventions in the chronic stage.

An evidence-based review of the effectiveness of cognitive behavioral therapy for psychosocial issues post-spinal cord injury

STUDY DESIGN Systematic review. OBJECTIVE To examine the evidence supporting the effectiveness of cognitive behavioral therapy (CBT) for improving psychosocial outcomes in individuals with spinal cord injury (SCI). METHOD Electronic databases (MEDLINE, CINAHL, EMBASE, and PsycINFO) were searched for studies published between 1990 and October 2010. Randomized control trials (RCTs) and nonrandomized control trials (non-RCTs) utilizing a CBT intervention to improve psychosocial outcomes (depressive symptomatology, anxiety, coping, and adjustment to disability) in outpatient persons with SCI were included for review. Levels of evidence were assigned to each study using a modified Sackett scale. Effect size calculations for the interventions were provided where possible. RESULTS Nine studies met the inclusion criteria. The studies reviewed included two RCTs, six prospective controlled trials (PCTs) and one cohort study. All studies examined at least two groups. There is Level 1 and Level 2 evidence supporting the use of specialized CBT protocols in persons with SCI for improving outcomes related to depression, anxiety, adjustment, and coping. CONCLUSIONS CBT holds promise as an effective approach for persons with SCI experiencing depression, anxiety, adjustment, and coping problems. As CBT may involve many different components, it is important in the future to determine which of these elements alone or in combination is most effective in treating the emotional consequences of SCI.

Rethinking the continuum of stroke rehabilitation.

Suffering a stroke can be a devastating and life-changing event. Although there is a large evidence base for stroke rehabilitation in the acute and subacute stages, it has been long accepted that patients with stroke reach a plateau in their rehabilitation recovery relatively early. We have recently published the results of a systematic review designed to identify all randomized controlled trials (RCTs) where a rehabilitation intervention was initiated more than 6 months after the onset of the stroke. Of the trials identified, 339 RCTs met inclusion criteria, demonstrating an evidence base for stroke rehabilitation in the chronic phase as well. This seems at odds with the assumption that further recovery is unlikely and the subsequent lack of resources devoted to chronic stroke rehabilitation and management.

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 comparison of heterotopic ossification treatment within the traumatic brain and spinal cord injured population: An evidence based systematic review

BACKGROUND To compare the treatment of heterotopic ossification (HO) within the traumatic brain and spinal cord injured populations. METHODS MEDLINE/Pubmed, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing treatment of HO post-injury. Articles were constrained to: English language and human subjects. Studies were included if: n ≥ 50% of the subjects had a spinal cord injury (SCI) or a traumatic brain injury (TBI), n ≥ 3 SCI or TBI subjects, and study subjects participated in a treatment or intervention. Study quality, for randomized control trials (RCTs), were assessed using the PEDro assessment scale, while non-RCTs was assessed using the Downs and Black evaluation tool. A modified Sackett scale was used to apply levels of evidence for each intervention. RESULTS In total 26 studies (NTBI = 12; NSCI = 14) met inclusion criteria. The majority of studies (10/12) conducted in the TBI population were surgical interventions. Studies conducted with the SCI population investigated diverse pharmacological treatments including: bisphosphonates, non-steroidal anti-inflammatory drugs (NSAIDs) and Warfarin. Non-pharmacological studies investigated the benefits of pulse low-intensity electromagnetic field therapy, surgical excision, and radiotherapy in the treatment of HO. CONCLUSIONS Within the SCI literature, NSAIDs showed the greatest efficacy in the prevention of HO when administered early after a SCI, and biphosphonates were found to be the most effective treatment strategy. In the TBI population, surgical excision was the most effective treatment.

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.