Upper limb motor deficits in severe stroke survivors often remain unresolved over extended time periods. Novel neurotechnologies have the potential to significantly support upper limb motor ...restoration in severely impaired stroke individuals. Here, we review recent controlled clinical studies and reviews focusing on the mechanisms of action and effectiveness of single and combined technology-aided interventions for upper limb motor rehabilitation after stroke, including robotics, muscular electrical stimulation, brain stimulation and brain computer/machine interfaces. We aim at identifying possible guidance for the optimal use of these new technologies to enhance upper limb motor recovery especially in severe chronic stroke patients. We found that the current literature does not provide enough evidence to support strict guidelines, because of the variability of the procedures for each intervention and of the heterogeneity of the stroke population. The present results confirm that neurotechnology-aided upper limb rehabilitation is promising for severe chronic stroke patients, but the combination of interventions often lacks understanding of single intervention mechanisms of action, which may not reflect the summation of single intervention's effectiveness. Stroke rehabilitation is a long and complex process, and one single intervention administrated in a short time interval cannot have a large impact for motor recovery, especially in severely impaired patients. To design personalized interventions combining or proposing different interventions in sequence, it is necessary to have an excellent understanding of the mechanisms determining the effectiveness of a single treatment in this heterogeneous population of stroke patients. We encourage the identification of objective biomarkers for stroke recovery for patients' stratification and to tailor treatments. Furthermore, the advantage of longitudinal personalized trial designs compared to classical double-blind placebo-controlled clinical trials as the basis for precise personalized stroke rehabilitation medicine is discussed. Finally, we also promote the necessary conceptual change from 'one-suits-all' treatments within in-patient clinical rehabilitation set-ups towards personalized home-based treatment strategies, by adopting novel technologies merging rehabilitation and motor assistance, including implantable ones.
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.
Methods
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.
The effectiveness of Pilates as an exercise therapy for low back pain has been attracting attention, but it has not yet been fully verified in Japan. In November 2021, the Department of Orthopedics ...at Tokushima University, in collaboration with the University Hospital and five other hospitals and two universities in the prefecture, launched a project on the promotion and effectiveness of Pilates-based exercise therapy for low back pain.Patients were either hospitalized at Tokushima University Hospital or were returnees who had undergone surgery in the past and had given their consent. Patients were either inpatients (6 days a week, 40-120 minutes a day, for 2-4 weeks) or outpatients (1-2 days a week, 40 minutes a time) at the collaborating hospital, and exercise therapy with Pilates was performed. Pilates aimed to improve the stability of the lumbar spine and the mobility of the thoracic spine and hip joint based on Joint-by-Joint theory. These exercise therapies were administered by physicians, physical therapists, and occupational therapists who were fully trained in Pilates instruction.A 73-year-old woman with kyphosis and scoliosis complained of low back pain throughout the day. After 4 weeks of Pilates, the pain disappeared. In addition, her balance function improved, and her posture improved in standing, sitting, and walking.In the future, we would like to increase the number of cases by utilizing the network with partner hospitals and verify the effectiveness of Pilates exercise therapy.
Cardio-oncology is an emerging discipline focused predominantly on the detection and management of cancer treatment-induced cardiac dysfunction (cardiotoxicity), which predisposes to development of ...overt heart failure or coronary artery disease. The direct adverse consequences, as well as those secondary to anticancer therapeutics, extend beyond the heart, however, to affect the entire cardiovascular-skeletal muscle axis (ie, whole-organism cardiovascular toxicity). The global nature of impairment creates a strong rationale for treatment strategies that augment or preserve global cardiovascular reserve capacity. In noncancer clinical populations, exercise training is an established therapy to improve cardiovascular reserve capacity, leading to concomitant reductions in cardiovascular morbidity and its attendant symptoms. Here, we overview the tolerability and efficacy of exercise on cardiovascular toxicity in adult patients with cancer. We also propose a conceptual research framework to facilitate personalized risk assessment and the development of targeted exercise prescriptions to optimally prevent or manage cardiovascular toxicity after a cancer diagnosis.
