Repetitive task training after stroke: a Cochrane systematic review

1
Repetitive task training after stroke a Cochrane
systematic review

• French B, Thomas L, Leathley MJ, Sutton CJ,
  McAdam J,, Forster A1, Langhorne P2, Price CIM3,
  Walker A2, Watkins CL.
• University of Central Lancashire, University of
  Leeds1, University of Glasgow2 Northumbria
  Healthcare NHS Trust3
• Contact details bfrench1_at_uclan.ac.uk or
  lhthomas_at_uclan.ac.uk

2
Background

• more than 110,000 people per annum will suffer
  from stroke
• single largest cause of severe adult disability
  (Bonita 1992)
• major cause of long-term neurological disability
• around half of all stroke survivors left with
  severe functional problems
• 5-20 with initial upper limb impairment fully
  regain arm function
• 30-66 regain no functional use at six months

3
Repetitive task training background

• systematic reviews for affected upper limb
  suggest participants benefit from exercise
  programmes where functional tasks directly
  trained
• more intensive therapy may improve rate of
  activities of daily living recovery (Kwakkel
  2004)
• repetitive task practice combines elements of
• intensity of practice
• functional relevance

4
Why did we do the review?

• repetitive task training has potential to
• be a resource efficient component of stroke
  rehabilitation
• be delivered in a group setting
• lead to sustainable, functional gains

5
Objectives I

• Primary
• to determine if RTT improves functional ability
  in adults after stroke in
• upper limb function/reach
• lower limb function/balance
• global motor function
• Secondary
• 1) To determine effect of RTT on
• ADL function
• Motor impairment
• Quality of life/health status
• Adverse outcomes

6
Objectives II

• 2) to determine factors that could influence
  primary and secondary outcome measures, including
  the effect of
• dose of task practice
• timing of intervention
• type of intervention

7
Inclusion criteria

• type of study
• randomised and quasi-randomised trials
• one arm had to include RTT compared against usual
  practice (including no treatment or attention
  control)
• type of participants
• adults who have had a stroke according to WHO
  criteria (WHO 1989)
• type of intervention
• active motor sequence performed repetitively
  within a single training session
• practice aimed towards a clear functional goal
• time duration or number of repetitions within a
  single session and the number of sessions needed
  to be stated

8
Inclusion criteria

• types of outcome measures
• primary
• upper limb function/reach
• Arm function (e.g. Wolf Motor Function Test)
• Hand function (e.g. Motor Assessment Scale
  hand)
• lower limb function/balance
• Lower limb function (e.g. walking distance,
  walking speed)
• Global motor function (e.g. Rivermead Motor
  Assessment Scale)

9
Process of Review

10
Results upper limb, arm function
11
Results hand function and sitting balance/reach

• no evidence for the effectiveness of RTT on
• hand function
• SMD 0.16, 95 CI -0.07 to 0.40
• sitting balance/reach
• SMD 0.23, 95 CI -0.05 to 0.50
• results for later follow-up were not
  statistically significant
• up to 6 months post-therapy
• between 6 months and 1 year post-therapy

12
Results lower limb, walking distance
13
Results lower limb

• Evidence for statistically significant small to
  moderate impact of RTT training on
• walking speed (SMD 0.29, 95 CI 0.04 to 0.53)
• Sit-to-stand (standard effect estimate 0.35, 95
  CI 0.13 to 0.56)
• Results for functional ambulation small, of
  borderline significance
• SMD 0.25, 95 CI 0.00 to 0.51

14
Implications for practice

• evidence to support the general principle that
  repetitive, task-specific training for lower
  limbs and result in functional gain
• repetitive task training for upper limbs showed
  no significant advantage

15
Implications for research

• further primary research exploring impact of
  type and amount of task training,
• and how to maintain functional gain
• trials evaluating efficacy and cost effectiveness
  of different intervention delivery methods
• e.g. group training, or practice at home

16
Acknowledgements

• This presentation is based on a wider project
  funded by the NHS RD Health Technology
  Assessment Programme (Project No 05/07/04). The
  views and opinions expressed herein are those of
  the authors and do not necessarily reflect those
  of the Department of Health.
• The full review for RTT was carried out using
  Cochrane Collaborative methodology and resources.
  The review can be found athttp//www.mrw.intersci
  ence.wiley.com/cochrane/clsysrev/articles/CD006073
  /frame.html
• French B, Thomas LH, Leathley MJ, Sutton CJ,
  McAdam J, Forster A, Langhorne P, Price CIM,
  Walker A, Watkins CL. Repetitive task training
  for improving functional ability after stroke.
  Cochrane Database of Systematic Reviews 2007,
  Issue 4. Art. No. CD006073. DOI
  10.1002/14651858.CD006073.pub2.