Standing with electrical stimulation and splinting is no better than standing alone for management of ankle plantarflexion contractures in people with traumatic brain injury: a randomised trial

Overview of systematic reviews: Management of common Traumatic Brain Injury-related complications

Background

Many clinical interventions are trialled to manage medical complications following Traumatic Brain Injury (TBI). However, published evidence for the effects of those clinical interventions is limited. This article is an overview of common complications and their management from published systematic reviews in TBI.

Methods and findings

A health science electronic database search for published systematic reviews for management of common complications in TBI was conducted in the last decade till 31st January 2021. Methodological quality and evidence were critically appraised using the Grading of Recommendations, Assessment, Development and Evaluations and Revised-Assessment of Multiple Systematic review tools. Overall, only six systematic reviews complied with search criteria, these evaluated fatigue, spasticity and post traumatic seizures (29 RCTs, 13 cohort studies, n = 5639 participants). No systematic reviews for other common TBI-related complications met criteria for this review. The included reviews varied from ‘moderate to high’ in methodological quality. The findings suggest beneficial treatment effect of anti-epileptic drugs (phenytoin/levetiracetam) compared with placebo in reducing early seizure incidence, but no significant benefit of phenytoin over levetiracetam, valproate, or neuroprotective agent for early or late posttraumatic seizures. There was ‘limited’ evidence for spasticity-related interventions, and ‘insufficient’ evidence of cardiorespiratory training on fatigue levels.

Conclusions

Despite the high prevalence and associated functional impact of TBI-related complications, there is limited evidence to guide treating clinicians for management of common TBI complications. More robust studies are needed to build evidence in this population.

Physical Activity Interventions That Address Motor and Balance Impairments and Skills for Adults With Traumatic Brain Injury (TBI) (2012-2021)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. The systematic review is on interventions to address motor and balance impairments to improve occupational performance for adults with traumatic brain injury.

Neurologic and musculoskeletal effects of tilt-table standing on adults: a systematic review

[Purpose] Tilt table use is associated, most often, with the assessment of syncope. However, it also has applications for patients with neurologic and orthopedic problems. These applications do not appear to be widely applied. The purpose of this review, therefore, was to summarize the research literature addressing the use of tilt tables for treating specific musculoskeletal and neurologic impairments in adults. [Methods] Relevant literature was identified by searches of the PubMed, CINAHL, and Scopus databases and hand searches (December 2018 and October 2020). The methodological quality of the identified research articles was assessed using the PEDro scale. [Results] Of 482 unique articles identified, 20 matched the eligibility criteria of the review and were included. The studies varied widely in the populations studied, procedures used, and responses reported. The studies provide limited support for tilt table standing as an intervention. [Conclusion] However, evidence that some patients with neurologic conditions may respond positively to tilt-table standing is available. Among such individuals are those with decreased ankle range of motion, positive neurologic signs in the lower limbs, and decreased levels of consciousness.

Non-drug therapies for the secondary prevention of lower limb muscle cramps

BACKGROUND

Lower limb muscle cramps are common and painful. They can limit exercise participation, and reduce quality of sleep, and quality of life. Many interventions are available for lower limb cramps; some are controversial or could cause harm, and often, people experience no benefit from the interventions used. This is an update of a Cochrane Review first published in 2012. We updated the review to incorporate new evidence.

OBJECTIVES

To assess the effects of non-drug, non-invasive therapies for lower limb muscle cramps.

SEARCH METHODS

In August 2018 and May 2020, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of included studies. We imposed no restrictions by language or publication date.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) of non-drug, non-invasive interventions tested over at least four weeks, for lower limb muscle cramps in any group of people, except pregnant women. The primary outcome was cramp frequency. Secondary outcomes were cramp pain severity, cramp duration, health-related quality of life, quality of sleep, participation in activities of daily living, proportion of participants reporting lower limb muscle cramps, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias, and cross-checked data extraction and analyses according to standard Cochrane procedures.

MAIN RESULTS

We included three trials, with 201 participants, all 50 years of age and older; none had neurological disease. All trials evaluated a form of stretching for lower limb muscle cramps. A combination of daily calf and hamstring stretching for six weeks may reduce the severity of night-time lower limb muscle cramps (measured on a 10 cm visual analogue scale (VAS) where 0 = no pain and 10 cm = worst pain imaginable) in people aged 55 years and older, compared to no intervention (mean difference (MD) -1.30, 95% confidence interval (CI) -1.74 to -0.86; 1 RCT, 80 participants; low-certainty evidence). The certainty of evidence was very low for cramp frequency (change in number of cramps per night from week zero to week six) comparing the stretching group and the no intervention group (MD -1.2, 95% CI -1.8 to -0.6; 80 participants; very low-certainty evidence). Calf stretching alone for 12 weeks may make little to no difference to the frequency of night-time lower limb muscle cramps in people aged 60 years and older (stretching group median number of cramps in the last four weeks (Md) 4, interquartile range (IQR) 8; N = 48; sham stretching group Md 3, IQR 7.63; N = 46) (U = 973.5, z = -0.995, P = 0.32, r = 0.10; 1 RCT, 94 participants; low-certainty evidence). This trial did not report cramp severity. The evidence is very uncertain about the effects of a combination of daily calf, quadriceps, and hamstring stretching on the frequency and severity of leg cramps in 50- to 60-year-old women with metabolic syndrome (N = 24). It was not possible to fully analyse the frequency data and the scale used to measure cramp severity is not validated. No study reported health-related quality of life, quality of sleep, or participation in activities of daily living. No participant in these three studies reported adverse events. The evidence for adverse events was of moderate certainty as the studies were too small to detect uncommon events. In two of the three studies, outcomes were at risk of recall bias, and tools used to measure outcomes were not validated. Due to limitations in study designs that led to risks of bias, and imprecise findings with wide CIs, we cannot be certain that findings of future studies will be similar to those presented in this review.