Inflammageing – characterized by age-related chronic low-grade inflammation is considered to be positively influenced by physical exercises. The aim of this systematic review is to provide an update ...of the most recent literature regarding exercise effects on the inflammatory profile in older adults.
This review is an update of an earlier published literature review and was performed according to the NICE guidelines. Databases PubMed and Web-of-Science were systematically searched by two independent authors screening for papers published since 2016. Effect sizes of outcome parameters related to the inflammatory profile were calculated where possible.
Twenty-three articles were included. Resistance training (RT) was the most investigated type of exercise (13 articles: 8 in healthy, 1 in frail and 4 in older adults with a specific condition or disease). Aerobic training (AT) was investigated in 8 articles, including 5 studies in older adults with a specific disease or condition. Combined resistance & aerobic training (CT) was investigated in 7 articles: 3 were in healthy, 1 in frail and 3 in older adults with a specific condition or disease. 1 study investigated the effects of Tai Chi in older adults with mild cognitive impairment. In frail older subjects, IGF-1 - sole marker investigated - significantly increased after 8 weeks RT and CT, whereas AT showed no significant effects compared to control. Most consistent exercise effects consisted in lowering of circulating levels of CRP, IL-6 and TNF-α; which seemed more prominent in healthy older adults compared to those with a specific disease or condition. None of the studies reported an exacerbation of inflammation following exercise and all studied exercise protocols were feasible and safe for older adults.
Overall, significant anti-inflammatory effects of exercise in older persons were reported. Literature remains extremely scarce regarding the exercise-induced effects in frail older persons. Therefore, there is an urgent need for more studies focusing on the frail elderly. There is growing literature data on exercise interventions in older adults with a specific condition or disease; however, it appears more challenging to reduce inflammageing through exercise in these specific patient groups. Importantly, the exercise interventions performed in all studies appeared to be feasible and safe for older patients, thus the presence of a specific condition or disease should not be considered as a contra-indication to perform physical exercise.
Exercise for hand osteoarthritis Østerås, Nina; Kjeken, Ingvild; Smedslund, Geir ...
Cochrane database of systematic reviews,
01/2017, Letnik:
2017, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Background
Hand osteoarthritis (OA) is a prevalent joint disease that may lead to pain, stiffness and problems in performing hand‐related activities of daily living. Currently, no cure for OA is ...known, and non‐pharmacological modalities are recommended as first‐line care. A positive effect of exercise in hip and knee OA has been documented, but the effect of exercise on hand OA remains uncertain.
Objectives
To assess the benefits and harms of exercise compared with other interventions, including placebo or no intervention, in people with hand OA. Main outcomes are hand pain and hand function.
Search methods
We searched six electronic databases up until September 2015.
Selection criteria
All randomised and controlled clinical trials comparing therapeutic exercise versus no exercise or comparing different exercise programmes.
Data collection and analysis
Two review authors independently selected trials, extracted data, assessed risk of bias and assessed the quality of the body of evidence using the GRADE approach. Outcomes consisted of both continuous (hand pain, physical function, finger joint stiffness and quality of life) and dichotomous outcomes (proportions of adverse events and withdrawals).
Main results
We included seven studies in the review. Most studies were free from selection and reporting bias, but one study was available only as a congress . It was not possible to blind participants to treatment allocation, and although most studies reported blinded outcome assessors, some outcomes (pain, function, stiffness and quality of life) were self‐reported. The results may be vulnerable to performance and detection bias owing to unblinded participants and self‐reported outcomes. Two studies with high drop‐out rates may be vulnerable to attrition bias. We downgraded the overall quality of the body of evidence to low owing to potential detection bias (lack of blinding of participants on self‐reported outcomes) and imprecision (studies were few, the number of participants was limited and confidence intervals were wide for the outcomes pain, function and joint stiffness). For quality of life, adverse events and withdrawals due to adverse events, we further downgraded the overall quality of the body of evidence to very low because studies were very few and confidence intervals were very wide.
Low‐quality evidence from five trials (381 participants) indicated that exercise reduced hand pain (standardised mean difference (SMD) ‐0.27, 95% confidence interval (CI) ‐0.47 to ‐0.07) post intervention. The absolute reduction in pain for the exercise group, compared with the control group, was 5% (1% to 9%) on a 0 to 10 point scale. Pain was estimated to be 3.9 points on this scale (0 = no pain) in the control group, and exercise reduced pain by 0.5 points (95% CI 0.1 to 0.9; number needed to treat for an additional beneficial outcome (NNTB) 9).
