Randomized clinical trials in medical rehabilitation research

Methods for a Multisite Randomized Trial to Investigate the Effect of Constraint-Induced Movement Therapy in Improving Upper Extremity Function among Adults Recovering from a Cerebrovascular Stroke

This article describes the study design, methodological considerations, and demographic characteristics of a phase III RCT to determine if 1) constraint-induced therapy (CI therapy) can be applied with therapeutic success 3 to 9 months after stroke across different sites, 2) gains that might occur persist over 2 years, 3) initial level of motor ability determines responsiveness to CI therapy, and 4) the treatment effect differs between those treated before 9 months and after 1 year. Six sites will screen and recruit poststroke survivors stratified on initial level of motor ability and after randomization allocate participants to immediate or delayed intervention. Primary outcomes include a laboratory-based measure of function (Wolf Motor Function Test [WMFT]) and a real-world participant-centered functional use measure (Motor Activity Log [MAI]). Secondary outcomes concern function, behavior, and compliance. This is the first multisite, single-blind RCT of a formal training intervention for upper extremity rehabilitation in subacute stroke in the United States.

Evidentiary Pluralism as a Strategy for Research and Evidence-Based Practice in Rehabilitation Psychology

This paper examines the utility of evidentiary pluralism, a research strategy that selects methods in service of content questions, in the context of rehabilitation psychology. Hierarchical views that favor randomized controlled clinical trials (RCTs) over other evidence are discussed, and RCTs are considered as they intersect with issues in the field. RCTs are vital for establishing treatment efficacy, but whether they are uniformly the best evidence to inform practice is critically evaluated. We argue that because treatment is only one of several variables that influence functioning, disability, and participation over time, an expanded set of conceptual and data analytic approaches should be selected in an informed way to support an expanded research agenda that investigates therapeutic and extra-therapeutic influences on rehabilitation processes and outcomes. The benefits of evidentiary pluralism are considered, including helping close the gap between the narrower clinical rehabilitation model and a public health disability model. KEY WORDS: evidence-based practice, evidentiary pluralism, rehabilitation psychology, randomized controlled trials.

The Place and Promise of Theory in Rehabilitation Psychology

OBJECTIVE: Although rehabilitation psychology is more focused on empirical evidence and clinical application than theory development, we argue for the primacy of theory, and explain why theories are needed in and useful for rehabilitation psychology. Impediments to theory development are discussed, including the difficulties of applying psychological theories in multidisciplinary enterprises, and the difficulties in developing a theory-driven research program. We offer suggestions by reviewing research settings, knowledge gained through controlled studies, grantsmanship, and then identify topical areas where new theories are needed. We remind researcher-practitioners that rehabilitation psychology benefits from a judicious mix of scientific rigor and real-world vigor. CONCLUSIONS: We close by advocating for theory-driven research programs that embrace a methodological pluralism, which will in turn advance new theory, produce meaningful research programs that inform practice, and realize the goals of this special issue of Rehabilitation Psychology-advances in research and methodology.

The State of Rehabilitation Research: Art or Science?

Rehabilitation research has been criticized as not standing up enough to the rigors of scientific method to be called "science." The field has been portrayed as slow to promote its scientific achievements and to include them under the rubric of evidence-based rehabilitation. Following in the footsteps of psychology, rehabilitation as a broad-based discipline has faced many similar obstacles in achieving scientific status. Controversy exists about what exactly constitutes rehabilitation science versus its art and its respective multidisciplinary domains. The conception of these domains is directly related to current methods available to assess the state of the discipline and its research accomplishments. I used quantitative methods, such as randomized clinical and/or controlled trials (RCTs) and systematic reviews, to assess the status of rehabilitation research. Findings suggest that, as a field, rehabilitation makes significant contributions to science, measurable by the number and quality of RCTs and systematic reviews conducted so far on topics of critical importance for clinical care. In "artful" complement, qualitative approaches can be used as research tools to aid investigators in seeking knowledge beyond that obtained by quantitative methods, assessing many complexities associated with the various contexts of rehabilitation research. Other requirements to develop a common vision of rehabilitation science are also discussed.

Conducting multiple-site clinical trials in medical rehabilitation research

This article examines the distinctive opportunities and challenges of multiple-site clinical trials, as distinguished from trials conducted by a single program. Among the topics discussed are: the role of clinical trials generally in medical rehabilitation research; definitions of "clinical trials" and "multiple site"; the distinction between exploratory and capstone trials; the potential advantages and disadvantages of multiple-site trials; planning issues in terms of sampling designs, the choice of outcome measures, approaches to dealing with intervention fidelity, organizational structures, authorship, and the conduct of collateral studies; and implementation issues in terms of pilot-testing procedures, handling emerging issues, and optimizing communication.

Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke

OBJECTIVES

To determine the effect of two different community-based group exercise programs on functional balance, mobility, postural reflexes, and falls in older adults with chronic stroke.

