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. 2018 Sep 3;9(9):CD006876.
doi: 10.1002/14651858.CD006876.pub5.

Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke

Jan Mehrholz  1 , Marcus Pohl, Thomas Platz, Joachim Kugler, Bernhard Elsner
Affiliations

Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke

Jan Mehrholz et al. Cochrane Database Syst Rev. .

Abstract

Background: Electromechanical and robot-assisted arm training devices are used in rehabilitation, and may help to improve arm function after stroke.

Objectives: To assess the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength in people after stroke. We also assessed the acceptability and safety of the therapy.

Search methods: We searched the Cochrane Stroke Group's Trials Register (last searched January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2018, Issue 1), MEDLINE (1950 to January 2018), Embase (1980 to January 2018), CINAHL (1982 to January 2018), AMED (1985 to January 2018), SPORTDiscus (1949 to January 2018), PEDro (searched February 2018), Compendex (1972 to January 2018), and Inspec (1969 to January 2018). We also handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trialists, experts, and researchers in our field, as well as manufacturers of commercial devices.

Selection criteria: Randomised controlled trials comparing electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation or placebo interventions, or no treatment, for people after stroke.

Data collection and analysis: Two review authors independently selected trials for inclusion, assessed trial quality and risk of bias, used the GRADE approach to assess the quality of the body of evidence, and extracted data. We contacted trialists for additional information. We analysed the results as standardised mean differences (SMDs) for continuous variables and risk differences (RDs) for dichotomous variables.

Main results: We included 45 trials (involving 1619 participants) in this update of our review. Electromechanical and robot-assisted arm training improved activities of daily living scores (SMD 0.31, 95% confidence interval (CI) 0.09 to 0.52, P = 0.0005; I² = 59%; 24 studies, 957 participants, high-quality evidence), arm function (SMD 0.32, 95% CI 0.18 to 0.46, P < 0.0001, I² = 36%, 41 studies, 1452 participants, high-quality evidence), and arm muscle strength (SMD 0.46, 95% CI 0.16 to 0.77, P = 0.003, I² = 76%, 23 studies, 826 participants, high-quality evidence). Electromechanical and robot-assisted arm training did not increase the risk of participant dropout (RD 0.00, 95% CI -0.02 to 0.02, P = 0.93, I² = 0%, 45 studies, 1619 participants, high-quality evidence), and adverse events were rare.

Authors' conclusions: People who receive electromechanical and robot-assisted arm training after stroke might improve their activities of daily living, arm function, and arm muscle strength. However, the results must be interpreted with caution although the quality of the evidence was high, because there were variations between the trials in: the intensity, duration, and amount of training; type of treatment; participant characteristics; and measurements used.

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Conflict of interest statement

Jan Mehrholz: was a coauthor of one included trial (Hesse 2005). He did not participant in the quality assessment or data extraction of this study. Marcus Pohl: was a coauthor of one included trial (Hesse 2005). He did not participant in the quality assessment or data extraction of this study. Thomas Platz: none known. Joachim Kugler: none known. Bernhard Elsner: none known.