Four studies (369 participants) indicated that exercise improved hand function (SMD ‐0.28, 95% CI ‐0.58 to 0.02) post intervention. The absolute improvement in function noted in the exercise group, compared with the control group, was 6% (0.4% worsening to 13% improvement). Function was estimated at 14.5 points on a 0 to 36 point scale (0 = no physical disability) in the control group, and exercise improved function by 2.2 points (95% CI ‐0.2 to 4.6; NNTB 9).
One study (113 participants) evaluated quality of life, and the effect of exercise on quality of life is currently uncertain (mean difference (MD) 0.30, 95% CI ‐3.72 to 4.32). The absolute improvement in quality of life for the exercise group, compared with the control group, was 0.3% (4% worsening to 4% improvement). Quality of life was 50.4 points on a 0 to 100 point scale (100 = maximum quality of life) in the control group, and the mean score in the exercise group was 0.3 points higher (3.5 points lower to 4.1 points higher).
Four studies (369 participants) indicated that exercise reduced finger joint stiffness (SMD ‐0.36, 95% CI ‐0.58 to ‐0.15) post intervention. The absolute reduction in finger joint stiffness for the exercise group, compared with the control group, was 7% (3% to 10%). Finger joint stiffness was estimated at 4.5 points on a 0 to 10 point scale (0 = no stiffness) in the control group, and exercise improved stiffness by 0.7 points (95% CI 0.3 to 1.0; NNTB 7).
Three studies reported intervention‐related adverse events and withdrawals due to adverse events. The few reported adverse events consisted of increased finger joint inflammation and hand pain. Low‐quality evidence from the three studies showed an increased likelihood of adverse events (risk ratio (RR) 4.55, 95% CI 0.53 to 39.31) and of withdrawals due to adverse events in the exercise group compared with the control group (RR 2.88, 95% CI 0.30 to 27.18), but the effect is uncertain and further research may change the estimates.
Included studies did not measure radiographic joint structure changes. Two studies provided six‐month follow‐up data (220 participants), and one (102 participants) provided 12‐month follow‐up data. The positive effect of exercise on pain, function and joint stiffness was not sustained at medium‐ and long‐term follow‐up.
The exercise intervention varied largely in terms of dosage, content and number of supervised sessions. Participants were instructed to exercise two to three times a week in four studies, daily in two studies and three to four times daily in another study. Exercise interventions in all seven studies aimed to improve muscle strength and joint stability or function, but the numbers and types of exercises varied largely across studies. Four studies reported adherence to the exercise programme; in three studies, this was self‐reported. Self‐reported adherence to the recommended frequency of exercise sessions ranged between 78% and 94%. In the fourth study, 67% fulfilled at least 16 of the 18 scheduled exercise sessions.
Authors' conclusions
When we pooled results from five studies, we found low‐quality evidence showing small beneficial effects of exercise on hand pain, function and finger joint stiffness. Estimated effect sizes were small, and whether they represent a clinically important change may be debated. One study reported quality of life, and the effect is uncertain. Three studies reported on adverse events, which were very few and were not severe.
Purpose
This study aims to summarize and critically evaluate the effects of Tai Chi and Qigong (TCQ) mind–body exercises on symptoms and quality of life (QOL) in cancer survivors.
Methods
A ...systematic search in four electronic databases targeted randomized and non-randomized clinical studies evaluating TCQ for fatigue, sleep difficulty, depression, pain, and QOL in cancer patients, published through August 2016. Meta-analysis was used to estimate effect sizes (ES, Hedges’
g
) and publication bias for randomized controlled trials (RCTs). Methodological bias in RCTs was assessed.
