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Mehrabi S, Cameron L, Bowman A, Fleet JL, Eng J, Bayley MT, Teasell R. A Systematic Review of Female Participation in Randomized Controlled Trials of Post-Stroke Upper Extremity Rehabilitation in Low- to Middle-Income Countries and High-Income Countries and Regions. Cerebrovasc Dis 2024:1-10. [PMID: 38583429 DOI: 10.1159/000538610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024] Open
Abstract
INTRODUCTION Female participation is lower than males in both acute stroke and stroke rehabilitation trials. However, less is known about how female participation differs across countries and regions. This study aimed to assess the percentage of female participants in randomized controlled trials (RCTs) of post-stroke rehabilitation of upper extremity (UE) motor disorders in low-middle-income (LMICs) and high-income countries (HICs) as well as different high-income world regions. METHODS CINAHL, Embase, PubMed, Scopus, and Web of Science were searched from 1960 to April 1, 2021. Studies were eligible for inclusion if they (1) were RCTs or crossovers published in English; (2) ≥50% of participants were diagnosed with stroke; 3) included adults ≥18 years old; and (4) applied an intervention to the hemiparetic UE as the primary objective of the study. Countries were divided into HICs and LMICs based on their growth national incomes. The HICs were further divided into the three high-income regions of North America, Europe, and Asia and Oceania. Data analysis was performed using SPSS and RStudio v.4.3.1. RESULTS A total of 1,276 RCTs met inclusion criteria. Of them, 298 RCTs were in LMICs and 978 were in HICs. The percentage of female participants was significantly higher in HICs (39.5%) than LMICs (36.9%). Comparing high-income regions, there was a significant difference in the overall female percentages in favor of RCTs in Europe compared to LMICs but not North America or Asia and Oceania. There was no significant change in the percentage of female participants in all countries and regions over the last 2 decades, with no differences in trends between the groups. CONCLUSIONS Sufficient female representation in clinical trials is required for the generalizability of results. Despite differences in overall percentage of female participation between countries and regions, females have been underrepresented in both HICs and LMICs with no considerable change over 2 decades.
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Affiliation(s)
- Sarvenaz Mehrabi
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada,
| | - Lindsay Cameron
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
| | - Andrew Bowman
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
| | - Jamie L Fleet
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care London, London, Ontario, Canada
- Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Janice Eng
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver, British Columbia, Canada
| | - Mark Theodore Bayley
- KITE Research Institute, UHN-Toronto Rehabilitation institute, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert Teasell
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care London, London, Ontario, Canada
- Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Freitas M, Pinho F, Pinho L, Silva S, Figueira V, Vilas-Boas JP, Silva A. Biomechanical Assessment Methods Used in Chronic Stroke: A Scoping Review of Non-Linear Approaches. SENSORS (BASEL, SWITZERLAND) 2024; 24:2338. [PMID: 38610549 PMCID: PMC11014015 DOI: 10.3390/s24072338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/22/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
Non-linear and dynamic systems analysis of human movement has recently become increasingly widespread with the intention of better reflecting how complexity affects the adaptability of motor systems, especially after a stroke. The main objective of this scoping review was to summarize the non-linear measures used in the analysis of kinetic, kinematic, and EMG data of human movement after stroke. PRISMA-ScR guidelines were followed, establishing the eligibility criteria, the population, the concept, and the contextual framework. The examined studies were published between 1 January 2013 and 12 April 2023, in English or Portuguese, and were indexed in the databases selected for this research: PubMed®, Web of Science®, Institute of Electrical and Electronics Engineers®, Science Direct® and Google Scholar®. In total, 14 of the 763 articles met the inclusion criteria. The non-linear measures identified included entropy (n = 11), fractal analysis (n = 1), the short-term local divergence exponent (n = 1), the maximum Floquet multiplier (n = 1), and the Lyapunov exponent (n = 1). These studies focused on different motor tasks: reaching to grasp (n = 2), reaching to point (n = 1), arm tracking (n = 2), elbow flexion (n = 5), elbow extension (n = 1), wrist and finger extension upward (lifting) (n = 1), knee extension (n = 1), and walking (n = 4). When studying the complexity of human movement in chronic post-stroke adults, entropy measures, particularly sample entropy, were preferred. Kinematic assessment was mainly performed using motion capture systems, with a focus on joint angles of the upper limbs.
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Affiliation(s)
- Marta Freitas
- Escola Superior de Saúde do Vale do Ave, Cooperativa de Ensino Superior Politécnico e Universitário, Rua José António Vidal, 81, 4760-409 Vila Nova de Famalicão, Portugal; (F.P.); (L.P.); (S.S.); (V.F.)
- HM—Health and Human Movement Unit, Polytechnic University of Health, Cooperativa de Ensino Superior Politécnico e Universitário, CRL, 4760-409 Vila Nova de Famalicão, Portugal
- Center for Rehabilitation Research (CIR), R. Dr. António Bernardino de Almeida 400, 4200-072 Porto, Portugal;
- Porto Biomechanics Laboratory (LABIOMEP), 4200-450 Porto, Portugal
| | - Francisco Pinho
- Escola Superior de Saúde do Vale do Ave, Cooperativa de Ensino Superior Politécnico e Universitário, Rua José António Vidal, 81, 4760-409 Vila Nova de Famalicão, Portugal; (F.P.); (L.P.); (S.S.); (V.F.)
- HM—Health and Human Movement Unit, Polytechnic University of Health, Cooperativa de Ensino Superior Politécnico e Universitário, CRL, 4760-409 Vila Nova de Famalicão, Portugal
| | - Liliana Pinho
- Escola Superior de Saúde do Vale do Ave, Cooperativa de Ensino Superior Politécnico e Universitário, Rua José António Vidal, 81, 4760-409 Vila Nova de Famalicão, Portugal; (F.P.); (L.P.); (S.S.); (V.F.)
- HM—Health and Human Movement Unit, Polytechnic University of Health, Cooperativa de Ensino Superior Politécnico e Universitário, CRL, 4760-409 Vila Nova de Famalicão, Portugal
- Center for Rehabilitation Research (CIR), R. Dr. António Bernardino de Almeida 400, 4200-072 Porto, Portugal;
- Porto Biomechanics Laboratory (LABIOMEP), 4200-450 Porto, Portugal
| | - Sandra Silva
- Escola Superior de Saúde do Vale do Ave, Cooperativa de Ensino Superior Politécnico e Universitário, Rua José António Vidal, 81, 4760-409 Vila Nova de Famalicão, Portugal; (F.P.); (L.P.); (S.S.); (V.F.)