Figures

1
1
Study flow diagram. Please note that several studies have been published in multiple full‐text articles. Hence the number of assessed full‐text articles and the number of identified studies may differ.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Funnel plot of comparison: 1 Electromechanical and robotic assisted training versus all other intervention, outcome: 1.1 Activities of daily living at the end of intervention phase.
4
4
Funnel plot of comparison: 1 Electromechanical and robotic assisted training versus all other intervention, outcome: 1.2 Activities of daily living at the end of intervention phase: subgroup analysis comparing acute and chronic phase.
5
5
Funnel plot of comparison: 1 Electromechanical and robotic assisted training versus all other intervention, outcome: 1.3 Arm function at the end of intervention phase.
6
6
Funnel plot of comparison: 1 Electromechanical and robotic assisted training versus all other intervention, outcome: 1.4 Arm muscle strength at the end of intervention phase.
1.1
1.1. Analysis
Comparison 1 Electromechanical and robotic assisted training versus all other intervention, Outcome 1 Activities of daily living at the end of intervention phase.
1.2
1.2. Analysis
Comparison 1 Electromechanical and robotic assisted training versus all other intervention, Outcome 2 Activities of daily living at the end of intervention phase: subgroup analysis comparing acute and chronic phase.
1.3
1.3. Analysis
Comparison 1 Electromechanical and robotic assisted training versus all other intervention, Outcome 3 Arm function at the end of intervention phase.
1.4
1.4. Analysis
Comparison 1 Electromechanical and robotic assisted training versus all other intervention, Outcome 4 Arm muscle strength at the end of intervention phase.
1.5
1.5. Analysis
Comparison 1 Electromechanical and robotic assisted training versus all other intervention, Outcome 5 Acceptability: dropouts during intervention period.
2.1
2.1. Analysis
Comparison 2 Sensitivity analysis: by trial methodology, Outcome 1 Activities of daily living.
2.2
2.2. Analysis
Comparison 2 Sensitivity analysis: by trial methodology, Outcome 2 Arm function.
3.1
3.1. Analysis
Comparison 3 Subgroup analysis by treatment approach, Outcome 1 Activities of daily living at the end of intervention phase: subgroup analysis comparing different device groups.
3.2
3.2. Analysis
Comparison 3 Subgroup analysis by treatment approach, Outcome 2 Arm function at the end of intervention phase: subgroup analysis comparing different device groups.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Orihuela‐Espina 2016 {published data only}
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Timmermans 2014 {published data only}
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References to studies excluded from this review

