Repetitive task training after stroke: a Cochrane systematic review

1. University of Central Lancashire Repetitive task training after stroke: a Cochrane systematic review French B, Thomas L, Leathley MJ, Sutton CJ, McAdam J,, Forster A1, Langhorne P2, Price CIM3, Walker A2, Watkins CL. University of Central Lancashire, University of Leeds1, University of Glasgow2 Northumbria Healthcare NHS Trust3 Contact details: bfrench1@uclan.ac.uk or lhthomas@uclan.ac.uk

2. University of Central Lancashire Background more than 110,000 people per annum will suffer from stroke single largest cause of severe adult disability (Bonita 1992) major cause of long-term neurological disability around half of all stroke survivors left with severe functional problems 5%-20% with initial upper limb impairment fully regain arm function 30%-66% regain no functional use at six months

3. University of Central Lancashire Repetitive task training: background systematic reviews for affected upper limb suggest participants benefit from exercise programmes where functional tasks directly trained more intensive therapy may improve rate of activities of daily living recovery (Kwakkel 2004) repetitive task practice combines elements of intensity of practice functional relevance Systematic reviews for affected upper limb suggest participants benefit from exercise programmes where functional tasks are directly trained Less benefit if intervention is impairment focussed, for example muscle strengthening. Recent meta-analysis (Kwakkel 2004) found that more intensive therapy may improve the rate of activities of daily living recovery, particularly if a functional approach is adopted.Systematic reviews for affected upper limb suggest participants benefit from exercise programmes where functional tasks are directly trained Less benefit if intervention is impairment focussed, for example muscle strengthening. Recent meta-analysis (Kwakkel 2004) found that more intensive therapy may improve the rate of activities of daily living recovery, particularly if a functional approach is adopted.

4. University of Central Lancashire Why did we do the review? repetitive task training has potential to: be a resource efficient component of stroke rehabilitation be delivered in a group setting lead to sustainable, functional gains RTT has the potential to be a resource efficient component of stroke rehabilitation, including delivery in a group setting or as a basis for self-initiated practice in the home. We conducted our review to see if RTT could lead to sustainable functional gainsRTT has the potential to be a resource efficient component of stroke rehabilitation, including delivery in a group setting or as a basis for self-initiated practice in the home. We conducted our review to see if RTT could lead to sustainable functional gains

5. University of Central Lancashire Objectives I Primary: to determine if RTT improves functional ability in adults after stroke in: upper limb function/reach lower limb function/balance global motor function Secondary: 1) To determine effect of RTT on: ADL function Motor impairment Quality of life/health status Adverse outcomes

6. University of Central Lancashire Objectives II 2) to determine factors that could influence primary and secondary outcome measures, including the effect of: �dose� of task practice timing of intervention type of intervention

7. University of Central Lancashire Inclusion criteria type of study randomised and quasi-randomised trials one arm had to include RTT compared against usual practice (including �no treatment� or attention control) type of participants adults who have had a stroke according to WHO criteria (WHO 1989) type of intervention active motor sequence performed repetitively within a single training session practice aimed towards a clear functional goal time duration or number of repetitions within a single session and the number of sessions needed to be stated Type of study: we included randomised controlled trials and quasi-randomised trials, for example those allocating by date or alternation) One arm had to include RTT compared against usual practice (including �no treatment� or attention control). An example of attention control treatment could be comparable time spent receiving therapy on a different limb, or participating in an activity with no potential motor benefits. Type of intervention: Functional goals could involve complex whole tasks, e.g. putting cups onto a shelf, or pre-task movements, e.g. reaching forward.Type of study: we included randomised controlled trials and quasi-randomised trials, for example those allocating by date or alternation) One arm had to include RTT compared against usual practice (including �no treatment� or attention control). An example of attention control treatment could be comparable time spent receiving therapy on a different limb, or participating in an activity with no potential motor benefits. Type of intervention: Functional goals could involve complex whole tasks, e.g. putting cups onto a shelf, or pre-task movements, e.g. reaching forward.