- HM—Health and Human Movement Unit, Polytechnic University of Health, Cooperativa de Ensino Superior Politécnico e Universitário, CRL, 4760-409 Vila Nova de Famalicão, Portugal
- Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
- School of Health Sciences, University of Aveiro, 3810-193 Aveiro, Portugal;
| | - Vânia Figueira
- Escola Superior de Saúde do Vale do Ave, Cooperativa de Ensino Superior Politécnico e Universitário, Rua José António Vidal, 81, 4760-409 Vila Nova de Famalicão, Portugal; (F.P.); (L.P.); (S.S.); (V.F.)
- HM—Health and Human Movement Unit, Polytechnic University of Health, Cooperativa de Ensino Superior Politécnico e Universitário, CRL, 4760-409 Vila Nova de Famalicão, Portugal
- Porto Biomechanics Laboratory (LABIOMEP), 4200-450 Porto, Portugal
| | - João Paulo Vilas-Boas
- School of Health Sciences, University of Aveiro, 3810-193 Aveiro, Portugal;
- Centre for Research, Training, Innovation and Intervention in Sport (CIFI2D), Faculty of Sport, University of Porto, 4200-450 Porto, Portugal
| | - Augusta Silva
- Center for Rehabilitation Research (CIR), R. Dr. António Bernardino de Almeida 400, 4200-072 Porto, Portugal;
- Department of Physiotherapy, School of Health, Polytechnic of Porto, 4200-072 Porto, Portugal
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Ding K, Chen H, Wang Y, Liu H, Zhang W, Wu Y. Emergency medical service utilization and timely treatment among acute ischemic stroke patients in Beijing from 2018 to 2021. Eur J Emerg Med 2023; 30:125-131. [PMID: 36719172 DOI: 10.1097/mej.0000000000001004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND IMPORTANCE Activation of emergency medical services (EMS) is recommended for timely reperfusion therapy for acute ischemic stroke (AIS). The association of EMS utilization and time intervals from hospital arrival to a series of necessary procedures before reperfusion therapy was rarely investigated. OBJECTIVE The objective of this study is to investigate the association of EMS utilization with the time intervals from hospital arrival to therapy in patients with AIS. DESIGN Observational study. SETTINGS AND PARTICIPANTS Medical records for AIS in all emergency departments in Beijing were obtained from January 2018 to December 2021. INTERVENTION OR EXPOSURE Patients transported by ambulance were defined as the EMS group, whereas others as the non-EMS group. OUTCOME MEASURES AND ANALYSIS Door-to-imaging time (DIT), door-to-needle time (DTN) and door-to-puncture time (DTP) were compared between the two groups. MAIN RESULTS There were 11 190 (46%) and 13 106 (54%) AIS patients in the EMS and non-EMS groups. Compared with the non-EMS group, patients in the EMS group were more likely to receive intravenous thrombolysis or endovascular therapy (OR, 1.81; 95% CI, 1.68-1.94). For intravenous thrombolysis therapy, the DIT, ITN (time in minutes from obtaining the first brain imaging to tPA delivery) and DTN times in the EMS group were significantly shorter with time differences between the two groups of -1.1 (95% CI, -1.1 to -1.1) min, -2.6 (-2.6 to -2.6) min, and -3.7 (-3.8, -3.7) min, respectively. The proportion of DIT ≤25 min, DTN ≤45 min or DTN ≤60 min was significantly higher in the EMS group (OR, 1.03, 95% CI, 1.02-1.05; 1.11, 1.07-1.14; 1.05, 1.03-1.07). For endovascular therapy, the differences in DIT, ITP (time in minutes from obtaining the first brain imaging to groin puncture) and DTP times between the EMS and non-EMS groups were +1.1 (1.0-1.2) min, -3.8 (-4.2 to -3.5) min, -2.7 (-3.1 to -2.4) min, respectively, but no significant association was observed between EMS usage and the proportion of DIT ≤25 min or DTP ≤90 min. CONCLUSION In this observational study, the use of EMS for patient with AIS was associated with a shorter time from hospital arrival to intravenous thrombolysis and endovascular therapy.
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Affiliation(s)
- Kexin Ding
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University
| | - Hui Chen
- Department of Internet Management and Quality Control, Beijing Emergency Medical Center
| | - Yong Wang
- Beijing Emergency Medical Center, Beijing, China
| | - Hongmei Liu
- Beijing Emergency Medical Center, Beijing, China
| | | | - Yiqun Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University
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Logan A, Freeman J, Kent B, Pooler J, Creanor S, Enki D, Vickery J, Barton A, Marsden J. Functional standing frame programme early after severe sub-acute stroke (SPIRES): a randomised controlled feasibility trial. Pilot Feasibility Stud 2022; 8:50. [PMID: 35241176 PMCID: PMC8892736 DOI: 10.1186/s40814-022-01012-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 02/20/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early mobilisation (> 24 h post-stroke) is recommended for people with stroke. However, there is a paucity of evidence about how to implement early mobilisation for people who have had a severe stroke. Prolonged standing and task-specific training (sit-to-stand repetitions) have separately been evaluated in the literature; however, these functionally linked tasks have not been evaluated in combination for people with severe sub-acute stroke. METHODS The objective was to determine the feasibility of conducting a randomised controlled trial (RCT) of a functional standing frame programme compared with usual physiotherapy for people with severe sub-acute stroke. An assessor-blinded feasibility RCT with nested qualitative component (interviews and focus group) and process evaluation was adopted. Participants were aged ≥ 18 years with new diagnosis of severe sub-acute stroke (modified Rankin Scale (mRS) 4/5) from four Stroke Rehabilitation Units across South West England. Participants were randomised to receive either: (1) functional standing frame programme (30 min. standing plus sit-to-stand repetitions) plus 15 min of usual physiotherapy daily (intervention); (2) usual physiotherapy (45 min) daily (control). Both programmes were protocolised to be undertaken a minimum of five sessions per week for 3 weeks. Feasibility indicators included process, resource, management, and safety. Adherence, fidelity, and acceptability of the trial and intervention were evaluated using data recorded by therapists, observation of intervention and control sessions, interviews and one focus group. Patient measures of motor impairment, activities/participation, and quality of life were carried out by blinded assessors at baseline, 3, 15, 29, and 55 weeks post-randomisation. RESULTS Forty-five participants (51-96 years; 42% male, mRS 4 = 80% 5 = 20%) were randomised (n = 22 to intervention). Twenty-seven (60%) participants were followed-up at all time points. Twelve participants (27%) died during the trial; no deaths were related to the trial. Adherence to the minimum number of sessions was low: none of the participants completed all 21 sessions, and only 8 participants (18%) across both groups completed ≥ 15 sessions, over the 3 weeks; 39% intervention; 51% control sessions were completed; mean session duration 39 min (SD 19) control, 37 min intervention (SD 11). Intervention group: mean standing time 13 min (SD 9); mean sit-to-stand repetitions/session 5 (SD 4). Interviews were conducted with 10 participants, four relatives and six physiotherapists. Five physiotherapists attended a focus group. CONCLUSIONS The majority of progression criteria for this feasibility trial were met. However, adherence to the interventions was unacceptably low. This aspect of the trial design needs to be addressed prior to moving to a definitive RCT of this standing frame intervention in people with severe sub-acute stroke. Solutions have been identified to address these concerns. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number ISRCTN15412695 . Registration 19 December 2016.