AUTHORS' CONCLUSIONS

A combination of daily calf and hamstring stretching for six weeks may reduce the severity of night-time lower limb muscle cramps in people aged 55 years and older, but the effect on cramp frequency is uncertain. Calf stretching alone compared to sham stretching for 12 weeks may make little or no difference to the frequency of night-time lower limb muscle cramps in people aged 60 years and older. The evidence is very uncertain about the effects of a combination of daily calf, quadriceps, and hamstring stretching on the frequency and severity of leg cramps in 50- to 60-year-old women with metabolic syndrome. Overall, use of unvalidated outcome measures and inconsistent diagnostic criteria make it difficult to compare the studies and apply findings to clinical practice. Given the prevalence and impact of lower limb muscle cramps, there is a pressing need to carefully evaluate many of the commonly recommended and emerging non-drug therapies in well-designed RCTs across all types of lower limb muscle cramps. A specific cramp outcome tool should be developed and validated for use in future research.

Nonsurgical Treatment Options for Muscle Contractures in Individuals With Neurologic Disorders: A Systematic Review With Meta-Analysis

OBJECTIVE

To investigate whether nonsurgical treatment can reduce muscle contractures in individuals with neurologic disorders. The primary outcome measure was muscle contractures measured as joint mobility or passive stiffness.

DATA SOURCES

Embase, MEDLINE, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database in June-July 2019 and again in July 2020.

STUDY SELECTION

The search resulted in 8020 records, which were screened by 2 authors based on our patient, intervention, comparison, outcome criteria. We included controlled trials of nonsurgical interventions administered to treat muscle contractures in individuals with neurologic disorders.

DATA EXTRACTION

Authors, participant characteristics, intervention details, and joint mobility/passive stiffness before and after intervention were extracted. We assessed trials for risk of bias using the Downs and Black checklist. We conducted meta-analyses investigating the short-term effect on joint mobility using a random-effects model with the pooled effect from randomized controlled trials (RCTs) as the primary outcome. The minimal clinically important effect was set at 5°.

DATA SYNTHESIS

A total of 70 trials (57 RCTs) were eligible for inclusion. Stretch had a pooled effect of 3° (95% CI, 1-4°; prediction interval (PI)=-2 to 7°; I 2=66%; P<.001), and robot-assisted rehabilitation had an effect of 1 (95% CI, 0-2; PI=-8 to 9; I 2=73%; P=.03). We found no effect of shockwave therapy (P=.56), physical activity (P=.27), electrical stimulation (P=.11), or botulinum toxin (P=.13). Although trials were generally of moderate to high quality according to the Downs and Black checklist, only 18 of the 70 trials used objective measures of muscle contractures. In 23 trials, nonobjective measures were used without use of assessor-blinding.

CONCLUSIONS

We did not find convincing evidence supporting the use of any nonsurgical treatment option. We recommend that controlled trials using objective measures of muscle contractures and a sufficiently large number of participants be performed.

Electrical stimulation for limb spasticity in children with traumatic brain injury: Study protocol for a systematic review of randomized controlled trial

BACKGROUND

Previous clinical studies have reported that electrical stimulation (ES) can be utilized to treat children with limbs spasticity (LS) after traumatic brain injury (TBI). Currently, no systematic review has addressed the effect of ES in children with LS following TBI. Thus, this systematic review will assess the effect and safety of ES for the children with LS after TBI.

METHODS

We will conduct the present systematic review of randomized controlled trials that will be retrieved from searches of PubMed, PsycINFO, WOS, Scopus, OpenGrey, Google Scholar, Cochrane Central Register of Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and Chinese Biomedical Literature Database from the inception to the date of the literature searched. In addition, the clinical register websites, and reference lists of relevant studies will also be searched. Two independent reviewers will evaluate the eligibility criteria for all papers, extract the data and determine the methodology quality by using Cochrane risk of bias tool.

RESULTS

The results of this systematic review will pool the latest available data, and are expected to provide the summary of present evidence of ES for children with LS following TBI.

TIMELINE

This systematic review will start on January 10, 2019 and expected to complete by June 1, 2019.

ETHICS AND DISSEMINATION

No research ethic approval is needed in this study, because the data of this systematic review will not base on the individual data level. The results will be disseminated to publish at peer-reviewed journals or will present at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42019120037.

Interventions for managing skeletal muscle spasticity following traumatic brain injury

BACKGROUND

Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI.

OBJECTIVES

To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI.

SEARCH METHODS

In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data.

MAIN RESULTS

We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes.

AUTHORS' CONCLUSIONS

The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.