The Structure of Research Questions in Randomized Controlled Trials in the Rehabilitation Field: A Methodological Study

The clinical effects of brain-computer interface with robot on upper-limb function for post-stroke rehabilitation: a meta-analysis and systematic review

PURPOSE

Many recent clinical studies have suggested that the combination of brain-computer interfaces (BCIs) can induce neurological recovery and improvement in motor function. In this review, we performed a systematic review and meta-analysis to evaluate the clinical effects of BCI-robot systems.

METHODS

The articles published from January 2010 to December 2020 have been searched by using the databases (EMBASE, PubMed, CINAHL, EBSCO, Web of Science and manual search). The single-group studies were qualitatively described, and only the controlled-trial studies were included for the meta-analysis. The mean difference (MD) of Fugl-Meyer Assessment (FMA) scores were pooled and the random-effects model method was used to perform the meta-analysis. The PRISMA criteria were followed in current review.

RESULTS

A total of 897 records were identified, eight single-group studies and 11 controlled-trial studies were included in our review. The systematic analysis indicated that the BCI-robot systems had a significant improvement on motor function recovery. The meta-analysis showed there were no statistic differences between BCI-robot groups and robot groups, neither in the immediate effects nor long-term effects (p > 0.05).

CONCLUSION

The use of BCI-robot systems has significant improvement on the motor function recovery of hemiparetic upper-limb, and there is a sustaining effect. The meta-analysis showed no statistical difference between the experimental group (BCI-robot) and the control group (robot). However, there are a few shortcomings in the experimental design of existing studies, more clinical trials need to be conducted, and the experimental design needs to be more rigorous.Implications for RehabilitationIn this review, we evaluated the clinical effects of brain-computer interface with robot on upper-limb function for post-stroke rehabilitation. After we screened the databases, 19 articles were included in this review. These articles all clinical trial research, they all used non-invasive brain-computer interfaces and upper-limb robot.We conducted the systematic review with nine articles, the result indicated that the BCI-robot system had a significant improvement on motor function recovery. Eleven articles were included for the meta-analysis, the result showed there were no statistic differences between BCI-robot groups and robot groups, neither in the immediate effects nor long-term effects.We thought the result of meta-analysis which showed no statistic difference was probably caused by the heterogenicity of clinical trial designs of these articles.We thought the BCI-robot systems are promising strategies for post-stroke rehabilitation. And we gave several suggestions for further research: (1) The experimental design should be more rigorous, and describe the experimental designs in detail, especially the control group intervention, to make the experiment replicability. (2) New evaluation criteria need to be established, more objective assessment such as biomechanical assessment, fMRI should be utilised as the primary outcome. (3) More clinical studies with larger sample size, novel external devices, and BCI systems need to be conducted to investigate the differences between BCI-robot system and other interventions. (4) Further research could shift the focus to the patients who are in subacute stage, to explore if the early BCI training can make a positive impact on cerebral cortical recovery.

A systematic review opens the black box of "usual care" in stroke rehabilitation control groups and finds a black hole

INTRODUCTION

In experimental trials, new methods are tested against the "best" or "usual" care. To appraise control group (CG) interventions provided as "usual care," we focused on stroke as a leading cause of disability demanding rehabilitation as a complex intervention.

EVIDENCE ACQUISITION

For this methodological appraisal, we conducted a systematic review of RCTs without timespan limitation. The PICO included stroke survivors, rehabilitation, control group intervention, lower limb function. To assess the risk of bias, we used the Cochrane risk of bias tool (RoB). We identified the terminology describing the CG Program (CGP), performed a knowledge synthesis and conducted a frequency analysis of provided interventions.

EVIDENCE SYNTHESIS

We included 155 publications. 13.6% of the articles did not describe the CG, and 11.6% indicated only the professionals involved. In the remaining 116 studies, three studies provided an intervention according to specific guidelines, 106 different "usual care" CGPs were detected, with nine proposed twice and two between four and five times. The most adopted terminology to state "usual care" was "conventional physiotherapy."

CONCLUSIONS

This study shows that usual care in CG does not actually exist, as both specific terminology and consistency within CGP contents are missing. Reporting guidelines should give better assistance on this issue. These results should be verified in other fields.

A systematic review that is ``rapid'' and ``living'': A specific answer to the COVID-19 pandemic

OBJECTIVE

This study aims to describe "rapid living" systematic reviews, an innovative methodological design used to systematically synthesize emerging evidence in the field of rehabilitation during the COVID-19 pandemic.

STUDY DESIGN AND SETTING

A methodological paper, with a formative approach to rapid living systematic reviews.