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Affiliation(s)
- Angela Logan
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK. .,Stroke Rehabilitation Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Jennifer Freeman
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK
| | - Bridie Kent
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK
| | - Jill Pooler
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK
| | - Siobhan Creanor
- Peninsula Clinical Trials Unit, Faculty of Health, University of Plymouth, Plymouth, UK.,Medical Statistics, Faculty of Health, University of Plymouth, Plymouth, UK.,Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Doyo Enki
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Jane Vickery
- Peninsula Clinical Trials Unit, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Andrew Barton
- NIHR Research Design Service, Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Jonathan Marsden
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK
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5
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Kaffenberger T, Venkatraman V, Steward C, Thijs VN, Bernhardt J, Desmond PM, Campbell BCV, Yassi N. Stroke population–specific neuroanatomical CT-MRI brain atlas. Neuroradiology 2022; 64:1557-1567. [PMID: 35094103 PMCID: PMC9271109 DOI: 10.1007/s00234-021-02875-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/02/2021] [Indexed: 11/30/2022]
Abstract
Purpose Development of a freely available stroke population–specific anatomical CT/MRI atlas with a reliable normalisation pipeline for clinical CT. Methods By reviewing CT scans in suspected stroke patients and filtering the AIBL MRI database, respectively, we collected 50 normal-for-age CT and MRI scans to build a standard-resolution CT template and a high-resolution MRI template. The latter was manually segmented into anatomical brain regions. We then developed and validated a MRI to CT registration pipeline to align the MRI atlas onto the CT template. Finally, we developed a CT-to-CT-normalisation pipeline and tested its reliability by calculating Dice coefficient (Dice) and Average Hausdorff Distance (AHD) for predefined areas in 100 CT scans from ischaemic stroke patients. Results The resulting CT/MRI templates were age and sex matched to a general stroke population (median age 71.9 years (62.1–80.2), 60% male). Specifically, this accounts for relevant structural changes related to aging, which may affect registration. Applying the validated MRI to CT alignment (Dice > 0.78, Average Hausdorff Distance < 0.59 mm) resulted in our final CT-MRI atlas. The atlas has 52 manually segmented regions and covers the whole brain. The alignment of four cortical and subcortical brain regions with our CT-normalisation pipeline was reliable for small/medium/large infarct lesions (Dice coefficient > 0.5). Conclusion The newly created CT-MRI brain atlas has the potential to standardise stroke lesion segmentation. Together with the automated normalisation pipeline, it allows analysis of existing and new datasets to improve prediction tools for stroke patients (free download at https://forms.office.com/r/v4t3sWfbKs). Supplementary Information The online version contains supplementary material available at 10.1007/s00234-021-02875-9.
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Affiliation(s)
- Tina Kaffenberger
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia.
| | - Vijay Venkatraman
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Chris Steward
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Vincent N Thijs
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Julie Bernhardt
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Melbourne Brain Centre, University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
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Hayward KS, Kramer SF, Dalton EJ, Hughes GR, Brodtmann A, Churilov L, Cloud G, Corbett D, Jolliffe L, Kaffenberger T, Rethnam V, Thijs V, Ward N, Lannin N, Bernhardt J. Timing and Dose of Upper Limb Motor Intervention After Stroke: A Systematic Review. Stroke 2021; 52:3706-3717. [PMID: 34601901 DOI: 10.1161/strokeaha.121.034348] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This systematic review aimed to investigate timing, dose, and efficacy of upper limb intervention during the first 6 months poststroke. Three online databases were searched up to July 2020. Titles/abstracts/full-text were reviewed independently by 2 authors. Randomized and nonrandomized studies that enrolled people within the first 6 months poststroke, aimed to improve upper limb recovery, and completed preintervention and postintervention assessments were included. Risk of bias was assessed using Cochrane reporting tools. Studies were examined by timing (recovery epoch), dose, and intervention type. Two hundred and sixty-one studies were included, representing 228 (n=9704 participants) unique data sets. The number of studies completed increased from one (n=37 participants) between 1980 and 1984 to 91 (n=4417 participants) between 2015 and 2019. Timing of intervention start has not changed (median 38 days, interquartile range [IQR], 22-66) and study sample size remains small (median n=30, IQR 20-48). Most studies were rated high risk of bias (62%). Study participants were enrolled at different recovery epochs: 1 hyperacute (<24 hours), 13 acute (1-7 days), 176 early subacute (8-90 days), 34 late subacute (91-180 days), and 4 were unable to be classified to an epoch. For both the intervention and control groups, the median dose was 45 (IQR, 600-1430) min/session, 1 (IQR, 1-1) session/d, 5 (IQR, 5-5) d/wk for 4 (IQR, 3-5) weeks. The most common interventions tested were electromechanical (n=55 studies), electrical stimulation (n=38 studies), and constraint-induced movement (n=28 studies) therapies. Despite a large and growing body of research, intervention dose and sample size of included studies were often too small to detect clinically important effects. Furthermore, interventions remain focused on subacute stroke recovery with little change in recent decades. A united research agenda that establishes a clear biological understanding of timing, dose, and intervention type is needed to progress stroke recovery research. Prospective Register of Systematic Reviews ID: CRD42018019367/CRD42018111629.