DESIGN

A randomized, clinical trial.

SETTING

Community center.

PARTICIPANTS

Sixty-one community-dwelling older adults with chronic stroke.

INTERVENTION

Participants were randomly assigned to an agility (n=30) or stretching/weight-shifting (n=31) exercise group. Both groups exercised three times a week for 10 weeks.

MEASUREMENTS

Participants were assessed before, immediately after, and 1 month after the intervention for Berg Balance, Timed Up and Go, step reaction time, Activities-specific Balance Confidence, and Nottingham Health Profile. Testing of standing postural reflexes and induced falls evoked by a translating platform was also performed. In addition, falls in the community were tracked for 1 year from the start of the interventions.

RESULTS

Although exercise led to improvements in all clinical outcome measures for both groups, the agility group demonstrated greater improvement in step reaction time and paretic rectus femoris postural reflex onset latency than the stretching/weight-shifting group. In addition, the agility group experienced fewer induced falls on the platform.

CONCLUSION

Group exercise programs that include agility or stretching/weight shifting exercises improve postural reflexes, functional balance, and mobility and may lead to a reduction of falls in older adults with stroke.

The κ statistic in rehabilitation research: An examination11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated

The number and sophistication of statistical procedures reported in medical rehabilitation research is increasing. Application of the principles and methods associated with evidence-based practice has contributed to the need for rehabilitation practitioners to understand quantitative methods in published articles. Outcomes measurement and determination of reliability are areas that have experienced rapid change during the past decade. In this study, distinctions between reliability and agreement are examined. Information is presented on analytical approaches for addressing reliability and agreement with the focus on the application of the kappa statistic. The following assumptions are discussed: (1) kappa should be used with data measured on a categorical scale, (2) the patients or objects categorized should be independent, and (3) the observers or raters must make their measurement decisions and judgments independently. Several issues related to using kappa in measurement studies are described, including use of weighted kappa, methods of reporting kappa, the effect of bias and prevalence on kappa, and sample size and power requirements for kappa. The kappa statistic is useful for assessing agreement among raters, and it is being used more frequently in rehabilitation research. Correct interpretation of the kappa statistic depends on meeting the required assumptions and accurate reporting.

Water-based exercise for cardiovascular fitness in people with chronic stroke: a randomized controlled trial

OBJECTIVE

To evaluate the effect of an 8-week, water-based exercise program (experimental group) with that of an upper-extremity function program (control group) to increase cardiovascular fitness within a community setting for people with stroke.

DESIGN

Single-blind randomized controlled trial.

SETTING

Public community center.

PARTICIPANTS

A volunteer sample of 12 community-dwelling people with stroke with mild to moderate residual motor deficits.

INTERVENTION

Study subjects participated in group exercise programs for 1 hour, 3 times a week for 8 weeks. The experimental group exercised in chest-deep water at targeted heart rates. The control group performed arm and hand exercises while sitting. Main outcome measures The primary outcome measure was cardiovascular fitness (V(O2)max). Secondary measures were maximal workload, muscle strength, gait speed, and the Berg Balance Scale score.

RESULTS

The experimental group attained significant improvements over the control group in cardiovascular fitness, maximal workload, gait speed, and paretic lower-extremity muscle strength. The relatively short program (8 wk) of water-based exercise resulted in a 22% improvement in cardiovascular fitness in a small group of people with stroke who had relatively high function.

CONCLUSIONS

A water-based exercise program undertaken as a group program may be an effective way to promote fitness in people with stroke.

Shaping the future of medical rehabilitation research: using the interdisciplinary research model

This memorial lecture addresses the fundamental requirements for developing a framework for interdisciplinary rehabilitation research. The needs for funding, clinical trials, staffing, education, and infrastructure are examined from the vantage points of my experiences as an educator, investigator, chief executive officer, department chair, and dean. Developing an academic base for the specialty of physical medicine and rehabilitation and demonstrating our expertise in rehabilitation research are fundamental to academic acceptance and will enhance our ability to compete for future funding for our investigations.

Overview of Clinical Trials in Medical Rehabilitation

The goal of clinical trials is to provide the strongest possible basis for inferring that the observed results of a health-oriented intervention are attributable to that intervention and not to other factors. Particularly strong causal inferences can be drawn from the randomized clinical trial in which participants are assigned on a random basis to either the intervention of interest or to a comparison condition. This article explains the reasons for that contention and explores its implications for medical rehabilitation research. Among the topics discussed are: the role of evidence-based practice in fostering interest in randomized clinical trials; a contextual view of randomized clinical trials that emphasizes strategies of investigation and the goals of particular studies; two key distinctions, efficacy-oriented vs. effectiveness-oriented clinical trials and pragmatic vs. explanatory clinical trials; the sequencing of different study designs, including randomized clinical trials; and needed advances in treatment theory, treatment fidelity, and adherence.