Results
Our search identified 22 studies, including 15 RCTs that evaluated 1283 participants in total, 75% women. RCTs evaluated breast (
n
= 7), prostate (
n
= 2), lymphoma (
n
= 1), lung (n = 1), or combined (
n
= 4) cancers. RCT comparison groups included active intervention (
n
= 7), usual care (
n
= 5), or both (
n
= 3). Duration of TCQ training ranged from 3 to 12 weeks. Methodological bias was low in 12 studies and high in 3 studies. TCQ was associated with significant improvement in fatigue (ES = − 0.53,
p
< 0.001), sleep difficulty (ES = − 0.49,
p
= 0.018), depression (ES = − 0.27,
p
= 0.001), and overall QOL (ES = 0.33,
p
= 0.004); a statistically non-significant trend was observed for pain (ES = − 0.38,
p
= 0.136). Random effects models were used for meta-analysis based on
Q
test and
I
2
criteria. Funnel plots suggest some degree of publication bias. Findings in non-randomized studies largely paralleled meta-analysis results.
Conclusions
Larger and methodologically sound trials with longer follow-up periods and appropriate comparison groups are needed before definitive conclusions can be drawn, and cancer- and symptom-specific recommendations can be made.
Implications for Cancer Survivors
TCQ shows promise in addressing cancer-related symptoms and QOL in cancer survivors.
Summary Background Non-immersive virtual reality is an emerging strategy to enhance motor performance for stroke rehabilitation. There has been rapid adoption of non-immersive virtual reality as a ...rehabilitation strategy despite the limited evidence about its safety and effectiveness. Our aim was to compare the safety and efficacy of virtual reality with recreational therapy on motor recovery in patients after an acute ischaemic stroke. Methods In this randomised, controlled, single-blind, parallel-group trial we enrolled adults (aged 18–85 years) who had a first-ever ischaemic stroke and a motor deficit of the upper extremity score of 3 or more (measured with the Chedoke-McMaster scale) within 3 months of randomisation from 14 in-patient stroke rehabilitation units from four countries (Canada 11, Argentina 1, Peru 1, and Thailand 1). Participants were randomly allocated (1:1) by a computer-generated assignment at enrolment to receive a programme of structured, task-oriented, upper extremity sessions (ten sessions, 60 min each) of either non-immersive virtual reality using the Nintendo Wii gaming system (VRWii) or simple recreational activities (playing cards, bingo, Jenga, or ball game) as add-on therapies to conventional rehabilitation over a 2 week period. All investigators assessing outcomes were masked to treatment assignment. The primary outcome was upper extremity motor performance measured by total time to complete the Wolf Motor Function Test (WMFT) at the end of the 2 week intervention period, analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov , number NTC01406912. Findings The study was done between May 12, 2012, and Oct 1, 2015. We randomly assigned 141 patients: 71 received VRWii therapy and 70 received recreational activity. 121 (86%) patients (59 in the VRWii group and 62 in the recreational activity group) completed the final assessment and were included in the primary analysis. Each group improved WMFT performance time relative to baseline (decrease in median time from 43·7 s IQR 26·1–68·0 to 29·7 s 21·4–45·2, 32·0% reduction for VRWii vs 38·0 s IQR 28·0–64·1 to 27·1 s 21·2–45·5, 28·7% reduction for recreational activity). Mean time of conventional rehabilitation during the trial was similar between groups (VRWii, 373 min SD 322 vs recreational activity, 397 min 345; p=0·70) as was the total duration of study intervention (VRWii, 528 min SD 155 vs recreational activity, 541 min 142; p=0·60). Multivariable analysis adjusted for baseline WMFT score, age, sex, baseline Chedoke-McMaster, and stroke severity revealed no significant difference between groups in the primary outcome (adjusted mean estimate of difference in WMFT: 4·1 s, 95% CI −14·4 to 22·6). There were three serious adverse events during the trial, all deemed to be unrelated to the interventions (seizure after discharge and intracerebral haemorrhage in the recreational activity group and heart attack in the VRWii group). Overall incidences of adverse events and serious adverse events were similar between treatment groups. Interpretation In patients who had a stroke within the 3 months before enrolment and had mild-to-moderate upper extremity motor impairment, non-immersive virtual reality as an add-on therapy to conventional rehabilitation was not superior to a recreational activity intervention in improving motor function, as measured by WMFT. Our study suggests that the type of task used in motor rehabilitation post-stroke might be less relevant, as long as it is intensive enough and task-specific. Simple, low-cost, and widely available recreational activities might be as effective as innovative non-immersive virtual reality technologies. Funding Heart and Stroke Foundation of Canada and Ontario Ministry of Health.