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Affiliation(s)
- Kathryn S Hayward
- Departments of Physiotherapy and Medicine, Florey Institute of Neuroscience and Mental Health (K.S.H.), University of Melbourne, Heidelberg, Australia
| | - Sharon F Kramer
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, and Alfred Health Partnership, Deakin University, Burwood, Australia (S.F.K.)
| | - Emily J Dalton
- Department of Physiotherapy (E.J.D.), University of Melbourne, Heidelberg, Australia
| | - Gemma R Hughes
- Physiotherapy, Austin Health, Heidelberg, Australia (G.R.H.).,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (G.R.H., A.B., T.K., V.R., V.T., J.B.)
| | - Amy Brodtmann
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (G.R.H., A.B., T.K., V.R., V.T., J.B.)
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Parkville, Australia (L.C.)
| | - Geoffrey Cloud
- Department of Neuroscience, Central Clinical School, Monash University and Alfred Health, Melbourne, Australia (G.C., N.L.)
| | - Dale Corbett
- Cellular and Molecular Medicine and Canadian Partnership for Stroke Recovery, University of Ottawa, Canada (D.C.)
| | - Laura Jolliffe
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia (L.J.)
| | - Tina Kaffenberger
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (G.R.H., A.B., T.K., V.R., V.T., J.B.)
| | - Venesha Rethnam
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (G.R.H., A.B., T.K., V.R., V.T., J.B.)
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (G.R.H., A.B., T.K., V.R., V.T., J.B.).,Neurology, Austin Health, Heidelberg, Australia (V.T.)
| | - Nick Ward
- Department of Clinical and Movement Neuroscience, UCL Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom (N.W.)
| | - Natasha Lannin
- Department of Neuroscience, Central Clinical School, Monash University and Alfred Health, Melbourne, Australia (G.C., N.L.)
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (G.R.H., A.B., T.K., V.R., V.T., J.B.)
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Kennedy C, Bernhardt J, Churilov L, Collier JM, Ellery F, Rethnam V, Carvalho LB, Donnan GA, Hayward KS. Factors associated with time to independent walking recovery post-stroke. J Neurol Neurosurg Psychiatry 2021; 92:702-708. [PMID: 33737383 DOI: 10.1136/jnnp-2020-325125] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Past studies have inconsistently identified factors associated with independent walking post-stroke. We investigated the relationship between pre-stroke factors and factors collected acutely after stroke and number of days to walking 50 m unassisted using data from A Very Early Rehabilitation Trial (AVERT). METHODS The outcome was recovery of 50 m independent walking, tested from 24 hours to 3 months post-stroke. A set of a priori defined factors (participant demographics: age, sex, handedness; pre-stroke: hypertension, ischaemic heart disease, hypercholesterolaemia, diabetes mellitus, atrial fibrillation; stroke-related: stroke severity, stroke type, ischaemic stroke location, stroke hemisphere, thrombolysis) were investigated for association with independent walking using a cause-specific competing risk Cox proportional hazards model. Respective effect sizes are reported as cause-specific adjusted HR (caHR) adjusted for age, stroke severity and AVERT intervention. RESULTS A total of 2100 participants (median age 73 years, National Institutes of Health Stroke Scale 7, <1% missing data) with stroke were included. The median time to walking 50 m unassisted was 6 days (IQR 2-63) and 75% achieved independent walking by 3 months. Adjusted Cox regression indicated that slower return to independent walking was associated with older age (caHR 0.651, 95% CI 0.569 to 0.746), diabetes (caHR 0.836, 95% CI 0.740 to 0.945), severe stroke (caHR 0.094, 95% CI 0.072 to 0.122), haemorrhagic stroke (caHR 0.790, 95% CI 0.675 to 0.925) and right hemisphere stroke (caHR 0.796, 95% CI 0.714 to 0.887). CONCLUSION Our analysis provides robust evidence for important factors associated with independent walking recovery. These findings highlight the need for tailored mobilisation programmes that target subgroups, in particular people with haemorrhagic and severe stroke.
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Affiliation(s)
- Caitlin Kennedy
- Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia.,NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Victoria, Australia
| | - Leonid Churilov
- Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Janice M Collier
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Fiona Ellery
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Venesha Rethnam
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Lilian B Carvalho
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia.,NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Victoria, Australia
| | - Geoffrey A Donnan
- Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Kathryn S Hayward
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia .,NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Victoria, Australia.,Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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8
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Strong B, Pudar J, Thrift AG, Howard VJ, Hussain M, Carcel C, de Los Campos G, Reeves MJ. Sex Disparities in Enrollment in Recent Randomized Clinical Trials of Acute Stroke: A Meta-analysis. JAMA Neurol 2021; 78:666-677. [PMID: 33900363 DOI: 10.1001/jamaneurol.2021.0873] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The underenrollment of women in randomized clinical trials represents a threat to the validity of the evidence supporting clinical guidelines and potential disparities in access to novel treatments. Objective To determine whether women were underenrolled in contemporary randomized clinical trials of acute stroke therapies published in 9 major journals after accounting for their representation in underlying stroke populations. Data Sources MEDLINE was searched for acute stroke therapeutic trials published between January 1, 2010, and June 11, 2020. Study Selection Eligible articles reported the results of a phase 2 or 3 randomized clinical trial that enrolled patients with stroke and/or transient ischemic attack and examined a therapeutic intervention initiated within 1 month of onset. Data Extraction Data extraction was performed by 2 independent authors in duplicate. Individual trials were matched to estimates of the proportion of women in underlying stroke populations using the Global Burden of Disease database. Main Outcomes and Measures The primary outcome was the enrollment disparity difference (EDD), the absolute difference between the proportion of trial participants who were women and the proportion of strokes in the underlying disease populations that occurred in women. Random-effects meta-analyses of the EDD were performed, and multivariable metaregression was used to explore the associations of trial eligibility criteria with disparity estimates. Results The search returned 1529 results, and 115 trials (7.5%) met inclusion criteria. Of 121 105 randomized patients for whom sex was reported, 52 522 (43.4%) were women. The random-effects summary EDD was -0.053 (95% CI, -0.065 to -0.040), indicating that women were underenrolled by 5.3 percentage points. This disparity persisted across virtually all geographic regions, intervention types, and stroke types, apart from subarachnoid hemorrhage (0.117 [95% CI, 0.084 to 0.150]). When subarachnoid hemorrhage trials were excluded, the summary EDD was -0.067 (95% CI, -0.078 to -0.057). In the multivariable metaregression analysis, an upper age limit of 80 years as an eligibility criterion was associated with a 6-percentage point decrease in the enrollment of women. Conclusions and Relevance Further research is needed to understand the causes of the underenrollment of women in acute stroke trials. However, to maximize representation, investigators should avoid imposing age limits on enrollment.
