Research question
Which interventions help to promote arm and hand recovery after a person has had a stroke?
Background
Problems with arm function (upper limb impairments) are very common after a stroke. These upper limb impairments commonly include difficulty moving and co-ordinating the arms, hands and fingers, often resulting in difficulty carrying out daily activities such as eating, dressing and washing. More than half of people with upper limb impairment after stroke will still have problems many months to years after their stroke. Improving arm function is a core element of rehabilitation. Many possible interventions have been developed; these may involve different exercises or training, specialist equipment or techniques, or they could take the form of a drug (pill or injection) given to help arm movement.
Upper limb rehabilitation after stroke often involves several different interventions and generally requires the co-operation of the patient, carers and rehabilitation team.
To help people easily access information about effective interventions, and to help them compare the effects of different interventions, we have carried out a Cochrane overview. We aimed to bring together all systematic reviews of interventions provided to improve upper limb (arm) function after stroke.
Review characteristics
We searched for Cochrane and non-Cochrane reviews of the effectiveness of interventions to improve arm function after stroke. We included 40 systematic reviews (19 Cochrane reviews and 21 non-Cochrane reviews). The evidence is current to June 2013.
The reviews covered 18 different types of interventions, as well as the dose of the intervention and the setting in which the intervention was delivered. These reviews varied in relation to the populations included (initial upper limb impairment and stroke severity) and in relation to the comparison groups included (which were given control interventions, no treatment and conventional therapy).
We extracted details of 127 comparisons that had been explored within the reviews. These showed the extent to which different interventions had had an effect on upper limb function, upper limb impairment and ability to perform activities of daily living.
Key results
Currently no high-quality evidence is available for any interventions currently used as part of routine practice. Evidence is insufficient to show which are the most effective interventions for improving upper limb function.
Moderate-quality evidence suggests that the following interventions may be effective: constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice. Moderate-quality evidence also indicates that unilateral arm training (exercise for the affected arm) may be more effective than bilateral arm training (doing the same exercise with both arms at the same time).
Some evidence shows that a greater dose of an intervention is better than a lesser dose. Additional research to identify the optimal dose of arm rehabilitation is essential.
Bringing together all available systematic review evidence has helped us make specific recommendations for future research. These recommendations include (but are not limited to) large randomised controlled trials of CIMT, mental practice, mirror therapy and virtual reality. We recommend high-quality up-to-date reviews and further primary research for several specific interventions.
Quality of the evidence
We judged the quality of evidence to be high in relation to one intervention: a type of brain stimulation called transcranial direct current stimulation (tDCS), which is not currently used within routine practice. This high-quality evidence shows that tDCS does not improve people's ability to perform activities of daily living.
We judged the quality of evidence to be moderate for 48 comparisons (covering seven individual interventions) and low or very low for 76 comparisons. Reasons for downgrading the quality of evidence to moderate, low or very low include small numbers of studies and participants, poor methodological quality or reporting of studies included within reviews, substantial heterogeneity (variation) between study results and poor review quality or reporting of methods.
We conclude that high-quality evidence related to the effectiveness of interventions to improve upper limb function is urgently needed, in particular for those interventions for which moderate-quality evidence currently suggests a beneficial effect.
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.
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.
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.
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.