RESULTS

Based on our experience, we propose the following definition of rapid living SR: ``A dynamic method of knowledge synthesis that allows for the constant updating of new emerging evidence and refinement of its methodological quality.'' This method has the benefit of accelerating the conduct of traditional systematic reviews and allows for a synergistic adaptation of methodology based on the quality of the evidence with a flexibility to update results, methods and collaborations.

CONCLUSION

Our proposed methodology has been helpful to synthesize the rapidly evolving evidence in the field of rehabilitation during the pandemic. Similarly, it may be useful when a rapid answer is urgently needed to make informed decisions. The COVID-19 disease has shown that modern medical science has the ability to produce new knowledge at a rate never seen before. Therefore, our proposed rapid living systematic reviews provide the scientific community with a method to rapidly synthesize evidence when facing health emergencies.

Cochrane Rehabilitation: 2020 annual report

During its fourth year of existence, Cochrane Rehabilitation went on to promote evidence-informed health decision-making in rehabilitation. In 2020, the outbreak of the COVID-19 pandemic has made it necessary to alter priorities. In these challenging times, Cochrane Rehabilitation has firstly changed its internal organisation and established a new relevant project in line with pandemic needs: the REH-COVER (Rehabilitation - COVID-19 evidence-based response) action. The aim was to focus on the timely collection, review and dissemination of summarised and synthesised evidence relating to COVID-19 and rehabilitation. Cochrane Rehabilitation REH-COVER action has included in 2020 five main initiatives: 1) rapid living systematic reviews on rehabilitation and COVID-19; 2) interactive living evidence map on rehabilitation and COVID-19; 3) definition of the research topics on "rehabilitation and COVID-19" in collaboration with the World Health Organization (WHO) rehabilitation programme; 4) Cochrane Library special collection on Coronavirus (COVID-19) rehabilitation; and 5) collaboration with COVID-END for the topics "rehabilitation" and "disability." Furthermore, we are still carrying on five different special projects: Be4rehab; RCTRACK; definition of rehabilitation for research purposes; ebook project; and a prioritization exercise for Cochrane Reviews production. The Review Working Area continued to identify and "tag" the rehabilitation-relevant reviews published in the Cochrane library; the Publication Working Area went on to publish Cochrane Corners, working more closely with the Cochrane Review Groups (CRGs) and Cochrane Networks, particularly with Cochrane Musculoskeletal, Oral, Skin and Sensory Network; the Education Working Area, the most damaged in 2020, tried to continue performing educational activities such as workshops in different online meetings; the Methodology Working Area organized the third and fourth Cochrane Rehabilitation Methodological (CRM) meetings respectively in Milan and Orlando; the Communication Working Area spread rehabilitation evidences through different channels and translated the contents in different languages.

Methodological Issues in Rehabilitation Research: A Scoping Review

OBJECTIVE

To identify, synthesize, and categorize the methodological issues faced by the rehabilitation field.

DATA SOURCES

A scoping review was conducted using studies identified in MEDLINE, the Cochrane Library, EMBASE, Web of Science, Scopus, Physiotherapy Evidence Database, and Google Scholar up to August 2018.

STUDY SELECTION

We included all type of publications describing methodological issues in rehabilitation research where rehabilitation is described as a multimodal process. The methodological issues have been categorized and classified.

DATA EXTRACTION

The synthesis included qualitative and quantitative analysis. To focus the attention on rehabilitation, we post hoc divided in "specific issues" (highly related to, even if not exclusive of, rehabilitation research) and "generic issues" (common in biomedical research).

DATA SYNTHESIS

Seventy-one publications were included: 68% were narrative reviews, 15% systematic reviews, 7% editorials, 4% meta-epidemiologic studies, and 5% others. Specific methodological issues include the following: problematic application of randomized controlled trials (32%), absent definition of core outcome sets (28%), poor interventions description (22%), weak methodological (conducting) and reporting quality (21%), scarce clinical practice applicability (14%), lack of blinding assessor (10%), inadequate randomization methods or inadequate allocation concealment (8%), and inadequate participants description and recruitment (8%). "Generic" issues included the following: data and statistical description (31%), authors' methodological training (7%), peer review process (6%, n=4), funding declaration (6%), ethical statement (3%), protocol registration (3%), and conflict of interest declaration (1%).

CONCLUSIONS

Methodological and reporting issues might influence the quality of the evidence produced in rehabilitation research. The next steps to move forward in the field of rehabilitation could be to evaluate the influence of all these issues on the validity of trial results through meta-epidemiologic studies and to develop specific checklists to provide guidance to authors to improve the reporting and conduct of trials in this field.