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Affiliation(s)
- Brent Strong
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Julia Pudar
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Murtaza Hussain
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Cheryl Carcel
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Gustavo de Los Campos
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
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9
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Carcel C, Reeves M. Under-Enrollment of Women in Stroke Clinical Trials: What Are the Causes and What Should Be Done About It? Stroke 2021; 52:452-457. [PMID: 33493049 DOI: 10.1161/strokeaha.120.033227] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The under-representation of women in clinical trials is a commonly recognized and seemingly intractable problem in many different areas of clinical medicine. Discrepancies in the enrollment of women in clinical trials raises concerns about the generalizability of trial evidence, as well as the potential for reduced access and utilization of new therapies in women. Recent studies confirm that the problem of under-enrollment of women continues to exist in stroke clinical trials, even after accounting for the sex ratio of stroke cases in the underlying population. The origins of these disparities are complex, and there remains a relative dearth of stroke studies that have examined the causes in detail. Although caution should be used when generalizing research findings from studies conducted in other medical conditions including cardiology trials, factors that contribute to lower enrollment in women include the use of specific trial eligibility criteria (eg, older age, presence of specific comorbidities), patient attitudes and beliefs (resulting in less interest and more refusals in women), and potentially implicit biases among study personnel. Beyond a general call to prioritize stroke research in this area, we also recommend the greater use of trial screening logs, the use of qualitative studies to understand patient attitudes and beliefs towards stroke research, avoiding the use of age-based exclusion criteria (eg, >80 years), and increasing the number of women who lead stroke clinical trials.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (C.C.).,The University of Sydney, Sydney School of Public Health, Sydney Medical School, New South Wales, Australia (C.C.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing (M.R.)
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10
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Rethnam V, Bernhardt J, Johns H, Hayward KS, Collier JM, Ellery F, Gao L, Moodie M, Dewey H, Donnan GA, Churilov L. Look closer: The multidimensional patterns of post-stroke burden behind the modified Rankin Scale. Int J Stroke 2020; 16:420-428. [DOI: 10.1177/1747493020951941] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background The utility-weighted modified Rankin Scale, representing patient perspectives of quality of life, is a newly proposed measure to improve the interpretability of the modified Rankin Scale. Despite obvious advantages, such weighting imperfectly reflects the multidimensional patterns of post-stroke burden. Aims To investigate multidimensional patterns of post-stroke burden formed by individual domains of Assessment of Quality of Life and Barthel Index for each modified Rankin Scale category. Methods In the A Very Early Rehabilitation Trial (n = 2104), modified Rankin Scale scores and modified Rankin Scale-stratified Barthel Index scores of Self-care and Mobility, and Assessment of Quality of Life scores of Independent Living, Senses, Mental Health and Relationships were collected at three months. The multivariate relationship between individual Assessment of Quality of Life and Barthel Index domains, and modified Rankin Scale was investigated using random effects linear regression models with respective interaction terms. Results Of 2104 patients, simultaneously collected Assessment of Quality of Life, Barthel Index and modified Rankin Scale scores at three months were available in 1870 patients. While individual Assessment of Quality of Life and Barthel Index domain scores decreased significantly as modified Rankin Scale increased (p < 0.0001), the patterns of decrease differed by domains (p < 0.0001). Patients with modified Rankin Scale 0–1 had the largest post-stroke burden in the Mental Health and Relationship domains, while patients with modified Rankin Scale >3 showed the greatest burden in Independent Living, Mobility and Self-care domains. Conclusions Across the modified Rankin Scale, individual domains are varyingly impacted demonstrating unique patterns of post-stroke burden, which facilitates appropriate assessment, articulation and interpretation of the modified Rankin Scale and utility-weighted modified Rankin Scale.
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Affiliation(s)
- Venesha Rethnam
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
| | - Hannah Johns
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
| | - Kathryn S Hayward
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
- Melbourne School of Health Sciences, University of Melbourne, Parkville, Australia
| | - Janice M Collier
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
| | - Fiona Ellery
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
| | - Lan Gao
- Deakin Health Economics, Deakin University, Burwood, Australia
| | - Marj Moodie
- Deakin Health Economics, Deakin University, Burwood, Australia
| | - Helen Dewey
- Eastern Health and Eastern Health Clinical School, Monash University, Clayton, Australia
| | - Geoffrey A Donnan
- NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
- Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Australia
| | - Leonid Churilov
- NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
- Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Australia
- Melbourne Medical School, University of Melbourne, Parkville, Australia
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11
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Yen HC, Jeng JS, Chen WS, Pan GS, Chuang Pt Bs WY, Lee YY, Teng T. Early Mobilization of Mild-Moderate Intracerebral Hemorrhage Patients in a Stroke Center: A Randomized Controlled Trial. Neurorehabil Neural Repair 2019; 34:72-81. [PMID: 31858865 DOI: 10.1177/1545968319893294] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Few studies have addressed early out-of-bed mobilization specifically in acute intracerebral hemorrhage (ICH) patients. Patient benefit in such cases is unclear, with early intervention timing and duration identical to those in standard care. Objective. We investigated the efficacy of an early mobilization (EM) protocol, administered within 24 to 72 hours of stroke onset, for early functional independence in mild-moderate ICH patients. Methods. Sixty patients admitted to a stroke center within 24 hours of ICH were randomly assigned to early mobilization (EM) or standard early rehabilitation (SER). The EM group underwent an early out-of-bed mobilization protocol, while the SER group underwent a standard protocol focusing on in-bed training in the stroke center. Intervention in both groups lasted 30 minutes per session, once a day, 5 days a week. Motor subscales of the Functional Independence Measure (FIM-motor; primary outcome), Postural Assessment Scale for Stroke Patients, and Functional Ambulation Category (FAC) were evaluated (assessor-blinded) at baseline, and at 2 weeks, 4 weeks, and 3 months after stroke. Length of stay in the stroke center was also recorded. Results. The EM group showed significant improvement in FIM-motor score at all evaluated time points (P = .004) and in FAC outcomes at 2 weeks (P = .033) and 4 weeks (P = .011) after stroke. Length of stay in the stroke center was significantly shorter for the EM group (P = .004). Conclusion. Early out-of-bed mobilization via rehabilitation in a stroke center, within 24 to 72 hours of ICH, may improve early functional independence compared with standard early rehabilitation. Clinical Trial Registration: NCT03292211.