Summary Background Arm hemiparesis secondary to stroke is common and disabling. We aimed to assess whether robotic training of an affected arm with ARMin—an exoskeleton robot that allows ...task-specific training in three dimensions—reduces motor impairment more effectively than does conventional therapy. Methods In a prospective, multicentre, parallel-group randomised trial, we enrolled patients who had had motor impairment for more than 6 months and moderate-to-severe arm paresis after a cerebrovascular accident who met our eligibility criteria from four centres in Switzerland. Eligible patients were randomly assigned (1:1) to receive robotic or conventional therapy using a centre-stratified randomisation procedure. For both groups, therapy was given for at least 45 min three times a week for 8 weeks (total 24 sessions). The primary outcome was change in score on the arm (upper extremity) section of the Fugl-Meyer assessment (FMA-UE). Assessors tested patients immediately before therapy, after 4 weeks of therapy, at the end of therapy, and 16 weeks and 34 weeks after start of therapy. Assessors were masked to treatment allocation, but patients, therapists, and data analysts were unmasked. Analyses were by modified intention to treat. This study is registered with ClinicalTrials.gov , number NCT00719433. Findings Between May 4, 2009, and Sept 3, 2012, 143 individuals were tested for eligibility, of whom 77 were eligible and agreed to participate. 38 patients assigned to robotic therapy and 35 assigned to conventional therapy were included in analyses. Patients assigned to robotic therapy had significantly greater improvements in motor function in the affected arm over the course of the study as measured by FMA-UE than did those assigned to conventional therapy ( F =4·1, p=0·041; mean difference in score 0·78 points, 95% CI 0·03–1·53). No serious adverse events related to the study occurred. Interpretation Neurorehabilitation therapy including task-oriented training with an exoskeleton robot can enhance improvement of motor function in a chronically impaired paretic arm after stroke more effectively than conventional therapy. However, the absolute difference between effects of robotic and conventional therapy in our study was small and of weak significance, which leaves the clinical relevance in question. Funding Swiss National Science Foundation and Bangerter-Rhyner Stiftung.
Financial incentive designs to increase physical activity have not been well-examined.
To test the effectiveness of 3 methods to frame financial incentives to increase physical activity among ...overweight and obese adults.
Randomized, controlled trial. (ClinicalTrials.gov: NCT 02030119).
University of Pennsylvania.
281 adult employees (body mass index ≥27 kg/m2).
13-week intervention. Participants had a goal of 7000 steps per day and were randomly assigned to a control group with daily feedback or 1 of 3 financial incentive programs with daily feedback: a gain incentive ($1.40 given each day the goal was achieved), lottery incentive (daily eligibility expected value approximately $1.40 if goal was achieved), or loss incentive ($42 allocated monthly upfront and $1.40 removed each day the goal was not achieved). Participants were followed for another 13 weeks with daily performance feedback but no incentives.
Primary outcome was the mean proportion of participant-days that the 7000-step goal was achieved during the intervention. Secondary outcomes included the mean proportion of participant-days achieving the goal during follow-up and the mean daily steps during intervention and follow-up.
The mean proportion of participant-days achieving the goal was 0.30 (95% CI, 0.22 to 0.37) in the control group, 0.35 (CI, 0.28 to 0.42) in the gain-incentive group, 0.36 (CI, 0.29 to 0.43) in the lottery-incentive group, and 0.45 (CI, 0.38 to 0.52) in the loss-incentive group. In adjusted analyses, only the loss-incentive group had a significantly greater mean proportion of participant-days achieving the goal than control (adjusted difference, 0.16 CI, 0.06 to 0.26; P = 0.001), but the adjusted difference in mean daily steps was not significant (861 CI, 24 to 1746; P = 0.056). During follow-up, daily steps decreased for all incentive groups and were not different from control.
Single employer.
Financial incentives framed as a loss were most effective for achieving physical activity goals.
National Institute on Aging.
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