Abdollahi 2014 {published data only}
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Fluet 2012 {published data only}
    1. Fluet G. Robotically Facilitated Virtual Rehabilitation of Arm Transport Integrated With Finger Movement Versus Isolated Training of the Arm and Hand in Persons With Hemiparesis [Dissertation]. University of Medicine and Dentistry of New Jersey, 2012. [MEDLINE: ; 978‐1‐267‐42769‐4]
Hill 2011 {published data only}
    1. Hill V, Page S. The efficacy of using a combined regimen of portable robotics and a repetitive task specific practice to increase motor function in the upper arm. Archives of Physical Medicine and Rehabilitation 2011;92(10):1718. [MEDLINE: ; 0003‐9993]
    1. Page S, Hill V, White S. Portable upper extremity robotics is as efficacious as upper extremity rehabilitative therapy. Archives of Physical Medicine and Rehabilitation 2012;93(10):E21. [MEDLINE: ] - PMC - PubMed
    1. Page S, Hill V, White S. Portable upper extremity robotics is as efficacious as upper extremity rehabilitative therapy: a randomized controlled pilot trial. Clinical Rehabilitation 2013;27(6):494‐503. [MEDLINE: ; 1477‐0873] - PMC - PubMed
Hu 2009 {published data only}
    1. Hu XL, Tong KY, Song R, Zheng XJ, Leung WW. A comparison between electromyography‐driven robot and passive motion device on wrist rehabilitation for chronic stroke. Neurorehabilitation and Neural Repair 2009;23(8):837‐46. [MEDLINE: ] - PubMed
    1. Hu XL, Tong KY, Song R, Zheng XJ, Leung WWF. A randomized controlled trial on the recovery process of wrist rehabilitation assisted by electromyography (EMG)‐driven robot for chronic stroke. IEEE International Conference on Rehabilitation Robotics: Reaching Users & the Community (ICORR); 23‐26 June, 2009. 2009:28‐33. [MEDLINE: ]
    1. Hu XL, Tong KY, Song R, Zheng XJ, Lui KH, Leung WWF, et al. Quantitative evaluation of motor functional recovery process in chronic stroke patients during robot‐assisted wrist training. Neurorehabilitation and Neural Repair 2009;19(4):639‐50. [MEDLINE: ; 10506411] - PubMed
Hu 2015 {published data only}
    1. Hu XL, Tong RK, Ho NS, Xue JJ, Rong W, Li LS. Wrist rehabilitation assisted by an electromyography‐driven neuromuscular electrical stimulation robot after stroke. Neurorehabilitation and Neural Repair 2015;29(8):767‐76. - PubMed
Jackson 2013 {published data only}
    1. ISRCTN16472838. iPAM (robot) Stroke Intervention Trial (iSIT) for arm weakness. www.isrctn.com/ISRCTN16472838 (first received 8 August 2012). [DOI: 10.1186/ISRCTN16472838] - DOI
    1. Jackson AE, Levesley MC, Makower SG, Cozens JA, Bhakta BB. Development of the iPAM MkII system and description of a randomized control trial with acute stroke patients. IEEE 13th International Conference on Rehabilitation Robotics (ICORR 2013), 24‐26 June, 2013, Seattle, Washington, USA. 2013. [MEDLINE: ] - PubMed
Krebs 2000 {published data only}
    1. Krebs HI, Volpe BT, Aisen ML, Hogan N. Increasing productivity and quality of care: robot‐aided neuro‐rehabilitation. Journal of Rehabilitation Research and Development 2000;37(6):639‐52. - PubMed
Luft 2004 {published data only}
    1. Luft AR, McCombe‐Waller S, Whitall J, Forrester LW, Macko R, Sorkin JD, et al. Repetitive bilateral arm training and motor cortex activation in chronic stroke: a randomized controlled trial. JAMA 2004;292(15):1853‐61. - PMC - PubMed
Lum 2004a {published data only}
    1. Lum PS, Taub E, Schwandt D, Postman M, Hardin P, Uswatte G. Automated constraint‐induced therapy extension (AutoCITE) for movement deficits after stroke. Journal of Rehabilitation Research and Development 2004;41(3A):249‐58. - PubMed
Lum 2004b {published data only}
    1. Lum PS, Burgar CG, Shor PC. Evidence for improved muscle activation patterns after retraining of reaching movements with the MIME robotic system in subjects with post‐stroke hemiparesis. IEEE Transactions on Neural Systems and Rehabilitation Engineering 2004;12(2):186‐94. - PubMed
NCT0040766707 {published data only}
    1. NCT00407667. Transcranial direct current stimulation (tDCS) of the lesioned or non‐lesioned hemisphere plus computer‐assisted arm trainer: a randomized, placebo‐controlled double‐blind multi‐centre study in patients with severe arm paresis early after stroke. clinicaltrials.gov/show/NCT00407667 (first received 5 December 2006).
Page 2012 {published data only}
    1. Page SJ, Levin L, Hermann V, Dunning K, Levine P. Longer versus shorter daily durations of electrical stimulation during task‐specific practice in moderately impaired stroke. Archives of Physical Medicine and Rehabilitation 2012;93(2):200‐6. [MEDLINE: ] - PubMed
Peters 2017 {published data only}
    1. Peters H, Page S, Persch A. Wearing a myoelectric elbow‐wrist‐hand orthosis reduces upper extremity impairment in chronic stroke. Archives of Physical Medicine & Rehabilitation 2017;98(10):e13. [00039993] - PubMed