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Affiliation(s)
- Hsiao-Ching Yen
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center & Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Shiang Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Guan-Shuo Pan
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Ying Chuang Pt Bs
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Yun Lee
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ting Teng
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
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12
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Langhorne P, Collier JM, Bate PJ, Thuy MNT, Bernhardt J. Very early versus delayed mobilisation after stroke. Cochrane Database Syst Rev 2018; 10:CD006187. [PMID: 30321906 PMCID: PMC6517132 DOI: 10.1002/14651858.cd006187.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Very early mobilisation (VEM) is performed in some stroke units and recommended in some acute stroke clinical guidelines. However, it is unclear whether very early mobilisation independently improves outcome after stroke. OBJECTIVES To determine whether very early mobilisation (started as soon as possible, and no later than 48 hours after onset of symptoms) in people with acute stroke improves recovery (primarily the proportion of independent survivors) compared with usual care. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched 31 July 2017). We also systematically searched 19 electronic databases including; CENTRAL; 2017, Issue 7 in the Cochrane Library (searched July 2017), MEDLINE Ovid (1950 to August 2017), Embase Ovid (1980 to August 2017), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to August 2017) , PsycINFO Ovid (1806 to August 2017), AMED Ovid (Allied and Complementary Medicine Database), SPORTDiscus EBSCO (1830 to August 2017). We searched relevant ongoing trials and research registers (searched December 2016), the Chinese medical database, Wanfangdata (searched to November 2016), and reference lists, and contacted researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of people with acute stroke, comparing an intervention group that started out-of-bed mobilisation within 48 hours of stroke, and aimed to reduce time-to-first mobilisation, with or without an increase in the amount or frequency (or both) of mobilisation activities, with usual care, where time-to-first mobilisation was commenced later. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow-up. Secondary outcomes included death, dependency, institutionalisation, activities of daily living (ADL), extended ADL, quality of life, walking ability, complications (e.g. deep vein thrombosis), patient mood, and length of hospital stay. We also analysed outcomes at three-month follow-up. MAIN RESULTS We included nine RCTs with 2958 participants; one trial provided most of the information (2104 participants). The median (range) delay to starting mobilisation after stroke onset was 18.5 (13.1 to 43) hours in the VEM group and 33.3 (22.5 to 71.5) hours in the usual care group. The median difference within trials was 12.7 (4 to 45.6) hours. Other differences in intervention varied between trials; in five trials, the VEM group were also reported to have received more time in therapy, or more mobilisation activity.Primary outcome data were available for 2542 of 2618 (97.1%) participants randomized and followed up for a median of three months. VEM probably led to similar or slightly more deaths and participants who had a poor outcome, compared with delayed mobilisation (51% versus 49%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.92 to 1.26; P = 0.36; 8 trials; moderate-quality evidence). Death occurred in 7% of participants who received delayed mobilisation, and 8.5% of participants who received VEM (OR 1.27, 95% CI 0.95 to 1.70; P = 0.11; 8 trials, 2570 participants; moderate-quality evidence), and the effects on experiencing any complication were unclear (OR 0.88; 95% CI 0.73 to 1.06; P = 0.18; 7 trials, 2778 participants; low-quality evidence). Analysis using outcomes collected only at three-month follow-up did not alter the conclusions.The mean ADL score (measured at end of follow-up, with the 20-point Barthel Index) was higher in those who received VEM compared with the usual care group (mean difference (MD) 1.94, 95% CI 0.75 to 3.13, P = 0.001; 8 trials, 9 comparisons, 2630/2904 participants (90.6%); low-quality evidence), but there was substantial heterogeneity (93%). Effect sizes were smaller for outcomes collected at three-month follow-up, rather than later.The mean length of stay was shorter in those who received VEM compared with the usual care group (MD -1.44, 95% CI -2.28 to -0.60, P = 0.0008; 8 trials, 2532/2618 participants (96.7%); low-quality evidence). Confidence in the answer was limited by the variable definitions of length of stay. The other secondary outcome analyses (institutionalisation, extended activities of daily living, quality of life, walking ability, patient mood) were limited by lack of data.Sensitivity analyses by trial quality: none of the outcome conclusions were altered if we restricted analyses to trials with the lowest risk of bias (based on method of randomization, allocation concealment, completeness of follow-up, and blinding of final assessment), or information about the amount of mobilisation.Sensitivity analysis by intervention characteristics: analyses restricted to trials where the mean VEM time-to-first mobilisation was less than 24 hours, showed an odds of death of 1.35 (95% CI 0.99 to 1.83; P = 0.06; I² = 25%; 5 trials). Analyses restricted to the trials that clearly reported a more prolonged out-of-bed activity showed a similar primary outcome (OR 1.14; 0.96 to 1.35; P = 0.13; I² = 28%; 5 trials), and odds of death (OR 1.27; 0.93 to 1.73; P = 0.13; I² = 0%; 4 trials) to the main analysis.Exploratory network meta-analysis (NMA): we were unable to analyze by the amount of therapy, but low-quality evidence indicated that time-to-first mobilisation at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilisation. AUTHORS' CONCLUSIONS VEM, which usually involved first mobilisation within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke. VEM may have reduced the length of stay in hospital by about one day, but this was based on low-quality evidence. Based on the potential hazards reported in the single largest RCT, the sensitivity analysis of trials commencing mobilisation within 24 hours, and the NMA, there was concern that VEM commencing within 24 hours may carry an increased risk, at least in some people with stroke. Given the uncertainty around these effect estimates, more detailed research is still required.