Peer Review

Peer review, although the standard for evaluating scientific research, is not without flaws. Peer reviewers have been shown to be inconsistent and to miss major strengths and deficiencies in studies. Both reviewer and author biases, including conflicts of interest and positive outcome publication biases, are frequent topics of study and debate. Additional concerns have been raised regarding inappropriate authorship and adequate reporting of the ethical process involving human and animal experimentation. Despite these issues, a good peer review can provide positive feedback to authors and improve the quality of research reported in medical journals. This article reviews some issues and points of concern regarding the peer-review process, and it suggests guidelines for new (and established) reviewers in the area of physical medicine and rehabilitation. It also provides suggestions for editorial considerations and improvements in the peer-review process for physical medicine and rehabilitation research journals.

Pitfalls in effectiveness research: a comparative analysis of treatment goals and outcome measures in stroke rehabilitation

PROBLEM

There is a great diversity of movement therapies in stroke rehabilitation, each of which is treated as a more or less independent system.

OBJECTIVE

To articulate pitfalls in effectiveness research that has been employed to reduce the number of different forms of treatment.

METHODS

The contents of treatment goals and outcome measures in clinical and scientific texts on stroke rehabilitation were analysed and contrasted in order to uncover discrepancies.

ISSUES

The main issue is that theory, and conceptualization of therapy play a diminished role in treatment effectiveness research, which may hinder the interpretation of data. The notion that the methodological and statistical tools, if correctly applied, provide researchers with the distance that is thought to be necessary for an objective judgement will be challenged.

CONCLUSION

The analyses indicate that although scientifically credible measurement tools may be neutral with regard to the user, they are not necessarily neutral with regard to the therapies being compared in effectiveness research.

Effects of isokinetic strength training on walking in persons with stroke: a double-blind controlled pilot study

OBJECTIVES

The goal most often stated by persons with stroke is improved walking function. The purpose of this study was to determine the effects of isokinetic strength training on walking performance, muscle strength, and health-related quality of life in survivors of chronic stroke.

METHODS

Twenty participants (age, 61.2 +/- 8.4 years) with chronic stroke were randomized into 2 groups. The experimental group undertook maximal concentric isokinetic strength training, whereas the control group received passive range of motion of the paretic lower extremity 3 times a week for 6 weeks. The Kin-Com Isokinetic Dynamometer (Chattanooga Group Inc., TN) was used for both the strengthening and passive range of motion exercises. The Mann-Whitney U test was used to compare the changes in scores (postintervention minus baseline) between the control and experimental groups for a composite lower extremity strength score, walking speed (level-walking and stair-walking) and health-related quality of life measure (36-Item Short Form Health Survey [SF-36]).

RESULTS

Both the experimental and control groups increased their strength and walking speed postintervention; however, there were no differences in the changes in walking speed between the groups. There was a trend (P = .06) toward greater strength improvement in the experimental group compared with the control group. No changes in SF-36 scores were found in either group.

CONCLUSIONS

Intervention aimed at increasing strength did not result in improvements in walking. The results of this study stress the importance of controlled clinical trials in determining the effect of specific treatment approaches. Strength training in conjunction with other task-related training may be indicated.

Mobility status after inpatient stroke rehabilitation: 1-year follow-up and prognostic factors

OBJECTIVES

To evaluate the stability of mobility status achieved by stroke patients during hospital rehabilitation treatment over time and to identify reliable prognostic factors associated with mobility changes.

DESIGN

Follow-up evaluation in consecutive first-ever stroke patients 1 year after hospital discharge. Multiple logistic regressions were used to analyze increases and decreases in Rivermead Mobility Index (RMI) scores (dependent variables) between discharge and follow-up. Independent variables were medical, demographic, and social factors.

SETTING

Rehabilitation hospital.

PATIENTS

A cohort of 155 patients with sequelae of first stroke, with a final sample of 141.

MAIN OUTCOME MEASURES

Mobility status at 1-year follow-up, as measured by the RMI, and odds ratios (OR) for improvement and decline in mobility.

RESULTS

Functionally, 19.9% improved the mobility levels achieved during the inpatient rehabilitation treatment; levels of 42.6% worsened. Patients with global aphasia (OR = 5.66; 95% confidence interval [CI], 1.50-21.33), unilateral neglect (OR = 3.01; 95% CI, 1.21-7.50), and age 75 years or older (OR = 5.77; 95% CI, 1.42-23.34) had a higher probability of mobility decline than the remaining patients. Postdischarge rehabilitation treatment (PDT), received by 52.5% of the final sample, was significantly and positively associated with mobility improvement (OR = 5.86; 95% CI, 2.02-17.00). Absence of PDT was associated with a decline in mobility (OR = 3.73; 95% CI, 1.73-8.04).

CONCLUSIONS

In most cases, mobility status had not yet stabilized at hospital discharge. PDT was useful in preventing a deterioration in mobility improvement achieved during inpatient treatment and in helping increase the likelihood of further mobility improvement.