Prange 2015a {published data only}
    1. Prange GB, Kottink AIR, Buurke JH, Eckhardt MMEM, Keulen‐Rouweler BJ, Ribbers GM, et al. The effect of arm support combined with rehabilitation games on upper‐extremity function in subacute stroke: a randomized controlled trial. Neurorehabilitation and Neural Repair 2015;29:174‐82. - PubMed
    1. Rietman JS, Prange G, Kottink A, Ribbers G, Buurke J. The effect of an arm supporting training device in sub‐acute stroke patients: randomized clinical trial. Archives of Physical Medicine and Rehabilitation 2014;95(10):e8. [MEDLINE: ]
Prange 2015b {published data only}
    1. Prange GB, Kottink AIR, Buurke JH, Eckhardt MMEM, Keulen‐Rouweler BJ, Ribbers GM, et al. The effect of arm support combined with rehabilitation games on upper‐extremity function in subacute stroke: a randomized controlled trial. Neurorehabilitation and Neural Repair 2015;29(2):174‐82. [1552‐6844] - PubMed
Reinkensmeyer 2000 {published data only}
    1. Reinkensmeyer DJ, Kahn LE, Averbuch M, McKenna‐Cole A, Schmit BD, Rymer WZ. Understanding and treating arm movement impairment after chronic brain injury: progress with the ARM guide. Journal of Rehabilitation Research and Development 2000;37(6):653‐62. - PubMed
Samsygina 2010 {published data only}
    1. Samsygina O. Complex step‐by‐step rehabilitation program with robotic mechanotherapy in acute MCA ischemic cerebral stroke. Neurorehabilitation and Neural Repair 2010;24(9):NP100.
Simkins 2016 {published data only}
    1. Simkins M, Byl N, Kim H, Abrams G, Rosen J. Upper limb bilateral symmetric training with robotic assistance and clinical outcomes for stroke: a pilot study. International Journal of Intelligent Computing and Cybernetics 2016;9(1):83‐104. [1756378X]
Sun 2016 {published data only}
    1. Sun L, Zhang Y, Wang W. Effect of robot‐assisted upper limb rehabilitation training on motor function in patients with upper limb spasticity with shoulder subluxation after stroke. Chinese Journal of Cerebrovascular Diseases 2016;13(6):302‐6.
Takahashi 2008 {published data only}
    1. Takahashi CD, Der‐Yeghiaian L, Le V, Motiwala RR, Cramer SC. Robot‐based handmotor therapy after stroke. Brain 2008;131:425‐37. - PubMed
Takebayashi 2013 {published data only}
    1. Takahashi K, Amano S, Domen K, Hachisuka K, Kimura T, Takebayashi T. Which stroke patients benefit from robotic therapy for the upper extremities?. Cerebrovascular Diseases 2013;35:145. [MEDLINE: ; 1015‐9770]
    1. Takahashi K, Domen K, Hachisuka K, Sakamoto T, Toshima M, Otaka Y, et al. Upper extremity robotic therapy is effective in post‐stroke hemiplegia: a randomized controlled trial. International Stroke Conference; 2011 Feb 8‐11; Los Angeles, USA. 2011. [MEDLINE: ]
    1. Takebayashi T, Koyama T, Amano S, Hanada K, Tabusadani M, Hosomi M, et al. A 6‐month follow‐up after constraint‐induced movement therapy with and without transfer package for patients with hemiparesis after stroke: a pilot quasi‐randomized controlled trial. Clinical Rehabilitation 2013;27(5):418‐26. [MEDLINE: ] - PubMed
    1. Takebayashi T, Takahashi K, Amano S, Domen K, Hachisuka K, Kimura T. Which stroke patients benefit from robotic therapy for the upper extremities?. Cerebrovascular Diseases 2013;35 Suppl 3:145. [MEDLINE: ]
Thorsen 2013 {published data only}
    1. Thorsen R, Cortesi M, Jonsdottir J, Carpinella I, Morelli D, Casiraghi A, et al. Myoelectrically driven functional electrical stimulation may increase motor recovery of upper limb in poststroke subjects: a randomized controlled pilot study. Journal of Rehabilitation Research and Development 2013;50(6):785‐94. [MEDLINE: ; 0748‐7711] - PubMed
Tropea 2013 {published data only}
    1. Tropea P, Cesqui B, Monaco V, Aliboni S, Posteraro F, Micera S. Effects of the alternate combination of error‐enhancing and active assistive robot‐mediated treatments on stroke patients. IEEE Journal of Translational Engineering in Health and Medicine 2013;1:2100‐9. [MEDLINE: ; 2168‐2372] - PMC - PubMed
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Wang 2007 {published data only}
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Whitall 2000 {published data only}
    1. Whitall J, McCombe Waller S, Silver KH, Macko RF. Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke 2000;31(10):2390‐5. - PubMed
Willigenburg 2017 {published data only}
    1. Willigenburg NW, McNally MP, Hewett TE, Page SJ. Portable myoelectric brace use increases upper extremity recovery and participation but does not impact kinematics in chronic, poststroke hemiparesis. Journal of Motor Behavior 2017;49(1):46‐54. - PMC - PubMed
Yoo 2015 {published data only}
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Zahi 2017 {published data only}
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References to studies awaiting assessment