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Affiliation(s)
- Peter Langhorne
- ICAMS, University of GlasgowAcademic Section of Geriatric MedicineLevel 2, New Lister BuildingGlasgow Royal InfirmaryGlasgowUKG31 2ER
| | - Janice M Collier
- National Stroke Research InstituteVery Early Rehabilitation Stroke Research ProgramLevel 1, Neurosciences BuildingARMC Repat Campus, 300 Waterdale RoadHeidelberg HeightsVictoriaAustralia3081
| | | | - Matthew NT Thuy
- Austin HealthNational Stroke Research InstituteLevel 1, Neurosciences BuildingAustin Health, Repatriation Campus, 300 Waterdale RdHeidelberg HeightsVictoriaAustralia3081
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health245 Burgundy StreetHeidelbergVictoriaAustralia3081
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13
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Eisman JA, Geusens P, van den Bergh J. The Emperor's New Clothes: What Randomized Controlled Trials Don't Cover. J Bone Miner Res 2018; 33:1394-1396. [PMID: 29953664 DOI: 10.1002/jbmr.3539] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/18/2018] [Accepted: 06/24/2018] [Indexed: 11/08/2022]
Affiliation(s)
- John A Eisman
- Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, Sydney, NSW, Australia; School of Medicine Sydney, University of Notre Dame Australia, Darlinghurst, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia; Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia; Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - P Geusens
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; Faculty of Mediciney, University Hasselt, Maastricht, Belgium
| | - J van den Bergh
- Department of Rheumatology, Maastricht University, The Netherlands; Faculty of Medicine, University Hasselt, Belgium
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14
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Langhorne P, Wu O, Rodgers H, Ashburn A, Bernhardt J. A Very Early Rehabilitation Trial after stroke (AVERT): a Phase III, multicentre, randomised controlled trial. Health Technol Assess 2018; 21:1-120. [PMID: 28967376 DOI: 10.3310/hta21540] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Mobilising patients early after stroke [early mobilisation (EM)] is thought to contribute to the beneficial effects of stroke unit care but it is poorly defined and lacks direct evidence of benefit. OBJECTIVES We assessed the effectiveness of frequent higher dose very early mobilisation (VEM) after stroke. DESIGN We conducted a parallel-group, single-blind, prospective randomised controlled trial with blinded end-point assessment using a web-based computer-generated stratified randomisation. SETTING The trial took place in 56 acute stroke units in five countries. PARTICIPANTS We included adult patients with a first or recurrent stroke who met physiological inclusion criteria. INTERVENTIONS Patients received either usual stroke unit care (UC) or UC plus VEM commencing within 24 hours of stroke. MAIN OUTCOME MEASURES The primary outcome was good recovery [modified Rankin scale (mRS) score of 0-2] 3 months after stroke. Secondary outcomes at 3 months were the mRS, time to achieve walking 50 m, serious adverse events, quality of life (QoL) and costs at 12 months. Tertiary outcomes included a dose-response analysis. DATA SOURCES Patients, outcome assessors and investigators involved in the trial were blinded to treatment allocation. RESULTS We recruited 2104 (UK, n = 610; Australasia, n = 1494) patients: 1054 allocated to VEM and 1050 to UC. Intervention protocol targets were achieved. Compared with UC, VEM patients mobilised 4.8 hours [95% confidence interval (CI) 4.1 to 5.7 hours; p < 0.0001] earlier, with an additional three (95% CI 3.0 to 3.5; p < 0.0001) mobilisation sessions per day. Fewer patients in the VEM group (n = 480, 46%) had a favourable outcome than in the UC group (n = 525, 50%) (adjusted odds ratio 0.73, 95% CI 0.59 to 0.90; p = 0.004). Results were consistent between Australasian and UK settings. There were no statistically significant differences in secondary outcomes at 3 months and QoL at 12 months. Dose-response analysis found a consistent pattern of an improved odds of efficacy and safety outcomes in association with increased daily frequency of out-of-bed sessions but a reduced odds with an increased amount of mobilisation (minutes per day). LIMITATIONS UC clinicians started mobilisation earlier each year altering the context of the trial. Other potential confounding factors included staff patient interaction. CONCLUSIONS Patients in the VEM group were mobilised earlier and with a higher dose of therapy than those in the UC group, which was already early. This VEM protocol was associated with reduced odds of favourable outcome at 3 months cautioning against very early high-dose mobilisation. At 12 months, health-related QoL was similar regardless of group. Shorter, more frequent mobilisation early after stroke may be associated with a more favourable outcome. FUTURE WORK These results informed a new trial proposal [A Very Early Rehabilitation Trial - DOSE (AVERT-DOSE)] aiming to determine the optimal frequency and dose of EM. TRIAL REGISTRATION The trial is registered with the Australian New Zealand Clinical Trials Registry number ACTRN12606000185561, Current Controlled Trials ISRCTN98129255 and ISRCTN98129255. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 54. See the NIHR Journals Library website for further project information. Funding was also received from the National Health and Medical Research Council Australia, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, and the Stroke Association. In addition, National Health and Medical Research Council fellowship funding was provided to Julie Bernhardt (1058635), who also received fellowship funding from the Australia Research Council (0991086) and the National Heart Foundation (G04M1571). The Florey Institute of Neuroscience and Mental Health, which hosted the trial, acknowledges the support received from the Victorian Government via the Operational Infrastructure Support Scheme.
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Affiliation(s)
- Peter Langhorne
- Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Helen Rodgers
- Institute for Ageing and Health, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Ashburn
- Rehabilitation Research Unit, Southampton General Hospital, Southampton, UK
| | - Julie Bernhardt
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
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Kwakkel G, Lannin NA, Borschmann K, English C, Ali M, Churilov L, Saposnik G, Winstein C, van Wegen EEH, Wolf SL, Krakauer JW, Bernhardt J. Standardized Measurement of Sensorimotor Recovery in Stroke Trials: Consensus-Based Core Recommendations from the Stroke Recovery and Rehabilitation Roundtable. Neurorehabil Neural Repair 2018; 31:784-792. [PMID: 28934918 DOI: 10.1177/1545968317732662] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Finding, testing and demonstrating efficacy of new treatments for stroke recovery is a multifaceted challenge. We believe that to advance the field, neurorehabilitation trials need a conceptually rigorous starting framework. An essential first step is to agree on definitions of sensorimotor recovery and on measures consistent with these definitions. Such standardization would allow pooling of participant data across studies and institutions aiding meta-analyses of completed trials, more detailed exploration of recovery profiles of our patients and the generation of new hypotheses. Here, we present the results of a consensus meeting about measurement standards and patient characteristics that we suggest should be collected in all future stroke recovery trials. Recommendations are made considering time post stroke and are aligned with the international classification of functioning and disability. A strong case is made for addition of kinematic and kinetic movement quantification. Further work is being undertaken by our group to form consensus on clinical predictors and pre-stroke clinical data that should be collected, as well as recommendations for additional outcome measurement tools. To improve stroke recovery trials, we urge the research community to consider adopting our recommendations in their trial design.
