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Meta-Analysis
. 2014 Nov 12;2014(11):CD010820.
doi: 10.1002/14651858.CD010820.pub2.

Interventions for improving upper limb function after stroke

Alex Pollock  1 , Sybil E Farmer, Marian C Brady, Peter Langhorne, Gillian E Mead, Jan Mehrholz, Frederike van Wijck
Affiliations
Meta-Analysis

Interventions for improving upper limb function after stroke

Alex Pollock et al. Cochrane Database Syst Rev. .

Abstract

Background: Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking.

Objectives: To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke.

Search methods: We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews.

Selection criteria: We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this.

Data collection and analysis: Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research.

Main results: Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning.

Authors' conclusions: Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.

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Conflict of interest statement

The work presented here represents the views of the overview authors and not necessarily those of the funding bodies.

Alex Pollock: This Cochrane overview has received grant funding from the Chief Scientist Office of the Scottish Government. Sybil E Farmer: has an interest in using published evidence to improve the management of contractures after stroke and is exploring this with colleagues through a systematic review with a recently approved protocol. Marian C Brady: received a small consultancy fee paid to employer from Genentech in respect of time spent on a research project investigating the properties of EQ5‐D. Peter Langhorne: none relevant to the current review. Gillian E Mead: has developed a course on exercise after stroke that was licensed to Later Life Training, which pays royalties for the course; has received expenses for speaking at conferences on exercise and fatigue after stroke. Jan Mehrholz: none known Frederike van Wijck: none known.

Figures

1
1
Taxonomy of rehabilitation interventions used within this overview. Key: CIMT: constraint‐induced movement therapy; NDT: neurodevelopmental treatment; PNF: proprioceptive neuromuscular facilitation; Tx: treatment.
2
2
Summary of findings.
3
3
Study flow diagram.
4
4
AMSTAR and mAMSTAR results (AMSTAR in shaded columns; mAMSTAR in unshaded columns).
5
5
Effects of interventions: upper limb function. Moderate‐level GRADE evidence (comparisons reporting standardised mean differences only). Comparison of intervention versus any other control (including no treatment, control or usual care), unless otherwise stated (as in the comparison of bilateral arm training vs unilateral arm training). Favours intervention if to the right of the zero line (for comparison of bilateral vs unilateral arm training—favours unilateral arm training).
6
6
Date of last search for evidence for identified interventions.
See this image and copyright information in PMC

Update of

References

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