Chisari 2014 {published data only}
    1. Chisari C, Frisoli A, Sotgiu E, Procopio C, Bertolucci F, Bergamasco M, et al. Training and assessment of upper limb motor function with a robotic exoskeleton in chronic stroke patients. Gait and Posture 2014;40:S27‐8. [MEDLINE: ; 0966‐6362]
Esquenazi 2017 {published data only}
    1. Esquenazi A, Lee S, Watanabe TK, Nastaskin A, Scheponik K, O'Neill J. Randomized supplemental therapeutic conventional or robotic upper limb exercise in acute stroke rehabilitation. PM&R Journal 2017;9:S146. [1934‐1482]
Faran 2008 {published data only}
    1. Faran S, Kaick S, Eickhoff C, Mahoney R, Mauritz KH. An active and repetitive robot assisted training improves functional motor recovery of the arm in sub‐acute stroke patients. Stroke 2008;39(2):617.
Joo 2014 {published data only}
    1. Joo MC, Park HI, Noh SE, Kim JH, Kim HJ, Jang CH. Effects of robot‐assisted arm training in patients with subacute stroke. Brain Neurorehabilitation 2014;77(2):111‐7.
NCT00435617 {published data only}
    1. NCT00435617. Study of hand therapy 3 to 24 months after stroke. Clinical assessment of a massed practice therapy device ‐ study of hand therapy 3 to 24 months after stroke. clinicaltrials.gov/ct2/show/NCT00435617 (first received 15 February 2007).
Reinkensmeyer 2012 {published data only}
    1. Reinkensmeyer DJ, Wolbrecht ET, Chan V, Chou C, Cramer SC, Bobrow JE. Comparison of three‐dimensional, assist‐as‐needed robotic arm/hand movement training provided with Pneu‐WREX to conventional tabletop therapy after chronic stroke. American Journal of Physical Medicine and Rehabilitation 2012;91(11 Suppl):s232‐41. - PMC - PubMed
Seo 2014 {published data only}
    1. Seo HG, Beom J, Oh BM, Han TR. Effects of robot‐assisted upper limb training on hemiplegic patients. Brain Neurorehabilitation 2014;7(1):39‐47.