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Affiliation(s)
- Gert Kwakkel
- 1 Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, VU University Medical Center Amsterdam, The Netherlands; and Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, USA
| | - Natasha A Lannin
- 2 School of Allied Health, La Trobe University, Melbourne, Australia; and Department of Occupational Therapy, Alfred Health, Melbourne, Australia
| | - Karen Borschmann
- 3 Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.,4 NHMRC Centre of Research Excellence Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
| | - Coralie English
- 5 University of Newcastle School of Health Sciences and Priority Research Centre for Stroke and Brain Injury, Hunter Medical Research Institute, Australia; NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Australia
| | - Myzoon Ali
- 6 Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, UK, and Institutes of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Leonid Churilov
- 3 Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.,4 NHMRC Centre of Research Excellence Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
| | - Gustavo Saposnik
- 7 Stroke Outcomes Research & Center for Virtual Reality Studies ( www.sorcan.ca ); Department of Medicine (Neurology), Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Canada
| | - Carolee Winstein
- 8 Division Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry and Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Erwin E H van Wegen
- 9 Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, VU University Medical Center Amsterdam, The Netherlands
| | - Steven L Wolf
- 10 Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine, Atlanta; VA Center for Visual and Neurocognitive Rehabilitation, Atlanta, GA, USA
| | - John W Krakauer
- 11 Departments of Neurology, Neuroscience, and Physical Medicine & Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julie Bernhardt
- 3 Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.,4 NHMRC Centre of Research Excellence Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
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16
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Kwakkel G, Lannin NA, Borschmann K, English C, Ali M, Churilov L, Saposnik G, Winstein C, van Wegen EE, Wolf SL, Krakauer JW, Bernhardt J. Standardized measurement of sensorimotor recovery in stroke trials: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable. Int J Stroke 2018; 12:451-461. [PMID: 28697709 DOI: 10.1177/1747493017711813] [Citation(s) in RCA: 259] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Finding, testing and demonstrating efficacy of new treatments for stroke recovery is a multifaceted challenge. We believe that to advance the field, neurorehabilitation trials need a conceptually rigorous starting framework. An essential first step is to agree on definitions of sensorimotor recovery and on measures consistent with these definitions. Such standardization would allow pooling of participant data across studies and institutions aiding meta-analyses of completed trials, more detailed exploration of recovery profiles of our patients and the generation of new hypotheses. Here, we present the results of a consensus meeting about measurement standards and patient characteristics that we suggest should be collected in all future stroke recovery trials. Recommendations are made considering time post stroke and are aligned with the international classification of functioning and disability. A strong case is made for addition of kinematic and kinetic movement quantification. Further work is being undertaken by our group to form consensus on clinical predictors and pre-stroke clinical data that should be collected, as well as recommendations for additional outcome measurement tools. To improve stroke recovery trials, we urge the research community to consider adopting our recommendations in their trial design.
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Affiliation(s)
- Gert Kwakkel
- 1 Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, VU University Medical Center Amsterdam, The Netherlands; and Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, USA
| | - Natasha A Lannin
- 2 School of Allied Health, La Trobe University, Melbourne, Australia; and Department of Occupational Therapy, Alfred Health, Melbourne, Australia
| | - Karen Borschmann
- 3 The Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia; and NHMRC Centre of Research Excellence Stroke Rehabilitation and Brain Recovery, Australia
| | - Coralie English
- 4 University of Newcastle School of Health Sciences and Priority Research Centre for Stroke and Brain Injury, Hunter Medical Research Institute, Australia; NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Australia
| | - Myzoon Ali
- 5 Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, UK, and Institutes of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Leonid Churilov
- 3 The Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia; and NHMRC Centre of Research Excellence Stroke Rehabilitation and Brain Recovery, Australia
| | - Gustavo Saposnik
- 6 Stroke Outcomes Research & Center for Virtual Reality Studies ( www.sorcan.ca ); Department of Medicine (Neurology), Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Canada
| | - Carolee Winstein
- 7 Division Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry and Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Erwin Eh van Wegen
- 8 Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, VU University Medical Center Amsterdam, The Netherlands
| | - Steven L Wolf
- 9 Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine, Atlanta; VA Center for Visual and Neurocognitive Rehabilitation, Atlanta, GA, USA
| | - John W Krakauer
- 10 Departments of Neurology, Neuroscience, and Physical Medicine & Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julie Bernhardt
- 3 The Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia; and NHMRC Centre of Research Excellence Stroke Rehabilitation and Brain Recovery, Australia
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17
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Kafri M, Dickstein R. External validity of post-stroke interventional gait rehabilitation studies. Top Stroke Rehabil 2016; 24:61-67. [PMID: 27145119 DOI: 10.1080/10749357.2016.1176796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Gait rehabilitation is a major component of stroke rehabilitation, and is supported by extensive research. The objective of this review was to examine the external validity of intervention studies aimed at improving gait in individuals post-stroke. To that end, two aspects of these studies were assessed: subjects' exclusion criteria and the ecological validity of the intervention, as manifested by the intervention's technological complexity and delivery setting. Additionally, we examined whether the target population as inferred from the titles/abstracts is broader than the population actually represented by the reported samples. METHODS We systematically researched PubMed for intervention studies to improve gait post-stroke, working backwards from the beginning of 2014. Exclusion criteria, the technological complexity of the intervention (defined as either elaborate or simple), setting, and description of the target population in the titles/abstracts were recorded. RESULTS Fifty-two studies were reviewed. The samples were exclusive, with recurrent stroke, co-morbidities, cognitive status, walking level, and residency being major reasons for exclusion. In one half of the studies, the intervention was elaborate. Descriptions of participants in the title/abstract in almost one half of the studies included only the diagnosis (stroke or comparable terms) and its stage (acute, subacute, and chronic). CONCLUSIONS The external validity of a substantial number of intervention studies about rehabilitation of gait post-stroke appears to be limited by exclusivity of the samples as well as by deficiencies in ecological validity of the interventions. These limitations are not accurately reflected in the titles or abstracts of the studies.
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Affiliation(s)
- Michal Kafri
- a Department of Physical Therapy , Faculty of Social Welfare & Health Sciences , University of Haifa , Haifa , Israel
| | - Ruth Dickstein
- a Department of Physical Therapy , Faculty of Social Welfare & Health Sciences , University of Haifa , Haifa , Israel
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18
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Luft AR, Kesselring J. Critique of A Very Early Rehabilitation Trial (AVERT). Stroke 2015; 47:291-2. [PMID: 26658440 DOI: 10.1161/strokeaha.115.010483] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 10/30/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Andreas R Luft
- From the Division of Vascular Neurology and Rehabilitation, Department of Neurology, University of Zurich, Zurich, Switzerland (A.R.L.); Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland (A.R.L.); and Kliniken Valens, Valens, Switzerland (J.K.).
| | - Jürg Kesselring
- From the Division of Vascular Neurology and Rehabilitation, Department of Neurology, University of Zurich, Zurich, Switzerland (A.R.L.); Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland (A.R.L.); and Kliniken Valens, Valens, Switzerland (J.K.)
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