8. University of Central Lancashire Inclusion criteria types of outcome measures primary: upper limb function/reach Arm function (e.g. Wolf Motor Function Test) Hand function (e.g. Motor Assessment Scale [hand]) lower limb function/balance Lower limb function (e.g. walking distance, walking speed) Global motor function (e.g. Rivermead Motor Assessment Scale)

9. University of Central Lancashire Process of Review Database searches �download to refman, Cochrane �print out, unpublished databases & conferences-print out, secondary referencing from systematic reviews �added to refman file. Refman to excel alongside bibliography from refman. 71 not in english Online access and ILL to retrieve studies.Database searches �download to refman, Cochrane �print out, unpublished databases & conferences-print out, secondary referencing from systematic reviews �added to refman file. Refman to excel alongside bibliography from refman. 71 not in english Online access and ILL to retrieve studies.

10. University of Central Lancashire Results: upper limb, arm function There were 8 RTT trials with 467 participants. The impact of functional training on upper limb function post therapy indicated a small effect, SMD 0.17, which just failed to reach statistical significance, with a confidence interval of �0.03 to 0.36.There were 8 RTT trials with 467 participants. The impact of functional training on upper limb function post therapy indicated a small effect, SMD 0.17, which just failed to reach statistical significance, with a confidence interval of �0.03 to 0.36.

11. University of Central Lancashire Results: hand function and sitting balance/reach no evidence for the effectiveness of RTT on hand function SMD 0.16, 95% CI -0.07 to 0.40 sitting balance/reach SMD 0.23, 95% CI -0.05 to 0.50 results for later follow-up were not statistically significant up to 6 months post-therapy between 6 months and 1 year post-therapy

12. University of Central Lancashire Results: lower limb, walking distance Lower limb outcomes were more positive. In the 3 trials that measured walking distance over 6 minutes, the weighted mean difference between intervention and comparison groups was nearly 55 metres. Lower limb outcomes were more positive. In the 3 trials that measured walking distance over 6 minutes, the weighted mean difference between intervention and comparison groups was nearly 55 metres.

13. University of Central Lancashire Results: lower limb Evidence for statistically significant small to moderate impact of RTT training on walking speed (SMD 0.29, 95% CI 0.04 to 0.53) Sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56) Results for functional ambulation small, of borderline significance SMD 0.25, 95% CI 0.00 to 0.51

14. University of Central Lancashire Implications for practice evidence to support the general principle that repetitive, task-specific training for lower limbs and result in functional gain repetitive task training for upper limbs showed no significant advantage There is enough evidence to support the general principle that repetitive, task-specific training for lower limbs and result in functional gain, when compared against other forms of usual care or attention control. Functional gain is modest, but does appear to be clinically significant. However, it is unclear whether effects are sustained over time. There is enough evidence to support the general principle that repetitive, task-specific training for lower limbs and result in functional gain, when compared against other forms of usual care or attention control. Functional gain is modest, but does appear to be clinically significant. However, it is unclear whether effects are sustained over time.

15. University of Central Lancashire Implications for research further primary research exploring impact of type and amount of task training, and how to maintain functional gain trials evaluating efficacy and cost effectiveness of different intervention delivery methods e.g. group training, or practice at home In terms of upper limb function, while the review did not provide any evidence of a treatment effect, only three trials provided evidence of more intensive therapy. Further research relating to the type, amount and intensity of task training for arm function among participants with different clinical characteristics would be useful. There were not enough trials in the review to evaluate the efficacy and cost effectiveness of different intervention delivery methods for RTT, such as group training or practice in the home environment. Further research should look at practical ways of delivering RTT interventions. Future trials should be powered to detect cost-effectiveness as well as clinical effect.In terms of upper limb function, while the review did not provide any evidence of a treatment effect, only three trials provided evidence of more intensive therapy. Further research relating to the type, amount and intensity of task training for arm function among participants with different clinical characteristics would be useful. There were not enough trials in the review to evaluate the efficacy and cost effectiveness of different intervention delivery methods for RTT, such as group training or practice in the home environment. Further research should look at practical ways of delivering RTT interventions. Future trials should be powered to detect cost-effectiveness as well as clinical effect.

16. University of Central Lancashire Acknowledgements This presentation is based on a wider project funded by the NHS R&D Health Technology Assessment Programme (Project No 05/07/04). The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the Department of Health. The full review for RTT was carried out using Cochrane Collaborative methodology and resources. The review can be found at:http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006073/frame.html French B, Thomas LH, Leathley MJ, Sutton CJ, McAdam J, Forster A, Langhorne P, Price CIM, Walker A, Watkins CL. Repetitive task training for improving functional ability after stroke. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006073. DOI: 10.1002/14651858.CD006073.pub2.