References to ongoing studies

Krebs 2007 {published and unpublished data}
    1. Krebs HI, Volpe BT, Williams D, Celestino J, Charles SK, Lynch D, et al. Robot‐aided neurorehabilitation: a robot for wrist rehabilitation. IEEE Transactions on Neural Systems and Rehabilitation Engineering 2007;15(3):327‐34. - PMC - PubMed
NCT00272259 {published and unpublished data}
    1. NCT00272259. Robots for stroke survivors. clinicaltrials.gov/ct2/show/NCT00272259 (first received 5 January 2006).
NCT00343304 {published data only}
    1. NCT00343304. Pilot study ‐ comparison of upper body ergometer vs. robot in upper extremity motor recovery post‐stroke. clinicaltrials.gov/ct2/show/NCT00343304 (first received 22 June 2006).
NCT00453843 {published data only}
    1. NCT00453843. Shoulder, or elbow, or wrist: what should we train first after a stroke? The effect of proximal and distal training on stroke recovery. clinicaltrials.gov/ct2/show/NCT00453843 (first received 29 March 2007).
NCT00785343 {published data only}
    1. NCT00785343. Study of robot‐assisted arm therapy for acute stroke patients. clinicaltrials.gov/ct2/show/NCT00785343 (first received 5 November 2008).
NCT00878085 {published data only}
    1. NCT00878085. Functional magnetic resonance imaging (fMRI) and robot‐assisted practice of activities of daily living. clinicaltrials.gov/ct2/show/NCT00878085 (first received 8 April 2009).
NCT01117194 {published data only}
    1. NCT01117194. Rehabilitation robot for upper limbs, component project 5: effect on shoulder training using rehabilitation robot for stroke patients. clinicaltrials.gov/show/NCT01117194 (first received 5 May 2010).
NCT01253018 {published data only}
    1. NCT01253018. Evaluation of robot assisted neuro‐rehabilitation. clinicaltrials.gov/ct2/show/NCT01253018 (first received 3 December 2010).
NCT01552733 {published data only}
    1. NCT01552733. Robotic therapy early after stroke events. clinicaltrials.gov/ct2/show/NCT01552733 (first received 13 March 2012).
NCT01655446 {published data only}
    1. NCT01655446. Effects of RR and MT on patients with stroke. clinicaltrials.gov/ct2/show/NCT01655446 (first received 1 August 2012).
    1. NCT01724164. Robot‐ versus mirror‐assisted rehabilitation in stroke patients. clinicaltrials.gov/ct2/show/NCT01724164 (first received 9 November 2012).
NCT01767480 {published data only}
    1. NCT01767480. Effects and mechanisms of intensive robot‐assisted therapy in patients with subacute stroke: outcomes in brain/movement reorganization, sensorimotor and daily functions, and physiological markers. clinicaltrials.gov/show/NCT01767480 (first received 14 January 2013).
NCT01907139 {published data only}
    1. NCT01907139. Comparative efficacy research of robot‐assisted therapy with and without constraint‐induced therapy in stroke rehabilitation. clinicaltrials.gov/ct2/show/NCT01907139 (first received 24 July 2013).
NCT01939041 {published data only}
    1. NCT01939041. Efficacy of unilateral versus bilateral approach to robot‐assisted rehabilitation in patients with subacute stroke. clinicaltrials.gov/ct2/show/NCT01939041 (first received 11 September 2013).
NCT02077439 {published data only}
    1. NCT02077439. Trial: Interactive intention‐driven upper‐limb training robotic system. clinicaltrials.gov/show/NCT02077439 (first received 4 March 2014).
NCT02079779 {published data only}
    1. NCT0279779. Efficacy study of an interactive robot for the rehabilitation of the upper limb in acute stroke patients. clinicaltrials.gov/ct2/show/NCT02079779 (first received 6 March 2014).
NCT02096445 {published data only}
    1. NCT02096445. Neurocognitive robot‐assisted rehabilitation of hand function after stroke. clinicaltrials.gov/ct2/show/NCT02096445 (first received 26 March 2014).
NCT02188628 {published data only}
    1. NCT02188628. Refinement and clinical evaluation of the H‐Man for arm rehabilitation after stroke. clinicaltrials.gov/ct2/show/NCT02188628 (first received 11 July 2014).
NCT02228863 {published data only}
    1. NCT02228863. Upper extremity rehabilitation using robot and botulinum toxin. clinicaltrials.gov/ct2/show/NCT02228863 (first received 29 August 2014).
NCT02254343 {published data only}
    1. NCT02254343. Effects of proximal and distal robot‐assisted therapy combined with functional training. clinicaltrials.gov/ct2/show/NCT02254343 (first received 1 October 2014).
NCT02319785 {published data only}
    1. NCT02319785. Effects of robot‐assisted combined therapy in upper limb rehabilitation in stroke patients. clinicaltrials.gov/ct2/show/NCT02319785 (first received 18 December 2014).
NCT02323061 {published data only}
    1. NCT02323061. Brain Computer Interface (BCI) system for stroke rehabilitation. clinicaltrials.gov/ct2/show/NCT02323061 (first received 23 December 2014).
    1. NCT02323074. Brain training system using electroencephalography (EEG) for neurorehabilitation of hand function after stroke. clinicaltrials.gov/ct2/show/NCT02323074 (first received 23 December 2014).
NTR3669 {published data only}
    1. NTR3669. Feasibility of supervised care & rehabilitation involving personal tele‐robotics for arm/hand function of chronic stroke patients. www.trialregister.nl/trialreg/admin/rctview.asp?TC=3669 (first received 19 October 2012).
RATULS {published data only}
    1. Bosomworth H, Aird L, Andole S, Cohen D, Dawson J, Eyre J, et al. Robot assisted training for the upper limb after stroke (RATULS). European Stroke Organisation Annual Conference; 2015. 2015:421.
    1. ISRCTN33421390. Arm intervention after stroke (AIAS): a feasibility study. www.isrctn.com/ISRCTN33421390 (first received 7 July 2009).
    1. Rodgers H, Shaw L, Bosomworth H, Aird L, Alvarado N, Andole S, et al. Robot Assisted Training for the Upper Limb after Stroke (RATULS): study protocol for a randomised controlled trial. Trials 2017;18(1):340. - PMC - PubMed
    1. Stroke Research Group. RATULS: Robot Assisted Training for the Upper Limb after Stroke. research.ncl.ac.uk/ratuls/ (accessed 28 May 2015). [MEDLINE: ]

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References to other published versions of this review

Mehrholz 2008
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Publication types